Extubation Criteria
J. Prince Neelankavil, M.D.
Case
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71 y.o. male s/p laparascopic surgery
presents to the PACU intubated. Pt.
remained intubated secondary to
residual neuromuscular blockade
H/O HTN, DM
When should we extubate?
General Principles
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Why was the patient intubated in the
first place? Inadequate
oxygenation/ventilation/airway
protection.
Patient should have adequate
respiratory drive, respiratory muscle
strength, cough reflex to clear
secretions, laryngeal function and
clearance of sedative and
neuromuscular blocking medications.
Adequate Gas Exchange?
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Adequate arterial partial pressure
of oxygen: [PaO2/FIO2] ratio >
150-200
Appropriate pH (pH >7.25) and
arterial partial pressure of carbon
dioxide during spontaneous
ventilation
Pass a Breathing Trial?
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30–120 minute spontaneous
breathing trial with low level of
CPAP (e.g. 5 cm H2O) or low level
of pressure support (e.g. 5-7 cm
H2O)
Show gas exchange (ABG),
hemodynamic stability, and
subjective comfort
Pass These Numbers?
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RR < 35
Vital capacity > than 10 mL/kg
NIF > -20
Tidal Volume > 5mL/kg
Minute ventilation < 10L/min
Thoracic compliance > 25 mL/cm
H2O
Able to Protect Airway?
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Appropriate level of consciousness
Adequate airway protective
reflexes (cough, swallow, vocal
cord movement)
Adequate managed secretions
All Systems Go?
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Hemodynamic Stability (+/- 20%)
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Nutritional status allowing for respiratory
muscle strength
Risk Factors for Failed
Extubation
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ICU patient
Age > 70 or < 24 months
Hemoglobin <10 mg/dL
Longer duration of mechanical
ventilation
Medical or surgical airway condition
Frequent pulmonary toilet
Loss of airway protective reflexes
What do you need to
extubate?
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Oxygen source
Suction
Oral/Nasal airways
Face masks
Endotracheal tubes
LMA
Pulse ox
Cardiac Monitors
CO2 detectors
Ambu bags
What did we do before we
extubated our patient?
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Ensured proper equipment needed for
reintubation
Monitoring BP, HR, Sat, RR
Used a twitch monitor to demonstrate
no fade on TOF/sustained tetany
Turned off the propofol sedation
What did we do before we
extubated our patient?
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We did not quantitatively evaluate his
tidal volume, thoracic compliance, pH,
NIF, breathing trial, etc…
We qualitatively evaluated several
things 1. Stable hemodynamics
2. Able to protect airway
3. Able to exchange gases
Stable Hemodynamics
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His preoperative BP and HR were
134/77 and 68
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Prior to extubation his BP and HR were
126/72 and 61
Able to protect airway
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Patient was gagging on the ETT and
would gag when we suctioned him
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Patient was coughing
Able to exchange gases
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Patient was spontaneously breathing for
30 minutes
Good ventilatory effort
Maintained oxygen saturation
Case
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Our patient was extubated and had an
uneventful PACU stay.
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Another satisfied customer
References
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American Association for
Respiratory Care (AARC). Removal
of the endotracheal tube--2007
revision & update. Respir
Care 2007 Jan;52(1):81-93
Nir Hoftman, M.D.’s PACU
extubation criteria