Extubation: Overview and Practice Questions (2024)

Extubation is the process of removing an endotracheal tube from a patient’s airway after it is no longer needed for mechanical ventilation.

This procedure marks a significant step in the patient’s recovery, indicating that they can breathe independently and maintain their airway without assistance.

Extubation requires careful preparation and assessment to ensure the patient is ready, and a thorough understanding of potential risks and complications.

This article will cover the key aspects of extubation, including indications, the procedure itself, and post-extubation care.

What is Extubation?

Extubation is the medical procedure of removing an endotracheal tube from a patient’s airway after they no longer require mechanical ventilation or airway protection. It is typically performed when the patient has regained the ability to breathe independently, maintain adequate oxygen levels, and protect their airway from aspiration.

Extubation involves several key steps, including deflating the cuff of the endotracheal tube, suctioning the airway to remove secretions, and gently removing the tube.

Close monitoring is essential after extubation to ensure that the patient can continue breathing effectively and avoid complications such as airway obstruction, aspiration, or respiratory distress.

Criteria for Extubation

The criteria for extubation are essential to determine if a patient is ready to have the endotracheal tube removed and can safely breathe without mechanical ventilation. The key criteria include:

• Adequate Respiratory Mechanics: The patient must be able to generate sufficient spontaneous breaths, usually measured by a tidal volume of ≥ 5 mL/kg and a respiratory rate between 12-25 breaths per minute. The patient should demonstrate a negative inspiratory force (NIF) of at least -20 cmH2O, indicating the ability to take a deep breath.
• Stable Vital Signs: The patient’s heart rate, blood pressure, and oxygen saturation should be within acceptable ranges. No signs of hemodynamic instability (e.g., arrhythmias, severe hypotension).
• Sufficient Oxygenation: The patient should maintain a PaO2 of ≥ 60 mmHg on FiO2 ≤ 40%, with a PEEP (positive end-expiratory pressure) of ≤ 5 cmH2O. SpO2 (oxygen saturation) should remain ≥ 90%.
• Normal Blood Gases: Arterial blood gases (ABGs) should show normal or compensated levels of pH, CO2, and oxygen.
• Ability to Protect the Airway: The patient must be able to cough effectively to clear secretions and have intact gag and swallow reflexes to prevent aspiration.
• Recovery of Airway Reflexes: The patient should have regained sufficient consciousness and neuromuscular control to protect their airway from aspiration.
• Stable Chest X-ray: There should be no acute changes in the chest X-ray, such as worsening of pulmonary edema, pneumonia, or large pleural effusions.
• Minimal Secretions: Secretions should be manageable, with the patient able to cough or clear secretions adequately without significant suctioning.
• Adequate Mental Status: The patient should be alert and cooperative, with the ability to follow commands, indicating readiness for spontaneous breathing and airway control.
• Hemoglobin and Hematocrit Levels: Adequate levels of hemoglobin (Hgb) and hematocrit (Hct) to ensure proper oxygen-carrying capacity.

Note: Meeting these criteria ensures that the patient is ready for safe extubation, minimizing the risk of respiratory failure, aspiration, or the need for re-intubation.

Extubation Procedure

Extubation is the process of safely removing an endotracheal tube after a patient no longer needs mechanical ventilation. It requires careful planning and execution to ensure a smooth transition to independent breathing.

The following steps outline the extubation procedure:

• Verify the Physician’s Order: Ensure the order for extubation is confirmed by the attending physician.
• Review the Patient’s Chart: Carefully scan the chart to verify that the patient is ready for extubation. This includes assessing spontaneous breathing parameters and the patient’s clinical status.
• Measure Spontaneous Parameters and Blood Gases: Check the patient’s respiratory parameters and arterial blood gases to confirm readiness for extubation.
• Gather the Required Equipment:
  • Intubation tray: Have it on hand in case re-intubation becomes necessary.
  • 20 mL syringe: For deflating the cuff on the endotracheal tube.
  • Suction supplies: To clear the airway of secretions.
  • Oxygen/aerosol equipment: For administering oxygen after extubation.
  • Personal protective equipment (PPE): Gloves, goggles, or face shield to protect yourself from potential exposure.
• Wash Your Hands: Practice proper hand hygiene before beginning the procedure.
• Introduce Yourself and Explain the Procedure: Make sure the patient is aware of what will happen and is comfortable with the process.
• Position the Patient: Place the patient in a full Fowler’s position (upright sitting position) to optimize airway clearance and comfort.
• Suction the Patient Thoroughly: Perform thorough suctioning of the oropharynx and trachea to remove secretions.
• Oxygenate the Patient: Pre-oxygenate the patient with 100% oxygen using a flow-inflating manual resuscitator to ensure adequate oxygenation prior to extubation.
• Deflate the Cuff: While the patient is exhaling forcefully, deflate the cuff on the endotracheal tube and gently withdraw the tube.
• Assess the Patient: Encourage the patient to cough and speak. This allows you to assess their airway patency, evaluate for hoarseness, and check for any signs of airway obstruction.
• Administer Cool Aerosol Therapy: Provide cool aerosol therapy as ordered by the physician to reduce inflammation and keep the airway moist.
• Evaluate the Patient Post-Extubation: Closely monitor the patient’s respiratory rate, oxygen saturation, and overall condition after extubation for any signs of distress or complications.
• Clean Up the Area: Safely dispose of used equipment and clean the patient’s surrounding area.
• Chart the Procedure: Document the procedure in the patient’s medical record, including the time of extubation, patient response, and any post-extubation care provided.

