Extubation

Extubation

–    Weaning
–    Is the cause of respiratory failure gone or getting better ?
–    Is the patient well oxygenated and ventilated ?
–    Can the heart tolerate the increased work of breathing ?
–    Weaning: is the process of removing the patient from mechanical ventilation therapy
–    In truth, you are always weaning a patient in the sense that you are always trying to minimize the ventilator settings.
–    “True” weaning implies a different expectation – that the patient is improving and will soon not need mechanical ventilation.
–    This usually happens when the disease process is improving or resolved and the patient has acceptable parameters. It is important to assess the ability of the heart to handle the increased demands that extubation may place upon it (e.g., pneumonia/ARDS has resolved but significant septic shock with cardiovascular collapse is present).

Factors affecting weaning

 

–    Length of time the patient has been on mechanical ventilation
–    Physical condition
–    Tone and strength of respiratory muscles
–    Underlying disease status
–    Psychological dependence is a significant factor
Remember
    It is recognized that , when patients have been maintained on mechanical ventilatory, a period of gradual separation is necessary before spontaneous respiration can effectively meet ventilatory needs

Criteria for successful weaning
Subjective
–    Is the patient awake , oriented, alert and cooperative?
–    Can the patient cough & deep breath affectively?
–    Is there broncho-spasm?
–    Is there respiratory muscle disco-ordination
–    What are the secretions like & can the patient handle them effectively?
–    Is the patient hemodynamically stable ?

Objectives:
–    Vital capacity > 12- 15 ml / kg
–    Tidal volume > 5 -7 ml/kg
–    Respiratory rate within normal limits
–    PaO2> 60 mmHg
–    Paco2<45mmHg
–    pH  7.35 – 7.45
–    Oxygen Saturation 99%

Criteria for successful weaning
–    When is a patient ready to be extubated? First, they must be able to protect their airway.
–    They should have an acceptable SaO2 on an FiO2 of no more than .30-.35.
–    They should be breathing at a comfortable rate with a set ventilator rate of 5-8.
–    Patients may be trialed on just pressure support/CPAP to make sure they are generating an adequate spontaneous minute ventilation.
–    If these are the circumstances, then the patient is ready for an attempt at extubation and their time on mechanical ventilation.

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