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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

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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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