Note: This procedure should be carried out carefully, with continuous monitoring of the patient’s respiratory status, to ensure a safe and successful transition from mechanical ventilation.

What is Ventilator Weaning?

Ventilator weaning is the process of gradually reducing a patient’s dependence on mechanical ventilation as they regain the ability to breathe on their own. This is a critical step in the recovery process for patients who have required ventilatory support due to respiratory failure, surgery, or other conditions.

The goal of ventilator weaning is to transition the patient from full ventilatory support to spontaneous breathing while closely monitoring their respiratory function and overall stability.

Ventilator weaning typically involves the following:

• Assessment of Readiness: Before weaning begins, the patient is evaluated to determine if they are capable of breathing without full ventilatory support. This includes assessing factors such as respiratory effort, gas exchange, and hemodynamic stability.
• Reduction of Ventilatory Support: Ventilator settings are gradually reduced, often starting with a decrease in support modes like pressure support or synchronized intermittent mandatory ventilation (SIMV), allowing the patient to initiate more breaths on their own.
• Spontaneous Breathing Trials (SBTs): These trials are used to test the patient’s ability to breathe without assistance. During an SBT, the patient is allowed to breathe with minimal or no ventilator support, often through a T-piece or low-pressure support, while healthcare providers monitor vital signs and respiratory parameters.
• Monitoring During Weaning: Close observation of the patient’s respiratory rate, tidal volume, oxygen saturation, heart rate, and blood pressure is essential. Signs of respiratory distress or fatigue indicate that the patient may not yet be ready for complete ventilator independence.
• Successful Weaning: If the patient tolerates the reduction in ventilatory support and spontaneous breathing trials without signs of distress, they may be considered for extubation and complete removal from the ventilator.

The weaning process varies in duration depending on the patient’s underlying condition, overall health, and how well they respond to the reduction in support.

A gradual and monitored approach helps ensure a successful transition from mechanical ventilation to independent breathing, minimizing the risk of complications or the need for re-intubation.

Extubation Practice Questions

1. What are the indications for extubation?
Extubation is indicated when airway management is no longer required, the condition that necessitated intubation has been reversed, there is an obstruction of the endotracheal tube (ETT), or the patient is capable of maintaining their own airway.

2. What are the contraindications for extubation?
There are no absolute contraindications for extubation. However, it is essential to ensure that the patient is ready and capable of maintaining their airway before proceeding.

3. What are common complications of extubation?
Complications that can arise from extubation include hypoxemia, which occurs when the patient is not receiving enough positive pressure. Laryngospasm or bronchospasm can also occur, which can be treated with epinephrine and cool mist therapy. Hypercapnia may result if the patient’s breathing is not efficient, leading to shallow breathing and CO2 retention.

4. What is the weaning criteria for negative inspiratory force (NIF)?
The weaning criteria for Negative Inspiratory Force (NIF) is that it should be greater than -30 cmH2O, indicating the patient’s ability to take a deep breath and generate adequate inspiratory pressure.

5. What is the weaning criteria for vital capacity (VC)?
The vital capacity should be greater than 10 mL/kg of ideal body weight (IBW) to meet the weaning criteria for extubation.

6. What is the weaning criteria for respiratory rate (RR)?
The respiratory rate should be less than 35 breaths per minute to ensure the patient is breathing at an acceptable rate without distress.

7. What is the weaning criteria for the rapid shallow breathing index (RSBI)?
The rapid shallow breathing index (RSBI) should be less than 105, indicating that the patient can breathe efficiently without showing signs of rapid, shallow breaths.

8. How is the rapid shallow breathing index (RSBI) calculated?
The RSBI is calculated by dividing the respiratory rate by the tidal volume (RR / VT).

9. What are the general weaning criteria for extubation?
The patient must maintain adequate oxygenation, CO2 levels, and pH. Additionally, they should be alert, oriented, and have adequate cough and gag reflexes, particularly for neuro and stroke patients. They must also be able to manage secretions, and a cuff leak test should be performed to evaluate the airway’s condition, although a negative test does not necessarily prevent extubation.

