Weaning and Extubation

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Extubation criteria/Preparation
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Weaning 

• The transition from ventilatory support to
  completely spontaneous breathing,during which
  time the patient assumes the responsibility for
  effective gas exchange whilepositive pressure
  support is withdrawn.

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Extubation 

• Criteria for extubation include1. spontaneous
  ventilation, hemodynamic stability, intact
• airway reflexes, and manageable airway
  secretions.
• 2. Success is defined as 48 hours of
  spontaneous
• breathing without positive pressure
  support.
• 3. Early extubation failure is defined as
  that which occurs
• within 6 hours of extubation
  intermediate extubation
• failure is that which occurs from 6 to
  24 hours of
• extubation

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Spontaneous Breathing Test (SBT

• When purpose of Ventilating the patient achieved
• underlying disease process necessitating
  mechanical ventilation has improved sufficiently
• To allow the patient adequate gas exchange with
  spontaneous breathing.
• Usually mode is changed to PSV

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Spontaneous Breathing Test (SBT

• In a study by Esteban et al., 2-hour trials of
  unassisted breathing using PS of 7 cmH2O were
  compared to T-piece alone.
• More patients in the PS group tolerated the trial
  and were extubated at the end of the trial than
  the T-piece group (86 vs. 78)
• There was no difference in the rate of
  reintubation.
• A second similar study by Esteban et al., also
  showed no difference in reintubation rates
  between groups. However, the shorter T-piece
  trial benefited patients by reducing ICU and
  hospital duration (2 days and 5 days shorter,
  respectively).

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Extubation Readiness Test (ERT)

• is a formal trial of spontaneous breathing to
  evaluate readiness for dc of the ETT and/or
  ventilatory support.
• assessing Neurologically after stopping sedations
  Adequate muscle strength
• NBM for gt 4 hours
• Awake or easily roused
• Work of breathing acceptable on PS 10/5
• Good respiratory effort on T-piece
• Latest CXR reviewed
• Haemodynamically stable
• No residual muscle relaxation
• Good cough reflex on tracheal suctioning
• Leak test

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Other Parameters for readiness

• Adequate oxygenation (P/F ratio)
• HB and Temparature
• Normal acid base status no significant
  respiratory acidosis
• PEEP less than 8 cmH2O
• Satisfactory tidal volume VT gt 5ml/kg
• Satisfactory vital capacity VC gt 10ml/kg
• Satisfactory MIP less than 20-25 cmH2O (i.e
  pressure trigger)
• Satisfactory RSBI an  fR/VT less than 105

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Criteria for Failure During 2 Hours on CPAP lt 5
cmH2O or T-piece

• Clinical Criteria
• Diaphoresis
• Nasal flaring
• Increasing respiratory effort
• Tachycardia (increase in HR gt 40 bpm)
• Cardiac arrhythmias
• Hypotension
• Apnea
• Laboratory Criteria
• Increase of PetCO2 gt 10 mmHg
• Decrease of arterial pH lt 7.32
• PaO2 lt 60mmHg with an FiO2 gt 0.40 (P/F O2 ratio lt
  150)
• SpO2 declines gt 5

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Equipment to be Ready before Extubation

• Equipment
• Check oxygen sources
• Working Ambubag
• Suction system ready
• Appropriate sized mask Appropriate size syringe
  to deflate cuff.
• Capnography if avaiable
• Intubation trolley
• Laryngoscope and working different size of
  blades
• Bougie/stylet
• ETT (cuffed and uncuffed) correct sizes
• ET tie/Tape
• Drugs(Ventolin in case of spasm,Pulmicart,resmic
  epinephrine,Atrovent,Normal sline)
• Adrenalin Atropine in case of Vasovagal
  stimulation.

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Assess Readiness

• Known difficult airway? If yes, clarify plan with
  Consultant Extubation plan Nasal cannula/High
  Flow Nasal Oxygen CPAP/BiPAP

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Ventilator Free Days (VFD)

• is an outcome measure consisting of the number of
  days in a given time period.
• Successful discontinuation of ventilator support
  requires a minimum of 48 hourswithout positive
  pressure ventilation.
• Patients who die are considered to have
  zeroventilator free days.

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Management of post extubation stridor

• Manual CPAP
• High Flow Nasal Oxygen
• Mask CPAP/BiPAP
• Consider re-intubation
• DRUGS Dexamethasone 0.5mg/kg IV then 0.2mg/kg IV
  6 hourly for 24 hours Nebulised 11000 adrenaline
  0.4ml/kg (MAX 5mls) dilute to final volume of 5
  mls

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Croup score specialy for pediatric
Dr. Terry Klassen
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Thanks

• Shams Ali Shah
• RT at PSCCQ