1. Know the definition of extubation. - The process of removing an artificial tracheal airway 2. Know the indications of extubation.

- When the airway control afforded by the endotracheal tube is no longer necessary - Patient should be capable of maintaining a patent airway and adequate spontaneous ventilation and should not require high levels of positive airway pressure - The endotracheal tube should be removed in an environment in which the patient can be monitored and in which the equipment and personnel trained in airway management 3. Know the contraindications and hazards/complications of extubation. - Contraindications No absolute contraindications - Hazards/complications Hypoxemia hypercapnia 4. Know how to assess the patients readiness for extubation. - If the patient no longer needs an artificial airway then they must be assessed to determine if extubation will be successful. This includes: The risk for upper airway obstruction after extubation The level of protection against aspiration The ability of the patient to clear secretions, once extubated 5. Know the practical guidelines for the patients readiness for extubation. - Criterion - Description 6. What is the first Criterion for readiness of extubation? 1. Criterion - No immediate need for mechanical ventilation or intubation Description - Patients medical course does not suggest impending respiratory failure or need for mechanical ventilation; procedures requiring intubation and general anesthesia are not immediately planned Measure - Weaning parameters Criterion - Adequate oxygenation and ventilation can be achieved with spontaneous ventilation Description - Patients oxygen requirements can be achieved by mask or cannula; patient no longer needs mechanical ventilatory assistance Measure - PaO2 >60mmHg or SaO2 >90% on 50% or less oxygen; PEEP, CPAP not required 7. What is the second Criterion for readiness of extubation? 2. Criterion - Minimal risk for upper airway obstruction

Description - Patient has minimal upper airway edema and no encroachment of the oropharynx or upper airway Measure - Positive cuff-leak test - Laryngoscopy 8. What is the third Criterion for readiness of extubation? 3. Criterion - Minimal risk for upper airway obstruction Description - Patient has minimal upper airway edema and no encroachment of the oropharynx or upper airway Measure - Positive cuff-leak test - Laryngoscopy 9. What is the fourth Criterion for readiness of extubation? 4. Criterion - Adequate airway protection and minimal risk for aspiration Description - Patients level of consciousness and neuromuscular function is adequate to protect lower airway Measure - Positive gag reflex - Patient can hold head up off the bed 10. What is the fifth Criterion for readiness of extubation? 5. Criterion - Adequate clearance of pulmonary secretions Descriptions - Patients level of consciousness and muscle strength allow for effective cough Measure - Patient alert, with deep cough on suctioning - Peak cough flow >160 L/min - Maximum expiratory pressure >60 cm H2O pressure 11. Know the examples of the weaning criteria for extubation and their values. - The capacity to maintain adequate arterial oxygenation - The capacity to maintain appropriate pH and pCO2 during spontaneous ventilation - Adequate respiratory muscle strenght - Maximum negative inspiratory pressure >30 cm H2O - Vital capacity >10 mL/kg ideal body weight - In adults, respiratory rate <35/min during spontaneous breathing - In adults, a rapid shallow breathing index of <98-130 - Normal consciousness - Adequate airway protective reflexes - Easily managed secretions

12. Know the cuff leak test. - It is a test designed to help predict the occurrence of glottis edema and/or stridor after extubation 13. How do you perform cuff leak test? - For the spontaneously breathing patient, you totally deflate the tube cuff and then completely occlude the endotracheal tube The presence of a peritubular leak during spontaneous breathing indicates no encroachment of the airway and a positive test. A negative test is one where no peritubular leak is noted during breathing. This indicates a high potential for post extubation obstruction. - With positive-pressure ventilation, a peritubular leak is assessed during ventilation the same as with spontaneous ventilation. 14. What are the proper steps for extubation? - Step 1: Verify physicians order or protocol. Assess patient and establish readiness for extubation. - Step 2: Assemble needed equipment -This includes: suctioning apparatus suction kits oxygen and /or aerosol therapy equipment manual resuscitator and mask aerosol nebulizer with racemic epinephrine and normal saline scissors 10 ml syringe, an intubation tray - Step 3: Wash your hands and apply standard precautions. - Step 4: Place the patient in the High Fowlers position. - Step 5: Suction the Endotracheal tube and pharynx to above the cuff. Suctioning prior to extubation helps prevent aspiration of secretions after cuff deflation. Use the closed suction catheter to suction the tube. Use a suction kit to suction above the cuff. Prepare a Yankauer suction to be used after extubation, most patients cough after the tube is pulled and may need assistance - Step 6: Oxygenate the Patient after suctioning Extubation is a stressful procedure that can cause hypoxemia and unwanted cardiovascular side effects. Give 100% oxygen for 1 to 2 minutes to help avoid these problems. - Step 7: Remove the tape or securing device. Remove by cutting the tape, away from the patients face - Step 8: Deflate the Cuff. Slowly remove all of the air possible with a 20 ml syringe. Some practitioners cut the valve off the pilot tube to ensure that any remaining air may escape. - Step 9: Remove the tube. To remove the tube, there are two main techniques: The first method is to assist the patient in taking a large breath with the manual

