Transcript Post-Extubation Emergencies

Post-Extubation
Emergencies
OH SH..!
Discontinuing Mechanical
Ventilation
Resolution of the process that caused the
intubation.
Spontaneous breathing ability with
adequate ABG’s and Hemodynamics
Extubation Criteria
Ability to Cough
MIF
VC /PEF
Cognitive
Secretions
Can there be too many?
“Salam et al, “Neurologic status, cough, secretions and extubation outcomes”
Intensive Care Medicine (2004) 30:1334-1339”
Extubation Criteria
Hardware Issues
NG/OG tubes
Wired jaw
Cervical fixation devices
The Top Five
Laryngospasm
Laryngeal Stridor
Acute Hypoxemia
Acute Respiratory Failure
Neurologic pathology
Laryngospasm
Definition: The vocal folds spontaneously
closing and staying closed.
Presents as NO air movement and patient
in a panic (conscience or not)
Laryngospasm
Causes:
Hysteria
Mechanical
Chemical
Can you predict it?
Extubating with Positive pressure
Laryngospasm
How do you treat it?
Wait
Sedation
Laryngeal Stridor
Definition: High pitched inspiratory noise that occurs
when vocal folds are swollen and close together allowing
little air to pass through.
Can you predict it?
Cuff leak test
– Volume leak
“Kriner et al, The Endotracheal Tube Cuff-Leak Test as a Predictor for Postextubation
Stridor, Respiratory Care 2005 Dec;50(12)1632-1638
– ETT occlusion
Risk populations
Men vs. Women
Obesity
“Erginel S. et al “High body mass index and long duration of intubation increase postextubation stridor in patients with mechanical ventilation” J Exp Med. 2005
Oct;207(2)125-32.
Laryngeal Stridor
Is it stridor or obstruction?
Jaw Thrust/Sniff position
Secretion clearance
How do you treat the obstruction?
Nasal/oral airways
Mask CPAP
Laryngeal Stridor
Is it stridor or obstruction?
Jaw Thrust/Sniff position
Secretion clearance
How do you treat the obstruction?
Nasal/oral airways
Mask CPAP
Laryngeal Stridor
How can you treat?
Racemic epinephrine/ bronchodilators
.5cc/2ccNS
Heliox
80/20 mixture
Max. FiO2 .35
Sedation
Acute Hypoxemia
Definition: Sudden decrease of oxygen in
the blood.
Can you predict it?
Acute Hypoxemia
Secretions/Mucous plug
Cough or need for NTS quickly
Pulmonary edema
Negative pressure pulmonary edema
Support with oxygen
Cardiac
Mask CPAP
Vomiting/Aspiration
Position pt on side
Need for oral and NT suction quickly
Support oxygenation
Acute Ventilatory Failure
Definition: An inability for the patient to
ventilate to maintain a normal pH (7.357.45)
Presents itself by:
Increased RR
Increased WOB
Decreased SaO2
Acute Ventilatory Failure
Can you predict it?
How do you treat?
NPPV
– COPD vs. Non-COPD
Esteban et al. “Noninvasive Positive-Pressure Ventilation for Respiratory Failure
after Extubation” N Engl J Med 2004;350:2452-60
Ferrer et al. “Early Noninvasive Ventilation Averts Extubation Failure in Patients at Risk”
AM J Respir Crit Care Med 2006;173:164-170
Sedation withdrawal
Re-intubate
Neurologic Pathology
ALS
Traumatic Brain Injury
MS, Guillian Barre, Tetraplegia
Critical Illness neuromyopathy
Post-Extubation Emergencies
The inability to reliably predict
The Top Five
How to treat
BE PREPARED
Do not treat extubations as routine
Assess, Assess, Assess
Have Difficult Intubation Supply easily
available in unit
Don’t Panic