Extubation checklist

# 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