Extubation Assessment: Hot Case
GENERAL APPROACH
Cases
- post-operative surgical patient
- resolved respiratory failure
- head and neck surgical patients
- intra-oral sepsis (Ludwig’s angina)
- angioedemia
- upper airway burns
Approach
- Ensure criteria for successful weaning met
- Original condition requiring intubation (resolved?)
- Focal, systemic and logistic barriers?
- Airway
- Breathing (Respiratory function) – ventilation parameters including ABG and CXR
- Cardiovascular function
- Neurological function
- Assessment of environment – time of day, level of airway skill in unit, planned procedures
INTRODUCTION
CUBICLE
INFUSIONS
- steroids for airway swelling
- sedation
- high levels of cardiovascular support
VENTILATOR
- type of ventilation (NIV, invasive, spontaneous breaths)
- settings (FiO2, PEEP, RR, PS)
- assess weaning strategy (T piece, flow by, gentle weaning of pressure support or RR)
- unassisted TV (>325 mL)
- rapid shallow breathing index (f/VT) – “if RSBI <105 then can extubate”
- vital capacity (>15L)
- MV (<15 L/min)
- maximum inspiratory pressure (< -15cmH2O = good)
MONITOR
- oxygen saturation (A-a gradient)
- haemodynamic stability
- temperature (ongoing sepsis)
EQUIPMENT
- intercostals drains (number, bubbling, drainage)
QUESTION SPECIFIC EXAMINATION
- airway (size ETT, Mallampati, TMD, Cormack and Lehane grade, previous tracheostomies, ask to perform cuff leak and occlusion tests)
- breathing
- circulation
- gastrointestinal (fasted, distension, diarrhoea, nutritional state)
- neurological -> unconscious -> conscious
- nutritional state
- temperature
- trend in fluid balance over last 48 hours
- back
Questions
- ask to perform direct or video laryngoscopy
- previous intubation grade
- fed or fasted?
- consider time of day
- airway skills available
- surgical planning
- previous failed extubation?
RELEVANT INVESTIGATIONS
- CXR
- ABG
OPENING STATEMENT
= Yes or No
- List reasons -> present clinical signs that prove reasons
DISCUSSION
- indices that predicat successful weaning
- indications for percutaneous tracheostomy
- management of post-extubation stridor
- management of difficult airway
- awake fiber-optic intubation technique
- management of upper airway burns
References and Links
- Foote C, Steel L, Vidhani K, Lister B, MacPartlin M, Blackwell N. Examination Intensive Care Medicine (2nd Edition), Elsevier 2011. [Google Books Preview]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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