Extubation failure
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Extubation failure is defined as the need for reintubation within 24-72 hours after removal of an endotracheal or tracheostomy tube. Predictors of extubation failure include respiratory mechanics measures like rapid shallow breathing index and airway occlusion pressure. Other predictors are neurologic impairment, weak cough strength, excessive secretions, positive fluid balance, and acute cardiac dysfunction. Management of extubation failure involves treating the underlying causes, continued ventilation, non-invasive ventilation, diuretics, and prophylactic steroids to prevent laryngeal edema. Extubation success relies on careful assessment of neuro-muscular, respiratory, airway, and cardiovascular status to identify patients at risk and intervene early.
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Extubation failure
- 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
- 3. Weaning Outcome •More than 3 trials •More than 7 days •Passed first trial •70 % •Up to 3 trials •Up to 7 days needed
- 4. 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.
- 7. OUTCOMERA
- 8. Why? increased mortality Age sicker Comorbid dialysis reintubation. life- threatening events during • cardiac arrhythmias • cardiac arrest, • esophageal intubation, • endobronchial intubation, • aspiration failed extubation
- 9. Extubation Failure ? respiratory failure The most common cause • increased work of breathing, accessory muscle use • hypoxia • hypercapnea • respiratory acidosis. Why
- 11. Mortality for patients reintubated for upper airway obstruction 7% respiratory failure 30% not different in trauma patients Esteban and colleagues
- 12. 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
- 13. 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?
- 14. Several studies Delayed reintubation > 12-24 h
- 16. Respiratory Mechanics • f/ VT (50 ± 23) • successful extubation. • cut off RSBI ≥ 57 Rapid shallow breathing index (RSBI - f/VT )
- 17. 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.
- 18. Minute ventilation recovery time (VERT) respiratory muscle reserve
- 19. 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
- 20. 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
- 21. RT 50% ∆VE Hernandez and colleagues 7 minutes discriminate failures and successes.
- 22. (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.
- 23. 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
- 24. higher GCS score = successful extubation GCS ≥ 8 showed highest predictive accuracy GCS ≥ 10 for successful extubation
- 25. 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
- 26. 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.
- 27. Laryngeal ultrasound Ding and colleagues air-column width lower = post extubation stridor. noninvasive reliable method skilled expert
- 28. 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.
- 29. Fluid balance positive fluid balance in 24 h preceeding extubation need reintubation • cardiovascular insufficiency with pulmonary edema
- 30. Management of EF
- 31. 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
- 32. Treatment of extubation failure Laryngospasm epinephrine cardiac ischemia and heart failure Diuretics nitrates Stridor helium–oxygen specific
- 33. 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
- 35. Extubation failure upper airway edema stridor. recent double blinded trial Prophylactic methylprednisolone laryngeal edema from 22 to 3%)
- 36. 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
- 37. Home Takeaway
Editor's Notes
- An RSBI score of less than 65[3] indicating a relatively low respiratory rate compared to tidal volume is generally considered as an indication of weaning readiness. A patient with a rapid shallow breathing index (RSBI) of less than 105 has an approximately 80% chance of being successfully extubated, whereas an RSBI of greater than 105 virtually guarantees weaning failure
- Patients tolerating a spontaneous breathing trial (SBT) and ready for planned extubation were placed back on their pre-SBT ventilator settings for up to 25 min, during which respiratory parameters were recorded. Respiratory parameters (respiratory rate, tidal volume, E, rapid shallow breathing index [f/VT]) were obtained at three time points: baseline (pre-SBT), posttrial (immediate conclusion of SBT), and recovery (return to baseline). Patients were assumed to recover when E decreased to 110% of the predetermined baseline.
- Methylprednisolone 20 mg IV (intravenous) starting 12 hours before planned extubation (methylprednisolone), total of four doses. Methylprednisolone 40 mg IV single dose 4 hours before extubation (Methylprednisolone 40 mg). Dexamethasone 4 mg IV every 8 hourly for 24 hours (Dexamethasone). Hydrocortisone 100 mg IV single dose 4 hours before extubation (Hydrocortisone).