Proper method of extubation with adequate reversal

1. Extubation

2. Weaning : is the transition from ventilatory support
to completely spontaneous breathing .
SBT : spontaneous breathing trial is a period of
breathing without ventilatory assistance or with
minimal ventilatory support ( on CPAP or low level
of pressure support )
Extubation is the removal of the artificial airway .
Extubation can be of two types :
- Planned extubation
- Unplanned extubation

3. Planned extubation
Removal of the ET tube or any artificial airway by the clinician.
Criteria for extubation :
◦ Hemodynamically stable : no dysarrythmias , minimal inotrope requirements, optimal fluid balance
◦ Adequate ventilation & oxygenation :
- spO2 > 92 percent - vital capacity > 10 ml / kg
- tidal volume > 5 ml/ kg - respiratory rate < 25bpm
◦ Arterial blood gas :
-pH is normal - pCO2 < 60 mmHg
- pO2 > 60 mmHg on FIO2 of 0.4 and PEEP 5
◦ Full Reversal of Muscle relaxation:
- TOF > 0.9 - sustained 5 second head lift Or hand grasp
◦ Neurologically intact : awake , follows verbal commands & intact gag / cough reflex

4. SAD REMOVAL
◦ Should be left in place until the patient has recovered full ventilatory
capacity & regained consciousness.
◦ At the point of return of consciousness, airway reflexes are also recovering &
patient will normally protect their own airway.
◦ A better way to asses consciousness is to see the response to voice , making
spontaneous movements towards the SAD or following commands .
◦ Suction should be used to clear the oropharynx of secretions , the patient
should be asked to open the mouth and the SAD should be removed .
◦ The need to deflate cuff varies with SAD but as for LMAs , retaining some air
in the cuff will assist in clearing secretions .
◦ After removing the SAD , O2 should be administered by mask or nasal
canulae & respiration should be monitored.

5. TRACHEAL TUBE REMOVAL
◦ TRACHEAL TUBE maybe removed when :
- patient is unconscious. - patient is awake
◦ Deep tracheal extubation is a higher risk procedure & should
be reserved for very low risk patients.
◦ Awake tracheal extubation is generally preferred unless the
stimulus will have a negative impact on the patient’s
physiology.

7. ‘ At risk ‘ for Extubation
◦ Patients who had problems at induction or intubation.
◦ Blood in the airway from surgical or anesthetic causes .
◦ Patients who may have airway edema from anaesthetic or surgical
interventions.
◦ Obese patients particularly those with OSA
◦ Intraoral / airway Surgery

9. Special procedures
◦ These are non – routine actions at tracheal extubation performed to improve the
safety of extubation & to facilitate re – intubation if necessary. Certain examples
are :
- Insertion of a cricothyroid needle or AEC ( Airway exchange catheter ) before
extubation
- exchange of the tracheal tube for a SAD immediately before or after tracheal
extubation ( Bailey’s manoeuver )
- tracheal extubation followed by CPAP or high flow nasal oxygen

10. COMPLICATIONS
A. Immediately after extubation:
1.Aspiration / regurgitation : are increased in all
patients at high risk & by airway removal in the
light plane of anaesthesia before full
wakefulness . If a nasogastric tube is present ,
this should be auctioned before airway
removal.

11. 2. Laryngeal spasm / Bronchospasm / coughing : are all
likely to occur in those with an irritable airway eg :
smokers, patients with asthma , patients with current or
recent respiratory tract infection. Laryngospasm occurs as
a result of extubation when the patient is semiconscious .
Extubation during this excitement stage tends to stimulate
the vocal cords & lead to reflex protective spasm. For this
reason extubation should be done when patient is either
deeply anaesthesised or fully awake. In worst scenario
airway obstruction occur and reintubation is needed.

12. 3. Hoarseness
4. Laryngeal or subglottic edema :
stridor is seen .
Cuff leak test : Done to asses laryngeal swelling & is
very much dependent on the size of tracheal tube
used , in this test the tracheal tube cuff is deflated
and postive pressure is applied while listening for
an audible leak around the trachea . For this we can
use a cool aerosol & 0.25 – 0.5 ml of 2- 2.5 percent
racemic epinephrine in 5 ml of saline may be helpful.
Dexamethasone at 0.15 mg /kg may help prevent
worsening of edema .

