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    Extubation checklist

    liberation from mechanical ventilation, spontaneous breathing trial (SBT)

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    Assessment & Plan (short)

    #Extubation Criteria
    - FIO2 <= 0.5, PEEP <=10
    - RSBI <=105
    - Treatment of underlying disease
    - Spontaneous breathing, cough, gag, minimal sputum
    - Following commands

    Assessment & Plan (long)

    # Extubation checklist

    Is the patient ready for an SBT?

    Required criteriaCause of respiratory failure/need for intubation is being treated and is improving
    Adequate oxygenationPO2>=60 on FiO2 <=0.5
    PEEP <=10
    P/F >=150 (>=120 for patients with chronic hypoxemia)
    Adequate ventilationNo significant respiratory acidosis
    Patient-initiated inspiratory effort
    Hemodynamic stability without active cardiac ischemiaHR <=140
    Stable BP and at most moderate dose of 1 pressor
    pH>=7.25
    Optional Additional criteriaAdequate mentation: arousable, GCS>=8-13
    Afebrile T<=38-38.5
    Hb>8-10 g/dL
    No general anesthesia planned in next 24 hours
    Should not be on paralytics, have an open abdomen or undergoing therapeutic hypothermia

    Did the patient PASS their SBT?

    Best validated measurement of predicting successful extubation: Rapid shallow breathing index (RSBI) = RR/TV in mlPS 10-12cm, PEEP<=8, FiO2<=0.6 for 30-120 mins
    80% of patients with RSBI<=105 are successfully extubated
    Other predictors of successful extubationVentilator numbersRR<=30
    TV>=5 ml/kg
    MV<=15 L/min
    Negative maximal inspiratory force (MIF or NIF) <=-20 to -30cm H20
    Patient characteristicsStrong cough
    Scant secretions
    Adequate mentation demonstrated by:Opens eyes, tracks (aware and alert)
    Sticks out tongue (higher cortical function)
    Lifts head off of bed (sufficient strength)

    Did the patient FAIL their SBT?

    Objective criteriaRR>=30 or RR changes >=50%
    Inadequate gas exchangePaO2 <=60 or O2 sat <=85-90%
    Increase in PaCO2 >=10 mmhg
    Hemodynamic instabilityHR change >20%
    SBP >=180, DBP>90 or BP change >=20%
    Subjective criteriaChange in mentation (ex: anxiety, agitation, somnolence)
    Increased work of breathing (ex: diaphoresis, accessory muscles, paradoxical abdominal movement)

    Post extubation care

    Before extubation, consider the most likely causes of post-extubation failure and develop a post-extubation care plan:Volume (diuresis)
    Mucous (suctioning, pneumonia treatment, acapella, meta-nebs, cough assist)
    Atelectasis/collapse (positive pressure [NIVV, EZPAP], IS, meta-nebs, early ambulation)
    Bronchospasm (bronchodilators)
    Monitor for upper airway obstruction aka post-extubation stridor
    Avoid sedation and medication that can cause respiratory depression
    Good patient positioning
    Non-invasive ventilation (NIVV) -- in patients with high risk of failure, extubate directly to NIVV, don't want for post-extubation respiratory failure

    SOAR to RSBI

    Organ systems
    • Pulmonology/Critical Care
    Medical field
    • Internal medicine
    Setting
    • Inpatient
    Author
    Patrick Sanger
    Page info

    Originally created: March 31, 2020 by Patrick Sanger

    [xyz-ips snippet="lastupdated"] [xyz-ips snippet="sectioneditor"] [post-views]

    Number of revisions: [xyz-ips snippet="numrevisions"]

    References
    [xyz-ips snippet="easyfootnote"]
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