10. What does a negative cuff leak test indicate?
A negative cuff leak test suggests a higher risk of airway complications post-extubation but does not mean that the patient cannot be extubated.

11. What should be checked prior to extubation?
Before extubation, it is crucial to review the patient’s medications, lab results, white blood cell count (WBCs), and fluid balance (I’s and O’s). Additionally, ensure that the initial reason for intubation has resolved sufficiently for extubation to be safe.

12. Why should Diprivan (propofol) be cleared from the system before extubation?
Diprivan can suppress respiratory drive, so it must be fully metabolized before extubation to ensure that the patient can breathe independently.

13. What equipment is needed for extubation?
The necessary equipment for extubation includes suction catheters, oxygen, aerosol equipment (such as a nebulizer with albuterol and racemic epinephrine), a syringe, towel/chucks, scissors, tape, Ambu bag/mask, flowmeter, laryngoscope blades, stylet, Magill forceps, oral/nasal airways, tongue depressor, lubrication, suction setup, local anesthetic, ETCO2 indicator, stethoscope, personal protective equipment (PPE), and various sizes of endotracheal tubes (ETTs).

14. What are the steps in the extubation procedure?
The extubation procedure involves gathering and assembling the necessary equipment, suctioning the patient both down the ETT and above the cuff, pre-oxygenating the patient, removing the tape securing the tube, deflating the cuff, and removing the ETT at the end of inhalation. After the tube is removed, oxygen and aerosol therapy should be applied, and the patient’s neck, trachea, and lungs should be assessed.

15. What should you watch for after extubation?
After extubation, it is important to monitor the patient for stridor, which is a sign of airway narrowing or obstruction.

16. What are the treatments for stridor after extubation?
Treatments for stridor include administering racemic epinephrine, providing cool mist, using CPAP/BiPAP, administering systemic corticosteroids, and possibly using heliox, which is a helium-oxygen mixture.

17. What are common problems post-extubation?
Common post-extubation issues include a sore throat, hoarseness, coughing, laryngospasm, and aspiration.

18. When is extubation failure most likely to occur?
Extubation failure typically occurs within the first 8 hours after the procedure, with risk monitoring continuing for up to 48 hours.

19. What is the rapid shallow breathing index (RSBI) used for?
The RSBI is used to assess the likelihood of successful weaning from mechanical ventilation. A value below 105 suggests that the patient has a higher chance of successful extubation.

20. Why is a cuff leak test performed before extubation?
The cuff leak test is performed to evaluate the risk of airway swelling or obstruction after extubation. A negative test result indicates a higher risk but does not necessarily prevent extubation.

21. What is a Positive Leak test for?
A Positive Leak test helps predict the occurrence of glottic edema, which can indicate swelling around the vocal cords.

22. How does the Positive Leak test work?
The Positive Leak test works in two ways. First, after a spontaneous breath, you deflate the cuff and remove the ET tube. If there is a leak around the cuff, the test is positive, meaning no edema is present. Second, if the patient remains on the ventilator, the cuff is deflated, and the volume of the leak is measured.

23. What could happen if the Positive Leak test had a negative result?
A negative result indicates the potential for post-extubation edema, which can cause airway obstruction or complications when the tube is removed.

24. What are some extubation complications that could occur?
Complications from extubation include hoarseness (usually short-term and benign), laryngeal edema, laryngospasm, stridor due to glottic edema, vocal cord paralysis, and glottic stenosis.

25. How can stridor be treated?
Stridor can be treated with cool mist therapy, racemic epinephrine, steroids, and heliox therapy.

26. What equipment is used to perform ventilatory parameters?
The equipment used includes ABGs (arterial blood gases), a Wright respirometer, and an Inspiratory force meter.

27. What is a common test used to evaluate if a patient can be extubated?
The Rapid Shallow Breathing Index (RSBI) is commonly used to evaluate if a patient is ready for extubation.

28. How do you perform RSBI?
One minute after disconnecting the patient from the ventilator, the patient breathes for one minute. The respiratory rate is counted, and the tidal volume is measured using a respirometer. An RSBI value of less than 105 indicates a positive outcome for extubation.

29. How do you instruct a patient for an inspiratory force measurement?
Instruct the patient to breathe normally, then occlude the open port. The patient will breathe against a closed airway, creating a negative pressure.

30. What would indicate a positive result when performing an inspiratory force measurement?
A positive result is when the patient generates a pressure greater than -20 cmH2O within 20 seconds.

31. What is the concern before performing extubation, and how is it assessed?
The main concern is whether the upper airway is free of swelling and inflammation. This is assessed by performing a cuff leak test.