resuscitator and remove the tube at peak inspiration. This is when the cords are maximally abducted. The second method is to have the patient cough, the pull the tube during the expulsive expiratory phase, maximum abduction - Step 10: Apply appropriate oxygen and humidity therapy. Patients who have been receiving mechanical ventilation may still require some oxygen therapy, usually at a higher FIO2. A cool aerosol is indicated post extubation to decrease swelling. NOTE: Heated mist may only increase swelling that normally occurs after extubation. - Step 11: Assess/Reassess the Patient. Check for good air movement by auscultation. Stridor or decreased air movement after extubation indicates upper airway problems. Also assess the patients respiratory rate, heart rate, color, blood pressure, and SpO2. Mild hypertension and tachycardia immediately after extubation are common and resolve spontaneously in most cases. Encourage the patient to cough, with assistance as needed. Sample and analyze arterial blood gas values as needed. Monitor for laryngospasm. If it occurs, apply bag mask ventilation with 100% oxygen. If the spasm persists, a neuromuscular blocking agent may have to be given, which will necessitate manual ventilation and/or reintubation. If stridor due to glottic edema is noted a racemic epinephrine treatment may be needed. Vocal cords during intubation have had limited function, they may not fully close at this time. To avoid aspiration, oral feeding, except sips of cool water or ice chips, should be withheld for 24 hours after extubation. - Step 12: Chart the procedure and all that was noted or done. Date and Time Pre-assessment parameters- breath sounds, Heart rate, respiratory rate, blood pressure, SpO2, skin color. Post assessment parameters Any complications or hazards that occurred Oxygen requirements and oxygen device 15. Be familiar with the equipment needed to perform extubation. - This includes: suctioning apparatus suction kits oxygen and /or aerosol therapy equipment manual resuscitator and mask aerosol nebulizer with racemic epinephrine and normal saline scissors 10 ml syringe, an intubation tray 16. Know the importance of suctioning prior to extubation. - Suctioning prior to extubation helps prevent aspiration of secretions after cuff deflation.

17. Know the importance of use of a cool aerosol post extubation. - A cool aerosol is indicated post extubation to decrease swelling. - NOTE: Heated mist may only increase swelling that normally occurs after extubation 18. Know how to assess/reassess the patient following extubation. - Check for good air movement by auscultation. Stridor or decreased air movement after extubation indicates upper airway problems. - Also assess the patients respiratory rate, heart rate, color, blood pressure, and SpO2. Mild hypertension and tachycardia immediately after extubation are common and resolve spontaneously in most cases. Encourage the patient to cough, with assistance as needed. Sample and analyze arterial blood gas values as needed. Monitor for laryngospasm. If it occurs, apply bag mask ventilation with 100% oxygen. If the spasm persists, a neuromuscular blocking agent may have to be given, which will necessitate manual ventilation and/or reintubation. If stridor due to glottic edema is noted a racemic epinephrine treatment may be needed. Vocal cords during intubation have had limited function, they may not fully close at this time. To avoid aspiration, oral feeding, except sips of cool water or ice chips, should be withheld for 24 hours after extubation 19. Know how to treat post extubation stridor. - If stridor due to glottic edema is noted a racemic epinephrine treatment may be needed 20. Know what parameters need to be charted following the procedure. - Date and Time - Pre-assessment parameters- breath sounds, Heart rate, respiratory rate, blood pressure, SpO2, skin color. - Post assessment parameters - Any complications or hazards that occurred - Oxygen requirements and oxygen device. 21. Crit Thinking 3. You are called to the surgical ICU to assess Mrs. King, who had open heart surgery and is 20 hours postop. Describe how you would assess her readiness for extubation. - Assess mental status, current vent settings, vitals, ECG, Pulse oximetry, vital capacity, Max Inspiratory Pressure, Hemodynamic instability