Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Extubation failure

ICU

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all
  • Be the first to comment

Extubation failure

  1. 1. Extubation failure EF Predictors and management by Mahmoud Elhusseiny Abo Elmagd Assistant lecturer of pulmonary and critical care medicine Faculty of Medicine – Mansoura University
  2. 2. Weaning Outcome •More than 3 trials •More than 7 days •Passed first trial •70 % •Up to 3 trials •Up to 7 days needed
  3. 3. EF Extubation failure is defined as inability to sustain spontaneous breathing after removal of the artificial airway; an endotracheal tube or tracheostomy tube; and need for re-intubation within a specified time period: either within 24-72 h or up to 7 days.
  4. 4. EF reintubation 24-72 h
  5. 5. Incidence of EF 50% 14%
  6. 6. OUTCOMERA
  7. 7. Why? increased mortality Age sicker Comorbid dialysis reintubation. life- threatening events during • cardiac arrhythmias • cardiac arrest, • esophageal intubation, • endobronchial intubation, • aspiration failed extubation
  8. 8. Extubation Failure ? respiratory failure The most common cause • increased work of breathing, accessory muscle use • hypoxia • hypercapnea • respiratory acidosis. Why
  9. 9. Mortality for patients reintubated for upper airway obstruction 7% respiratory failure 30% not different in trauma patients Esteban and colleagues
  10. 10. Extubation Failure Pathophysiology Decreased conscious ness Sedative and analgesics Critical illness, polyneuro pathy Deconditio ned muscles Poor nutrition Upper airway edema • Prolonged intubation Inability to clear secretions
  11. 11. ICU positive fluid balance in preceding 24 h acute myocardial ischemia cardiac dysfunction Older severity prolonged ventilation continuous sedation Neurologic impairment Low cough peak flows Large secretions PCO2 ≥ 44 WHO WILL FAIL?
  12. 12. Several studies Delayed reintubation > 12-24 h
  13. 13. Predictors of EF Respiratory Mechanics
  14. 14. Respiratory Mechanics • f/ VT (50 ± 23) • successful extubation. • cut off RSBI ≥ 57 Rapid shallow breathing index (RSBI - f/VT )
  15. 15. Airway occlusion pressure (P0.1 ) Ratio of occlusion pressure to maximum inspiratory pressure (MIP) Low Ratio EF Meta- analysis ratio > 0.3 successful extubation P0.1/MIP limited special device P0.1/MIP Neuromuscular drive unaffected by respiratory compliance or resistance.
  16. 16. Minute ventilation recovery time (VERT) respiratory muscle reserve
  17. 17. Minute ventilation recovery time (VERT) Martinez and colleagues, • 2-h SBT, • back on pre-SBT settings for 25 min •Measured (VE) • baseline preceding 24 h • post-SBT trial
  18. 18. Minute ventilation recovery time (VERT) Shorter VERT successful extubation 3.6 ± 2.7 min vs. 9.6 ± 5.8 min Prolonged VERT limited resp. reserve unrecognized, underlying disease
  19. 19. RT 50% ∆VE Hernandez and colleagues 7 minutes discriminate failures and successes.
  20. 20. (WOB)failed SBT with normal physiological WOB ≤0.8 J/l increased imposed (WOB) secondary to ventilatory apparatus endotracheal tube Automatic Tube Compensation (ATC) Pressure support improve extubation success reducing imposed work of breathing.
  21. 21. Displacement of liver/spleen . Jiang and colleagues higher values successfully extubated Diaphragm fatigue reduced excursion cutoff value of 1.1 cm sensitivity 84.4% specificity 82.6%.• noninvasive • Bedside Needs expertise
  22. 22. higher GCS score = successful extubation GCS ≥ 8 showed highest predictive accuracy GCS ≥ 10 for successful extubation
  23. 23. Assessing Airway Protection Cough strength Low failed PCF 60 l/min airway secretions >2.5 ml/h increased the risk white card test (WCT) Negative WCT predicted EF
  24. 24. Assessing Airway Patency Cuff leak test 38% patients with absence of leak, required reintubation. reproducible and objective. Miller and Cole volume of <110 ml, predicted a stridor. Jaber and colleagues 12% of expired tidal volume De Bast and colleagues 15.5% expired tidal volume.
  25. 25. Laryngeal ultrasound Ding and colleagues air-column width lower = post extubation stridor. noninvasive reliable method skilled expert
  26. 26. Assessing Hemodynamics and Tissue Perfusion SBT as cardiovascular stress test. increase cardiac output increase O2 extraction. Grasso and colleagues acute LV dysfunction with failed weaning. Gastric mucosal CO2 • intramucosal pH • increase in Gastric - arterial CO2 difference (∆Pg-aCO2) beyond 10 mmHg indicates inadequate splanchnic blood flow.
  27. 27. Fluid balance positive fluid balance in 24 h preceeding extubation need reintubation • cardiovascular insufficiency with pulmonary edema
  28. 28. Management of EF
  29. 29. Management of Failed Extubation continued ventilation treatment of causes muscle weakness excessive secretions cardiac diuretics and vasodilators daily assessment for readiness to extubate non-invasive ventilation prophylactic steroids. Tracheostomy
  30. 30. Treatment of extubation failure Laryngospasm epinephrine cardiac ischemia and heart failure Diuretics nitrates Stridor helium–oxygen specific
  31. 31. Non- invasive ventilation (NIV) may avert reintubation studies -mixed results Nava and colleagues NIV reduced reintubation Ferrer and colleagues useful hypercapnea COPD chronic respiratory disorders not in general ICU population
  32. 32. Extubation failure upper airway edema stridor. recent double blinded trial Prophylactic methylprednisolone laryngeal edema from 22 to 3%)
  33. 33. Role of steroids prolonged intubation laryngeal edema. quantitative cuff leak test If positive prophylactic methylprednisolone to prevent reintubation. Methylprednisolone 4 (20 mg) doses starting 12 h before extubation at 4h intervals
  34. 34. Home Takeaway
  35. 35. Conclusion Extubation failure morbidity, costs mortality. success mentation Neuro-muscle airway secretions cardiovascular predictors alert intervene early

    Be the first to comment

    Login to see the comments

  • mikaaweke

    Aug. 13, 2018
  • dammikamadhusankha

    Dec. 14, 2018
  • SravaniJeeva

    Feb. 20, 2019
  • BGaneshReddy

    Mar. 28, 2019
  • PalakBhatia14

    Oct. 28, 2019
  • WiamWelly

    Aug. 25, 2020
  • drblgupta

    Oct. 15, 2020
  • naik4naik

    Nov. 3, 2020
  • SaranyaMurugesan13

    Apr. 5, 2021
  • AnanthanarayananPish

    Jun. 24, 2021

ICU

Views

Total views

2,670

On Slideshare

0

From embeds

0

Number of embeds

16

Actions

Downloads

0

Shares

0

Comments

0

Likes

10

×