UMEM Educational Pearls

The emergency department serves many critically ill patients that require airway management and mechanical ventilation. Most of these patients go on to require ICU care. However, some patients require only brief intubation and should be appropriate candidates considered for emergency physician-driven extubation. Early extubation can minimize the risks associated with mechanical ventilation for patients such as ventilator associated pneumonia (VAP), ventilator induced lung injury (VILI), and others. Additionally, in setting of high levels of ED boarding and limited ICU resources, extubating appropriate candidates in the ED can reduce boarding times and improve patient flow.

Who?

1. Patients with temporary neurologic dysfunction (alcohol/drug intoxication)
2. Need for brief procedural sedation that cannot be accomplished without a definitive airway (endoscopy)
3. Patients transitioning to a palliative, comfort-focused approach to treatment

Screening Checklist

• Returned to baseline mental status, able to follow commands
• Appropriate vital signs on minimal ventilator support
• Breathing spontaneously with RR <30, FiO2 of 30-40%, PEEP 5-8 cmH2O, achieving TV > 6-8 cc/kg
• May be on low-dose vasopressor to manage sedation-related hypotension
• No history of difficulty intubation (in case emergent reintubation is required)

Testing

• Perform spontaneous breathing trial (SBT):
  • IPAP 10 cmH2O over EPAP of 5 cmH2O, also described as pressure support of 5 cmH2O over PEEP of 5 cmH2O
  • 30 minutes
  • Assess the RSBI (Rapid Shallow Breathing Index — available on MDCalc)
• Patient fails for EP-driven extubation if one or more of the following is present:
  • respiratory distress
  • severe anxiety
  • hypoxemia (SaO2 < 90%)
  • tachypnea (usually RR > 30)
  • somnolence
  • RSBI > 105 breaths/min/L

Prepare - depending on institution, may require consultation with the hospital intensivist

• Notify the respiratory therapist (extubation ideally performed by the RT, if available)
• Have standard AND difficult airway equipment at bedside
• These specifically selected patients can usually be extubated to temporary standard nasal cannula
  • Optimal respiratory support post-extubation for palliative patients depends on patient-specific care plan
• For patients with respiratory distress with plan for compassionate extubation, we advise palliative opiate and anxiolytic administration closely titrated to patient comfort, adjusted as ventilator support is weaned down to a pressure support of 0 over PEEP of 0-5. This ensures the patient remains comfortable with minimal distress and air hunger when ventilator support is removed. Other palliative patients with no tachypnea or distress do not necessarily require this measure.
• Some of these patients may be anxious when transitioning off mechanical ventilation; consider use of dexmedetomidine in the peri-extubation period to facilitate patient comfort while maintaining respiratory drive

Perform - see this video courtesy of Respiratory Skills - LSC on performing extubation

• Make sure to monitor for post-extubation hypoxemia and post-extubation stridor
• Always be prepared for the potential need for re-intubation

References

1. Weingart SD, Menaker J, Truong H, Bochicchio K, Scalea TM. Trauma patients can be safely extubated in the emergency department. J Emerg Med. 2011 Feb;40(2):235-9. doi: 10.1016/j.jemermed.2009.05.033. Epub 2009 Aug 22. PMID: 19703744.
2. Nwakanma CC, Wright BJ. Extubation in the Emergency Department and Resuscitative Unit Setting. Emerg Med Clin North Am. 2019 Aug;37(3):557-568. doi: 10.1016/j.emc.2019.03.004. Epub 2019 May 21. PMID: 31262421.
3. Extubation Assessment in the ED. https://litfl.com/extubation-assessment-in-the-ed/.