IS YOUR PATIENT READY TO EXTUBATE?

It is poor form to extubate a patient who is unstable and on three vasopressors

Ask yourself if the reason they were intubated has now resolved.  If the answer is yes, then you can consider extubation

Edema is not just an eyesore.  Patients who are volume overloaded with pitting edema often have fluid everywhere.

Consider that we put patients on Bipap for pulmonary edema.  Bipap provides positive pressure ventilation and prevents airway collapse by providing PEEP.  In doing so, it redistributes the fluid in the alveoli while you are working to try to get the patient to diurese

The ventilator provides the same physiology.  If a patient is volume overloaded and extubate and take away the positive pressure venilation they will  be at high risk for developing pulmonary edema.  

Patients have to be wide awake with a cough and a gag in order to protect their airways.

One of the reasons we have to always be thinking ahead is because some ICU patients are on infusions of opioids and/or benzodiazepines that have to be discontinued in advance to allow some time for them to emerge

We often have patients in the ICU for the sole reason of airway protection due to Ludwig's Angina, Epiglotitis, Angioedema, or post-op spine patients who have airway swelling.  

Obviously these patients will be ready when they are ready.  

Coughing truly is a survival mechanism

Coughing and clearing our secretions is what keeps secretions from pooling in the lower airways and causing pneumonia and mucous plugs

If they have a weak cough or no cough, we can work with that but we need to know and we need to consider this in the context of other issues the patients may have

For instance, we have a way to provide a cough assist (insufflation/exsufflation) but patients have to be awake and cooperative with this and cannot be agitated

For additional learning see link below to jump to the "Lung Volume Recruitment"topic

A gag reflex is extremely important to prevent aspiration

Absent gag reflexes are often seen with strokes, brain tumors, and intraparenchymal hemorrhages involving the brainstem and posterior fossa in general

An absent gag should make you think twice about extubation and make you consider tracheostomy

These patients can often be awake and interactive while they continuously aspirate saliva or vomit and have a large aspiration.

Weakness despite adequate nutrition after critical illness is common and is a huge cause of morbidity and ultimately mortality.

Weakness contributes to a poor cough, rapid shallow breathing, pressure ulcers due to the inability to shift in bed., and vulnerability to complications

For patients who have potential to recover, this is a common reason to perform a tracheotomy .

Patients need to be off sedation and exercising in order to regain strength.

For additional learning see link below to jump to the "Tracheostomy and Trach Hood Trials"  topic

We will check for a cuff leak prior to extubation

A cuff leak simply means that when you deflate the cuff of the endotracheal tube, there should be an audible air leak.

The presence of a cuff leak will only suggest whether or not the vocal cords are swollen which can happen after a patient has been intubated for several days and/or edematous.  

It is nice when there is a solid audible leak from the bedside but when it is absent, there are pitfalls to over-reliance on this as a marker of vocal cord edema 

Some Intensivists will simply take a look with a laryngoscope to directly visualize the vocal cords

For additional learning see link below to jump to the "Cuff leak.  What is it?"  topic