13. B. Following extubation:
1. Mucosal injuries
2. Laryngeal stenosis
3. Tracheal inflammation, dilation, stenosis
4. Vocal cord paralysis

14. Neostigmine
◦ Appropriate neostigmine reversal is defined as “neostigmine ≤60 μg/kg given at a TOF
count of ≥2”
◦ It does require the simultaneous use of an anticholinergic agent such as glycopyrrolate
or atropine to prevent its muscarinic effects including bradycardia, bronchospasm, and
increased intestinal motility.
◦ It is only efficacious if :
- recovery from neuromuscular block has commenced: at least two twitches of the train-
of-four (TOF) response should be detectable before it is given.
- It also takes at least 8 min to have its maximum effect
- Neostigmine has a ceiling effect: increasing its dose does not necessarily increase its
efficacy, which is a limitation of its use.
◦ It may also cause depolarising block if given in excess. It is excreted in the urine and
hence has a prolonged muscarinic effect in patients with renal insufficiency.
◦ Allergic reaction to neostigmine is very rare.

15. RESIDUAL NEUROMUSCULAR BLOCK
◦ Inadequate recovery from neuromuscular block with a TOFR less
than 0.9 in the postoperative recovery room occurs in up to 45% of
patients receiving neuromuscular blocking drugs during
anaesthesia.
◦ There is increasing evidence of an association between inadequate
recovery from neuromuscular block and respiratory complications
in the immediate recovery period, such as : arterial desaturation,
obstruction of the upper airway, need for reintubation, and
pulmonary aspiration.

16. Clinical features :
◦ Inability to perform a :
head lift, hand grip, eye opening, or tongue protrusion; inability to clench a
tongue depressor between the incisor teeth; inability to smile, swallow,
speak, cough, track objects with eyes
◦ Blurry vision, diplopia, facial weakness, facial numbness, and general
weakness.

17. ◦ Impaired hypoxic respiratory drive and even unexpected
admission to the ICU may also ensue.
◦ Recovery from neuromuscular block should always be
monitored at the end of anaesthesia using a quantitative
monitor that gives a recording of the TOFR.
◦ Full recovery of the TOFR to more than 0.9 at tracheal
extubation is less common after neostigmine than after
sugammadex. This results in fewer immediate respiratory
complications if sugammadex is used.

18. EXTUBATION IN ICU
◦ Extubation is decided after a weaning readiness test is a formal trial of
spontaneous breathing to evaluate readiness for discontinuation of the
endotracheal tube and /or ventilatory support . This is evaluated on a CPAP or
T – piece .
◦ Others :
- sedating agents must be stopped for > 24 hours
- causative condition resolved / under control
- paralysing agents stopped > 24 hours
- normal metabolic status . Electrolytes balance must be normal.
- patient must be neurologically intact.
- take into consideration of aspiration risk & airway edema..

19. EXTUBATION FAILURE
◦ It is defined as the need for reinstitution of ventilatory support within 24 – 72
hours of planned endotracheal tube removal, occurs in 2 – 25 percent of
extubated patients.
◦ Occurs due to imbalance between respiratory muscle capacity & work of
breathing, upper airway obstruction, excess respiratory secretions, inadequate
cough , encephalopathy & cardiac dysfunction.
◦ Risk factors :
- Age > 70 years. - longer duration of mechanical ventilation
- continuous IV sedation. - anemia
◦ Preventive measures are :
- non – invasive ventilation after extubation in high risk or hypercapnic patients
.
- steroid administration several hours before extubation.

20. UNPLANNED EXTUBATION
◦ Deliberate or accidental removal of the ET tube by the patient.
◦ Inadvertent extubation occurs in 8 – 10 percent of all extubation in ICU
patients.
◦ About 50 percent do not need a reintubation.
◦ Whether or not to reintubate the patient can be a difficult decision.
◦ Delayed reintubation may lead to :
- hypoventilation - hypoxemia - hypoxia
◦ In general decision to reintubate depends on clinical observations & criteria for
Extubation :
- rapid shallow breathing index ( RSBI )
- blood gases - ventilatory reserve - general cardiopulmonary signs

21. EXTUBATION IN CHILDREN

24. Awake extubation is considered in :
◦ Difficult mask ventilation
◦ Difficult tracheal intubation
◦ High risk of difficult reintubation
◦ Case of high risk of aspiration
◦ Patients at risk for inadequate ventilation once extubated like :
- infants with prematurity or small size ( < 2 kg )
- obese patients
- patients with sleep disoriented breathing

27. Intubation is a skill but extubation is an
art....
Thank you