STRUCTURE STANDARD:

P10 EXTUBATION

STANDARD STATEMENT: DEFINITION: Extubation refers to the removal of an endotracheal tube once a patient has been successfully weaned from artificial ventilation and the patient has regained his/her ability to maintain his/her own airway. OBJECTIVES: Smooth, atraumatic extubation Stable respiratory status.

EQUIPMENT: Personal protective equipment. Yankhauer catheter. Sterile suction catheter. Functional source of suction and suction tubing. Stethoscope. 10ml syringe. Bag-valve-mask device connected to 100% oxygen. Supplemental oxygen and face mask. Emergency trolley with intubation equipment. Scissors

PROCESS STANDARD 1. 2. ACTION Confirm medical prescription for Extubation Confirm patient readiness for extubation: The required level of consciousness has been achieved Respiratory rate is 25 breaths per minute Absence of dyspnoea RATIONALE Legal requirement. Extubation cannot be performed if the patient is not able to maintain independent breathing and airway patency.

Spontaneous tidal volume > 5 ml/kg. Minute ventilation 10 l/min FiO2 .5 PEEP 5 cmH2O pH in normal range Pa CO2 in normal range. Stable heart rate and rhythm Stable blood pressure. Patient is able to cough out secretions Explain the procedure to the patient. Wash hands and don personal protective gear. Perform endotracheal suction and mouth care (See structure standards 7) Aspirate nasogastric tube Position patient in the Fowler's Position

3. 4. 5. 6. 7.

To reduce patient and family anxiety and to facilitate patient cooperation. Reduces the transmission of micro organisms and body secretions. Standard precaution. To clear the airway and pharynx of secretions which could cause pulmonary infection. To prevent aspiration Respiratory muscles are more effective in an upright position. The Fowler's position also facilitates coughing and minimizes the risk of vomiting and consequent aspiration To free the tube. Prepares for cuff deflation. To promote hyperinflation.

8. 9. 10. 11.

Remove the securing device from around the endotracheal tube. Insert syringe into valve in pilot balloon. Instruct patient to take a deep breath or hyperinflate for a patient with a bag-valvemask At the peak of a deep inspiration, deflate the cuff and remove the tube in one smooth motion on expiration.

Assists in a smooth, quick, less traumatic removal. Vocal cords are maximally abducted at peak inspiration. Initial cough response expected following extubation should be more forceful if started from maximal inspiration versus expiration. An alternative method to facilitate removal of secretions include application of suction

ACTION

RATIONALE while cuff is deflated and tube is removed.

This is done by insertion of a suction catheter 5cm below the distal end of the tube and application of suction while the tube is deflated and removed.

12.

Instruct patient to deep breath and cough.

Promotes hyperinflation Promotes secretion removal. Confirms an intact recurrent laryngeal nerve Removes secretions. Promotes warmth and moisture. Prevents oxygen desaturation. Cool humidification is usually preferred to help minimize upper airway swelling.

13. 14.

Suction the pharynx Apply humidified supplemental oxygen.

15.

Monitor vital signs, respiratory status and oxygenation status immediately after extubation and thereafter as per institutional policy.

Change in vital signs and oxygenation status following extubation may indicate respiratory compromise, necessitating reintubation. The following should be reported if they persist despite nursing interventions: Tachycardia

Tachypnea and dyspnea Bradypnea Elevated blood pressure

16.

Monitor for aspiration due to pooled secretions.

17. 18.

Encourage coughing and deep breathing. Assess swallowing ability.

SpO2 of 90% Stridor Failure to suction or ineffective suctioning of the pharynx allows accumulated secretions to further advance into the trachea on cuff deflation. Prevents atelectasis and secretion accumulation. Presence of tube over extended periods may result in impaired swallowing evidenced by inability to swallow without coughing.

DOCUMENTATION Documentation should include the following: Respiratory and vital signs assessment before and after procedure. Date and time of procedure. Unexpected outcomes and nursing interventions taken.

SOURCE 1. AACN Procedure Manual for Critical Care: Fourth Edition: 2001, W.B. Saunders Company.

Compiled by Date Date reviewed Review date

: : : :

MRS G. MEYER APRIL 2005 APRIL 2007 VALIDATION INSTRUMENT

NAME HOSPITAL UNIT ASSESSOR DATE MARK

: : : : : : ENDOTRACHEAL EXTUBATION.

Criteria marked F are critical criteria. If a staff member fails these criteria, he/she fails this assessment. One mark is allocated if staff member is compliant. No mark is allocated if staff member is non-compliant. A minimum of 80% is needed to pass this evaluation. C = Compliant NC = Non compliant N/A = Not applicable COGNITIVE The learner: C Discusses the clinical prerequisites that must be present in the patient to ensure safe extubation. Identifies the complications of extubation. PSYCHOMOTOR The learner: C Confirms the medical prescription for extubation Confirms the patient readiness for extubation Washes hands and dons protective gear Performs endotracheal suctioning and mouth care Aspirates nasogastric tube Positions patient in Fowler's position Removes the securing device from around the endotracheal tube Inserts syringe into valve of pilot balloon Instructs patient to take a deep breath OR hyperinflates lungs with a bag-valvemask NC F F F F N/A NC N/A

C Deflates the cuff at the peak of inspiration Removes tube with a smooth motion during expiration Instructs patient to take a deep breath and cough Suctions the pharynx Applies humidified oxygen to patient Assesses vital signs, respiratory status and oxygenation status of patient. Monitors the patient for aspiration Encourages deep breathing and coughing Assesses the patient's swallowing ability

NC F F F F F F F

N/A

AFFECTIVE: The learner: C Explains the procedure to the patient NC N/A

Mark:

/ 21

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