Extubation Criteria

J. Prince Neelankavil, M.D.

Case

71 y.o. male s/p laparascopic surgery

presents to the PACU intubated. Pt.
remained intubated secondary to
residual neuromuscular blockade
H/O HTN, DM
When should we extubate?

General Principles

Why was the patient intubated in the

first place? Inadequate
oxygenation/ventilation/airway
protection.
Patient should have adequate
respiratory drive, respiratory muscle
strength, cough reflex to clear
secretions, laryngeal function and
clearance of sedative and
neuromuscular blocking medications.

Adequate Gas Exchange?

Adequate arterial partial pressure

of oxygen: [PaO2/FIO2] ratio >
150-200
Appropriate pH (pH >7.25) and
arterial partial pressure of carbon
dioxide during spontaneous
ventilation

Pass a Breathing Trial?

30120 minute spontaneous

breathing trial with low level of
CPAP (e.g. 5 cm H2O) or low level
of pressure support (e.g. 5-7 cm
H2O)
Show gas exchange (ABG),
hemodynamic stability, and
subjective comfort

Pass These Numbers?

RR < 35
Vital capacity > than 10 mL/kg
NIF > -20
Tidal Volume > 5mL/kg
Minute ventilation < 10L/min
Thoracic compliance > 25 mL/cm
H 2O

Able to Protect Airway?

Appropriate level of consciousness

Adequate airway protective
reflexes (cough, swallow, vocal
cord movement)
Adequate managed secretions

All Systems Go?

Hemodynamic Stability (+/- 20%)

Nutritional status allowing for respiratory

muscle strength

Risk Factors for Failed

Extubation

ICU patient
Age > 70 or < 24 months
Hemoglobin <10 mg/dL
Longer duration of mechanical
ventilation
Medical or surgical airway condition
Frequent pulmonary toilet
Loss of airway protective reflexes

What do you need to

extubate?

Oxygen source
Suction
Oral/Nasal airways
Face masks
Endotracheal tubes
LMA
Pulse ox
Cardiac Monitors
CO2 detectors
Ambu bags

What did we do before we

extubated our patient?

Ensured proper equipment needed for

reintubation
Monitoring BP, HR, Sat, RR
Used a twitch monitor to demonstrate
no fade on TOF/sustained tetany
Turned off the propofol sedation

What did we do before we

extubated our patient?

We did not quantitatively evaluate his

tidal volume, thoracic compliance, pH,
NIF, breathing trial, etc
We qualitatively evaluated several
things 1. Stable hemodynamics
2. Able to protect airway
3. Able to exchange gases

Stable Hemodynamics

His preoperative BP and HR were

134/77 and 68

Prior to extubation his BP and HR were

126/72 and 61

Able to protect airway

Patient was gagging on the ETT and

would gag when we suctioned him

Patient was coughing

Able to exchange gases

Patient was spontaneously breathing

for 30 minutes
Good ventilatory effort
Maintained oxygen saturation

Case

Our patient was extubated and had an

uneventful PACU stay.

Another satisfied customer

References

American Association for

Respiratory Care (AARC). Removal
of the endotracheal tube--2007
revision & update. Respir
Care 2007 Jan;52(1):81-93
Nir Hoftman, M.D.s PACU
extubation criteria