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Post-Extubation Emergencies. OH SH..!. Discontinuing Mechanical Ventilation. Resolution of the process that caused the intubation. Spontaneous breathing ability with adequate ABG’s and Hemodynamics. Extubation Criteria. Ability to Cough MIF VC /PEF Cognitive Secretions - PowerPoint PPT Presentation
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Post-ExtubationPost-Extubation Emergencies Emergencies
OH SH..!OH SH..!
Discontinuing Mechanical Discontinuing Mechanical VentilationVentilation
Resolution of the process that caused the Resolution of the process that caused the intubation.intubation.
Spontaneous breathing ability with Spontaneous breathing ability with adequate ABG’s and Hemodynamicsadequate ABG’s and Hemodynamics
Extubation CriteriaExtubation Criteria
Ability to CoughAbility to CoughMIFMIF
VC /PEFVC /PEF
Cognitive Cognitive
SecretionsSecretionsCan there be too many?Can there be too many?
““Salam et al, “Neurologic status, cough, secretions and extubation outcomes” Salam et al, “Neurologic status, cough, secretions and extubation outcomes”
Intensive Care Medicine (2004) 30:1334-1339Intensive Care Medicine (2004) 30:1334-1339””
Extubation CriteriaExtubation Criteria
Hardware IssuesHardware IssuesNG/OG tubesNG/OG tubes
Wired jawWired jaw
Cervical fixation devicesCervical fixation devices
The Top FiveThe Top Five
LaryngospasmLaryngospasm
Laryngeal StridorLaryngeal Stridor
Acute HypoxemiaAcute Hypoxemia
Acute Respiratory FailureAcute Respiratory Failure
Neurologic pathologyNeurologic pathology
LaryngospasmLaryngospasm
Definition: The vocal folds spontaneously Definition: The vocal folds spontaneously closing and staying closed.closing and staying closed.
Presents as NO air movement and patient Presents as NO air movement and patient in a panic (conscience or not)in a panic (conscience or not)
LaryngospasmLaryngospasm
Causes:Causes:HysteriaHysteria
Mechanical Mechanical
ChemicalChemical
Can you predict it?Can you predict it?Extubating with Positive pressureExtubating with Positive pressure
LaryngospasmLaryngospasm
How do you treat it?How do you treat it?WaitWait
SedationSedation
Laryngeal StridorLaryngeal StridorDefinition: High pitched inspiratory noise that occurs Definition: High pitched inspiratory noise that occurs when vocal folds are swollen and close together allowing when vocal folds are swollen and close together allowing little air to pass through.little air to pass through.
Can you predict it?Can you predict it?Cuff leak testCuff leak test
– Volume leakVolume leak““Kriner et al, The Endotracheal Tube Cuff-Leak Test as a Predictor for Postextubation Kriner et al, The Endotracheal Tube Cuff-Leak Test as a Predictor for Postextubation
Stridor, Respiratory Care 2005 Dec;50(12)1632-1638Stridor, Respiratory Care 2005 Dec;50(12)1632-1638
– ETT occlusionETT occlusion
Risk populationsRisk populationsMen vs. WomenMen vs. WomenObesityObesity
“ “Erginel S. et al “High body mass index and long duration of intubation increase post-Erginel S. et al “High body mass index and long duration of intubation increase post-extubation stridor in patients with mechanical ventilation” J Exp Med. 2005 extubation stridor in patients with mechanical ventilation” J Exp Med. 2005 Oct;207(2)125-32.Oct;207(2)125-32.
Laryngeal StridorLaryngeal Stridor
Is it stridor or obstruction?Is it stridor or obstruction?Jaw Thrust/Sniff positionJaw Thrust/Sniff position
Secretion clearanceSecretion clearance
How do you treat the obstruction?How do you treat the obstruction?Nasal/oral airwaysNasal/oral airways
Mask CPAPMask CPAP
Laryngeal StridorLaryngeal Stridor
Is it stridor or obstruction?Is it stridor or obstruction?Jaw Thrust/Sniff positionJaw Thrust/Sniff position
Secretion clearanceSecretion clearance
How do you treat the obstruction?How do you treat the obstruction?Nasal/oral airwaysNasal/oral airways
Mask CPAPMask CPAP
Laryngeal StridorLaryngeal Stridor
How can you treat?How can you treat?Racemic epinephrine/ bronchodilatorsRacemic epinephrine/ bronchodilators
.5cc/2ccNS.5cc/2ccNS
HelioxHeliox80/20 mixture80/20 mixture
Max. FiO2 .35Max. FiO2 .35
SedationSedation
Acute HypoxemiaAcute Hypoxemia
Definition: Sudden decrease of oxygen in Definition: Sudden decrease of oxygen in the blood.the blood.
Can you predict it?Can you predict it?
Acute HypoxemiaAcute Hypoxemia
Secretions/Mucous plugSecretions/Mucous plugCough or need for NTS quicklyCough or need for NTS quickly
Pulmonary edemaPulmonary edemaNegative pressure pulmonary edemaNegative pressure pulmonary edema
Support with oxygenSupport with oxygen
Cardiac Cardiac Mask CPAPMask CPAP
Vomiting/AspirationVomiting/AspirationPosition pt on sidePosition pt on side
Need for oral and NT suction quicklyNeed for oral and NT suction quickly
Support oxygenationSupport oxygenation
Acute Ventilatory FailureAcute Ventilatory Failure
Definition: An inability for the patient to Definition: An inability for the patient to ventilate to maintain a normal pH (7.35-ventilate to maintain a normal pH (7.35-7.45)7.45)
Presents itself by:Presents itself by:Increased RRIncreased RR
Increased WOBIncreased WOB
Decreased SaO2Decreased SaO2
Acute Ventilatory FailureAcute Ventilatory Failure
Can you predict it?Can you predict it?
How do you treat?How do you treat?NPPVNPPV
– COPD vs. Non-COPDCOPD vs. Non-COPDEsteban et al. Esteban et al. ““Noninvasive Positive-Pressure Ventilation for Respiratory Failure Noninvasive Positive-Pressure Ventilation for Respiratory Failure
after Extubation” N Engl J Med 2004;350:2452-60after Extubation” N Engl J Med 2004;350:2452-60
Ferrer et al. “Early Noninvasive Ventilation Averts Extubation Failure in Patients at Risk” Ferrer et al. “Early Noninvasive Ventilation Averts Extubation Failure in Patients at Risk”
AM J Respir Crit Care Med 2006;173:164-170AM J Respir Crit Care Med 2006;173:164-170
Sedation withdrawalSedation withdrawal
Re-intubateRe-intubate
Neurologic PathologyNeurologic Pathology
ALSALS
Traumatic Brain InjuryTraumatic Brain Injury
MS, Guillian Barre, TetraplegiaMS, Guillian Barre, Tetraplegia
Critical Illness neuromyopathyCritical Illness neuromyopathy
Post-Extubation EmergenciesPost-Extubation Emergencies
The inability to reliably predictThe inability to reliably predict
The Top FiveThe Top Five
How to treatHow to treat
BE PREPAREDBE PREPARED
Do not treat extubations as routineDo not treat extubations as routine
Assess, Assess, Assess Assess, Assess, Assess
Have Difficult Intubation Supply easily Have Difficult Intubation Supply easily available in unitavailable in unit
Don’t PanicDon’t Panic
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