With the increasing LOS for many of our intubated critically ill ED patients, it is possible that select patients may be ready for extubation while still in the ED.
Patients who remain intubated unnecessarily are at increased risk for pneumonia, increased hospital LOS, and increased mortality.
To be considered for extubation, patients should meet the following criteria:
The condition that resulted in intubation is improved or resolved
Hemodynamically stable (off pressors)
PaO2/FiO2 > 200 with PEEP < 5 cm H2O
If these criteria are met, perform a spontaenous breathing trial (SBT).
Discontinue sedation
Adjust the ventilator to minimal settings: pressure support or CPAP (5 cm H2O) or use a T-piece.
Perform the trial for at least 30 minutes.
If the patient develops a RR > 35 bpm, SpO2 < 90%, HR > 140 bpm, SBP > 180 mm Hg or < 90 mm Hg, or increased anxiety, the SBT ends and the patient should remain intubated.
Before removing the endotracheal tube, be sure to assess mentation, the quantity of secretions, and strength of cough.
References
McConville JF, Kress JP. Weaning patients from the ventilator. NEJM 2012; 367:2233-9.
