Upload
modsom-ooui
View
527
Download
1
Embed Size (px)
Citation preview
AARC Clinical Practice GuidelineRemoval of the Endotracheal Tube- Jan 2007 Revision and update
Rattana pensrichon , MD แพทย์�ประจำ�บ้ �นป�ท�� 2 หน�วย์
เวชบ้�บ้�ดว�กฤต21 มิ�ถุ น�ย์น 2550
AARC Clinical Practice GuidelineRemoval of the Endotracheal Tube-2007 Revision and update
This guideline focus on the predictors that aid the decision to extubation
The procedure refered to as extubation
The immidiate post extubation interventions that may avoid potential reintubation
The risk of prolonged tranlaryngeal intubation include
Sinusitis Vocal cord injury Laryngeal injury Subglosstic stenosis in neonates and children Tracheal injury Hemoptysis Aspiration Pulmonary infection Endotracheal tube occlusion Accidental extubation
Complication post extubation
Upper airway obstruction from laryngospasm
Laryngeal edema Supraglottic obstruction Pulmonary edemaPulmonary aspiration syndrome Impaired respiratory gas exchange
Indication of extubation
improvement of the underlying condition
pulmonary function and/or gas exchange capacity
Patient should be capable of maintaining a patent airway generating adequate spontaneous ventilation
(central inspiratory drive ,respiratory muscle strength to clear secretion ,laryngeal function ,nutritional status ,clearance of sedative and neuromuscular drug effects)
Contraindications of extubation
No absolute contraindications
May require one or more of the following Noninvasive ventilationCPAP High inspired oxygen fraction Reintubation
Hazards
Hypoxemia after extubationUpper airway obstruction Post obstructive pulmonary edema Bronchospasm Lung atelectasisPulmonary aspiration Hypoventilation
Hazards
Hypercarbia after extubation Upper airway obstruction resulting from
edema of trachea ,vocal cords ,or larynx Respiratory muscle weaknessExcessive work of breathing Bronchospasm
Assessment of extubation readiness
Extubation readiness criteria Exp.maintain adequate arterial partial pressure
( PaO2/FiO2 > 150-200)
Low level of PEEP (< 5 to 8 cmH2O)
The capacity to maintain appropiate PH(PH >= 7.25) and PCO2 during spontaneous ventilation
Assessment of extubation readiness
Acceptable respiratory rate decrease inversely with age
Adequate respiratory muscle strength Maximum negative inspiratory pressure >-20
cmH2O Vital capacity > 10 ml/kg, in neonate > 150
ml/m2 Modified CROP
index(compliance,resistance,oxygenation,ventilating pressure) above a threshold of >=0.1-0.15 ml .mmHg/breath/min/kg
Assessment of extubation readiness
Thoracic compliance > 25 ml/cmH2o Work of breathing < 0.8 J/L Vd/Vt <= 0.5( in children) Maximum voluntary ventilation > twice resting
minute ventilation In neonates,total respiratory compliance <=
0.9 ml/cmH2O associated with extubation failure
Assessment of extubation readiness
Rapid shallow breathing index RR/Vt < 105 breath/min
Resolution of the need for airway protection
Appropiate level of conciousness Adequate airway protective reflexes – white card test –( grade 0-2 ) Early managed secretions
Assessment of extubation readiness
Presence of upper airway obstruction or laryngeal edema Air leak test
Age dependent predictor of post extubation stridor
Air leak > 20 cmH2O Predictive post extubation stridor in chlidren >= 7 years of age (sens 83%,spec 80%)
Air leak test – predictive of postextubation stridor or extubation failure for children of upper airway pathology : traumatic patients,crop
Assessment of extubation readiness
Evidene of stable ,adequate hemodynamic function
Evidence of stable nonrespiratory functions
Electrlytes values within normal range Evidence of appropiate nutrition
Risk factor for extubation failure
Admit in ICU Age > 70 years or < 24 months Higher severity of illness upon weaning HgB < 10 mg/dl Use of continuous IV sedation Longer duration of mechanical ventilation Presence of syndromic or chronic medical condition ,known
medical or surgical airway condition ,congenital condition associated with cervical instability ( Klippel-feil or trisomy 21 )
In pidiatric cardiothoracic surgery population Age < 6 months Prematurity Congestive heart failure Pulmonary hypertension
Prophylaxis medication
Consider use lidocaine to prevent cough and/or laryngospasm in patient at risk
Steriod may be helpful to prevent reintubation rates in high risk neonates but not in children
Steroid may help reduced the incidence of postextubation stridor in children but not in neonates or adult
Steriod for patients with croup correlates with reduced rates of reintubation
Caffeine citrate reduced the risk of apnea for infants but not reduced risk of extubation failure
Methylxanthine treatment stimulate breathing and reduced the rate of apnea for neonates with poor respiratory drive
Assessment of outcome
Assess by PE, auscultation, invasive and noninvasive measurements of gas exchange and chest radiography
Quality of the procedure assessed by monitoring extubation complications and the need for reintubation
Postextubation support
Noninvasive Respiratory Support NIPPV or nasal CPAP
Binasal prong CPAP or single nasal or nasopharyngeal CPAP
In patients with COPD ,CPAP 5 cmH2O and pressure support ventilation of 15 cmH2O improve gas exchange ,decreased intrapulmonary shunt fraction and reduced work of breathing
Postextubation Medical Therapy and diagnostic therapy
Aerosalized levo-epinephrine is as effective as aerosolized racemic epinephrine in treatment of postextubation laryngeal edema in children
Heliox may alleviate the symptom of partial airway obstruction and resultant stridor ,improve patient comfort
Fiberoptic bronchoscopy may provide direct airway inspection and therapeutic interventions
Resources
Equipment Personal
Mornitoring
Appropiately trained personnal to detect cardiopulmonary impairment
Frequent respiratory evaluation include: vital sign ,neurologic status ,patency of airway ,auscultatory findings ,hemodynamic status
Equipment Pulse oximeter Two channel cardiac monitor Capnography
Frequency
Any recommendation for tracheostomy placement in the mechanically ventilated patient Etiology of respiratory insult Expected or known duration of mechanical
ventilation Balance of risks and perceived benefits of
continued mechanical ventilation via tracheostomy as opposed to a tranlaryngeally placed EET