32. What is included in the evaluation for extubation?
The evaluation for extubation includes ensuring that the patient is free of upper airway obstruction, able to clear secretions, can protect their airway, and that the reason for intubation has either been reversed or significantly improved.

33. What are the physiological parameters for weaning and extubation?
These parameters include ABGs, oxygenation, ventilation, ventilatory mechanics, respiratory muscle strength, ventilatory drive, work of breathing, and ventilatory reserve.

34. What is the VD/Vt ratio formula?
The formula for the VD/Vt ratio is: VD/Vt = (PaCO2 – PeCO2) / PaCO2.

35. How do you calculate physiological dead space in ml?
To calculate physiological dead space in milliliters, use the formula: Vt * (VD/Vt).

36. What does RSBI stand for?
RSBI stands for Rapid Shallow Breathing Index.

37. What is the normal Qs/Qt percent?
The normal Qs/Qt percent is 3%.

38. What do the ABGs, Wright respirometer, and Inspiratory force meter measure?
They measure resting minute ventilation, average tidal volume (Vt), vital capacity (VC), and maximum voluntary ventilation (MVV).

39. What is resting minute ventilation?
Resting minute ventilation is the total volume of air the patient breathes over one minute. The goal is to record the respiratory rate and volume over this period.

40. What is the formula for average tidal volume (Vt)?
To calculate average tidal volume, divide the total volume of air breathed (e.g., 10 L) by the number of breaths (e.g., 20 breaths), which equals 500 ml.

41. How do you measure VC (Vital Capacity)?
The patient takes the deepest breath possible and exhales for as long as they can. The best attempt out of three is recorded.

42. What is MVV (Maximum Voluntary Ventilation)?
MVV is measured by having the patient breathe as fast and deep as possible for 15 seconds, then multiplying the result by 4.

43. How much CO2 is required to indicate the need for ventilation?
A CO2 level of 50 mmHg indicates the need for ventilation.

44. How much CO2 should measure for a patient to be extubated?
A CO2 level of 40 mmHg is a typical criterion for extubation.

45. How is ventilatory reserve measured?
Ventilatory reserve is measured by assessing the patient’s vital capacity (VC).

46. How much FiO2 should be present for a patient to be extubated?
FiO2 should be less than or equal to 40% to 50% before extubation.

47. How much PEEP should be present for a patient to be extubated?
PEEP should be less than or equal to 5 to 8 cmH2O for extubation.

48. How much PaO2 should be measured before extubation?
PaO2 should be greater than or equal to 60 mmHg on an FiO2 less than 40%.

49. How much SaO2 should be present to meet the criteria for extubation?
SaO2 should be greater than or equal to 90% before extubation.

50. How much SvO2 should measure before extubation?
SvO2 should be greater than or equal to 60% for extubation.

51. How much should the PaO2/PAO2 ratio be before extubation?
The PaO2/PAO2 ratio should be greater than or equal to 35% (Pilbeam >47%).

52. How much should the PaO2/FiO2 ratio be before extubation?
The PaO2/FiO2 ratio should be greater than 200 (Pilbeam >250) before extubation.

53. What is the equation for alveolar ventilation in ml?
The equation for alveolar ventilation is: Valv = Vt – (Vt * VD/Vt).

54. What is the extubation procedure?
The procedure includes: Assembling equipment (O2, aerosol therapy, manual resuscitation mask, epinephrine, SVN, suctioning equipment). Pre-oxygenating and suctioning the ET tube and pharynx, then suctioning above the cuff. Administering 100% O2, deflating the cuff, and removing the ET tube at peak inspiration while the patient coughs. Applying O2 and humidity therapy, increasing FiO2 by 10%, and placing the patient on cool mist using an AP neb. Assessing the patient and monitoring for air movement and skin color.

55. What should you do if stridor develops?
Administer 0.5 ml epinephrine in 4 ml saline via a small volume nebulizer (SVN).

56. What should you do if stridor continues?
Re-intubate the patient if stridor persists.

57. How much should the CROP index be before extubation?
The CROP index should be greater than 13 ml/breath/min before extubation.

58. How much should dynamic compliance be before extubation?
Dynamic compliance should be greater than 25 cmH2O before extubation.

59. How much should MVV measure before extubation?
MVV should measure greater than 20, or more than twice the patient’s minute ventilation (MV).

60. How much should Maximum Inspiratory Force (MIF) be before extubation?
MIF should be less than -20 to -30 cmH2O for successful extubation.

Final Thoughts

Extubation is a crucial milestone in the recovery of patients who have required mechanical ventilation. While the process may seem straightforward, it involves careful planning, monitoring, and teamwork to ensure a smooth transition to spontaneous breathing.

By understanding the indications, procedure, and potential complications of extubation, healthcare providers can better ensure patient safety and successful outcomes.