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Post-Extubation Emergencies

Post-extubation emergencies can pose significant risks in critically ill patients. Key factors for successful extubation include the resolution of the initial intubation causes, evidence of spontaneous breathing, adequate arterial blood gases (ABGs), and stable hemodynamics. Understanding potential complications such as laryngospasm, laryngeal stridor, and acute hypoxemia is essential. Appropriate assessment and preparedness are critical for managing these emergencies effectively, ensuring patient safety during mechanical ventilation transitions. Assessments should include cognitive function, secretions management, and predicting risks.

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Post-Extubation Emergencies

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  1. Post-Extubation Emergencies

  2. OH SH..!

  3. Discontinuing Mechanical Ventilation • Resolution of the process that caused the intubation. • Spontaneous breathing ability with adequate ABG’s and Hemodynamics

  4. 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”

  5. Extubation Criteria • Hardware Issues • NG/OG tubes • Wired jaw • Cervical fixation devices

  6. The Top Five • Laryngospasm • Laryngeal Stridor • Acute Hypoxemia • Acute Respiratory Failure • Neurologic pathology

  7. Laryngospasm • Definition: The vocal folds spontaneously closing and staying closed. • Presents as NO air movement and patient in a panic (conscience or not)

  8. Laryngospasm • Causes: • Hysteria • Mechanical • Chemical • Can you predict it? • Extubating with Positive pressure

  9. Laryngospasm • How do you treat it? • Wait • Sedation

  10. 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 post-extubation stridor in patients with mechanical ventilation” J Exp Med. 2005 Oct;207(2)125-32.

  11. Laryngeal Stridor • Is it stridor or obstruction? • Jaw Thrust/Sniff position • Secretion clearance • How do you treat the obstruction? • Nasal/oral airways • Mask CPAP

  12. Laryngeal Stridor • Is it stridor or obstruction? • Jaw Thrust/Sniff position • Secretion clearance • How do you treat the obstruction? • Nasal/oral airways • Mask CPAP

  13. Laryngeal Stridor • How can you treat? • Racemic epinephrine/ bronchodilators • .5cc/2ccNS • Heliox • 80/20 mixture • Max. FiO2 .35 • Sedation

  14. Acute Hypoxemia • Definition: Sudden decrease of oxygen in the blood. • Can you predict it?

  15. 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

  16. Acute Ventilatory Failure • Definition: An inability for the patient to ventilate to maintain a normal pH (7.35-7.45) • Presents itself by: • Increased RR • Increased WOB • Decreased SaO2

  17. 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

  18. Neurologic Pathology • ALS • Traumatic Brain Injury • MS, Guillian Barre, Tetraplegia • Critical Illness neuromyopathy

  19. Post-Extubation Emergencies • The inability to reliably predict • The Top Five • How to treat

  20. BE PREPARED • Do not treat extubations as routine • Assess, Assess, Assess • Have Difficult Intubation Supply easily available in unit • Don’t Panic

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