demonstration of extubation procedure by
Craig Smallwood
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my name is Craig small I'm a respiratory
therapist here at Children's Hospital in
Boston we're going to discuss with you
today the process of assessing a patient
and performing extubation introduction
extubation refers to the removal of the
airway or the endotracheal tube from the
patient there are several things to
consider before excavating your patient
number one do they have a Payton upper
airway number two do they have the
ability to protect their lower airway
from aspiration number three do they
have an adequate cough or are they able
to spontaneously clear secretions
adequately from the lower respiratory
tract fourthly do they have the ability
we'll discuss this at length in a few
moments it's a spontaneous 'support
adequate ventilation and oxygenation on
disconnection from the mechanical
ventilator it's also important to
consider the hemodynamic status as well
as the level of consciousness of your
patient extubation readiness test an
ex-patient readiness test is a formal
trial patients ventilation to ascertain
their specific readiness for extubation
and separation from the mechanical
ventilator there is a great degree of
variability from institution to
institution as to what specifically is
intent entailed during an extubation
readiness test in general there are two
main camps a t-piece trial in which the
patient is completely disconnected from
the mechanical ventilator and monitored
for a period of time in a minimal
pressure support trial in which the
patient is set on a minimal amount of
pressure support any minimal of peep and
monitor for a period of time vary
Children's Hospital we use a minimal
pressure support trial to evaluate our
patient's readiness for excavation our
patient here is recovering from their
disease they've been transitioned to
pressure support just about two hours
ago
and we're going to take a look at their
vital signs and ventilatory information
to ascertain their readiness for
extubation
let's take a look at their ventilator
we're gonna look at the tidal volume the
respiratory rate the oxygen saturation
and a subjective assessment of the
patient's work of breathing in general
we're looking for tidal volumes that are
greater than five MLS per kilo
respiratory rates that are
age-appropriate really ensure that
they're not labored or working too hard
and we're seeing accessory muscle use
with the ventilation and also we want to
make sure that our oxygenation is
appropriate on a minimal amount of fio2
in general we'll test on forty to fifty
percent o2 and want to look at SATs that
are greater than 95%
preparation
so we've assessed our patients
ventilation things look age-appropriate
and we're going to proceed with
extubation we've had a thoughtful
discussion with the care team our
medical doctor respiratory therapist and
nurse are all on board and know their
tasks that are going to be associated
with extubation before we get ready to
actually pull the breathing tube out we
want to make sure that we prepare for
the worst but hope for the best
what I mean by that is we should have
all the available equipment for
intubation should this patient fail
excitation upon removal of the breathing
tube let's talk about some equipment
that we're going to need to perform the
excavation we're going to need a manual
resuscitating bag or an anesthesia bag
we need appropriately sized mask
interfaces for the bag we need to make
sure that we have adequate suction
equipment on board and inline suction
catheter as well as a yankauer we want
to make sure that we have a oxygen
delivery device or an aerosol mask so
that we can provide oxygen to the
patient once they've been disconnected
from the mechanical ventilator
so on top of making an appropriate plan
with the care team ensuring that
everybody knows their specific tasks
during the excavation I found it
particularly helpful to explain the
procedure thoroughly and calmly to not
only the patient but also the parents or
guardians who may be at the bedside all
right kiddo we're gonna get that tube
out of your mouth okay and just a second
I'm gonna I'm going to suction that out
get all the goobers out of your throat
and I'm going to ask you to cough for me
okay and when you cough I'm going to
pull that tube out and you're going to
be able to be a lot more comfortable
breathe on your own all right
procedure one of the important things we
want to make sure we do is suction
immediately before excavation the reason
for doing this is to not only clear the
secretions that are in the distal
portions of the lung that also make sure
that no secretion is in the back of the
throat accidentally drop down the airway
and cause excavation failure due to
secretion clearance problems with our
patient I have all my equipment my
protective gear and my gloves my suction
catheter set up for the suction I give
this kid a quick suction and we're gonna
proceed with the extubation all right
kiddo give me a couple coughs and we'll
get those secretions of your lungs all
right minimal secretions from the lungs
I'm just going to clear out the
oropharynx we're gonna get ready to
extubate all right things look clear
down there so we've assessed our patient
they've passed our extubation readiness
test we've explained the process to the
patient in the family we decided to go
ahead and pull this tube let's do that
together
all right kiddo I'm gonna pull that to
better your throat okay it's gonna feel
a little bit funny on the way out but
it's gonna feel so much better once it's
done we have our aerosol oxygen ready to
provide some oxygen and a little bit of
moisture to what may be a dry throat
upon excavation I'm going to disconnect
from the ventilator and connect our kid
to the manual resuscitating bag I'm just
going to hold a little bit of CPAP while
the patient breathes spontaneously I'm
gonna loosen the tape from the child's
face please note that if the child has a
cuffed endotracheal tube the cuff should
be completely deflated following the
suctioning of the oropharynx and just
prior to removing the tube all right
kiddo just like we talked about I'm
gonna give you a nice big breath and
then I want you to cough and as you call
I'm gonna pull this tube out ready
one two three big breath and I would
have comes our patients excavated so
we've just excavated a patient I'm going
to hook up the aerosol mask here and
suction the back of the throat out
there's just a little bit of moist air
to help you through it okay it's gonna
suction the back of the throat here
looks good so we're gonna monitor this
kid really closely for the next five to
ten minutes while we're still in the
patient's room after which we'll just
keep a close eye on for a couple hours
and make sure that we don't need to
reintubate them please help us improve
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