UMEM Educational Pearls

Category: Critical Care

Title: Extubating in the ED

Posted: 3/19/2013 by Mike Winters, MD (Updated: 9/27/2022)
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Extubating in the ED

  • 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.