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Airway - Extubation (non-palliative)

This procedure is rarely performed in the emergency department, and not considered standard practice

Indications

Emergency department extubation may be considered if the following criteria are all present

No more appropriate alterative available (extubation in ICU)

One to one nursing and experienced airway provider available during and post procedure

Resolution of clinical issue requiring intubation

Brief intubation time (a few hours)

Contraindications (absolute in bold)

Airway

Known difficult intubation

Risk of airway deterioration

Breathing

Inadequate spontaneous ventilation (sats <95% or RR >30, FiO2 40% and PEEP 5cm H2O)

Secretions requiring suction more often than every two hours

Circulation

Haemodynamic compromise (SBP <100mmHg, HR>120, arrhythmia)

Vasopressors running

Acidosis or abnormal electrolytes

Disability

Reduced GCS and unable to follow commands (lift arms for 15 seconds)

Sedation or neuromuscular blockade

Uncontrolled pain

Others

Insufficient staffing levels or experience

Alternatives

Transfer of intubated patient (to ICU or alternative hospital)

Informed consent

Medical emergency

Consent is not required

Potential complications

Respiratory failure requiring re-intubation (10%)

Respiratory failure requiring temporary non-invasive ventilation

Aspiration

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, apron, surgical mask, protective eyewear or face shield

Area

Resuscitation bay with:

Continuous pulse oximetry

ECG monitoring

Blood pressure recordings 3-5 minutely

Wave form capnography

Staff

Minimum three – one clinician must remain a dedicated airway monitor throughout procedure

Procedural clinician with airway skills

Airway nurse

Assistant

Equipment

Suction

Oxygen via non-rebreathe mask

BVM and airway equipment

2x IV access with 1l crystalloid primed on pump set

Positioning

Supine, 30 degrees head up

Medication

Fentanyl 50mcg/hour after sedation discontinued

Sequence (preparation)

Turn off sedatives

Fentanyl continues at 50mcg/hour (for pain relief and tube tolerance)

Allow patient to regain full mental status

Sequence (testing for readiness)

Sit patient up to at least 45 degrees

Patient should be able to understand respond to commands

Ask patient to raise arm and leave in air for 15 seconds

Ask patient to raise their head off the bed

Ask patient to cough (they should be able to generate a strong cough)

Place on pressure support (PEEP) 5cm H20 without additional assistance

Observe for 15-30 minutes confirming no contraindications

Sequence (extubation)

Have nebuliser filled with saline attached to a mask

Sit patient up to at least 45 degrees

Suction ETT with bronchial suction catheter

Suction oropharynx with Yankeur suction

Instruct patient to take a deep breath and then exhale

During exhalation, deflate cuff and remove ETT in a single, smooth motion

Suction the oropharynx again

Encourage the patient to keep coughing up any secretions

Place saline nebuliser on patient with oxygen at 4-6 l/min

Post-procedure care

Monitor in resuscitation bay with one to one nursing for at least 60 minutes

If patient develops respiratory distress apply high flow nasal prongs or non-invasive ventilation

If patient continues to have respiratory distress, consider re-intubation

Tips

This procedure is generally avoided in the emergency department

It is better conducted in an ICU by clinicians experienced in regular extubation

Aggressive oxygenation and airway clearance can prevent re-intubation

Discussion

Extubation is a high-risk procedure conducted with full preparation for re-intubation in case of failure.

This procedure would typically only be performed without ICU capacity for the patient. This procedure is rarely performed in the emergency department by doctors or nurses and is labour intensive, requiring one to one monitoring. Consider requesting additional staffing and support from the ICU medical and nursing team if required.

Cuff leak tests display limited diagnostic performance for the detection of post-intubation stridor and are not required in the emergency department as the cohort meeting the criteria above are low risk for this complication.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Difficult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, et al. Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia. 2012;67(3):318‐340. doi:10.1111/j.1365-2044.2012.07075.x

El-Khatib MF, Bou-Khalil P. Clinical review: liberation from mechanical ventilation. Crit Care. 2008;12(4):221. doi:10.1186/cc6959

Cavallone LF, Vannucci A. Review article: Extubation of the difficult airway and extubation failure. Anesth Analg. 2013;116(2):368‐383. doi:10.1213/ANE.0b013e31827ab572

Artime CA, Hagberg CA. Tracheal extubation. Respir Care. 2014;59(6):991‐1005. doi:10.4187/respcare.02926

Schnell D, Planquette B, Berger A, et al. Cuff leak test for the diagnosis of post-extubation stridor: a multicenter evaluation study. J Intensive Care Med. 2019;34(5):391‐396. doi:10.1177/0885066617700095

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Weingart SD, Menaker J, Truong H, et al. Trauma patients can be safely extubated in the emergency department. J Emerg Med. 2011;40(2):235‐239. doi:10.1016/j.jemermed.2009.05.033

Hyzy RC. Extubation management in the adult intensive care unit. In: UpToDate. Waltham (MA): UpToDate. 2019 Oct 12. Retrieved June 2019. Available from: https://www.uptodate.com/contents/extubation-management-in-the-adult-intensive-care-unit

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