7.17 : Endotracheal Tube Extubation

Endotracheal tube extubation is a critical procedure in weaning patients from mechanical ventilation. It involves physically removing the oral or nasal endotracheal (ET) tube, marking the final step in liberating a patient from ventilatory support.

Procedure

Extubation removes the endotracheal tube (ETT) from the patient on mechanical ventilation. It requires a well-coordinated, multidisciplinary approach involving physicians, nurses, respiratory therapists, and other healthcare professionals. The patient should sit upright during the procedure, and the endotracheal tube and oral cavity should be suctioned. The ETT is then smoothly removed during exhalation. If an orogastric tube is present, it should also be removed. This decision must be made before extubation, considering the patient's need for oral medications and nutrition. Some patients might not be ready for oral intake immediately after extubation and may require the placement of a nasogastric tube after removing the orogastric tube.

Indications for Extubation

The decision to extubate is based on several factors. These include the resolution of the condition that necessitated intubation, the patient's ability to maintain adequate gas exchange, and the patient's ability to protect their airway against aspiration.

Before initiating extubation, assessing the patient's readiness for weaning is essential. It includes evaluating the cause of respiratory failure, oxygenation and ventilation parameters, mental status, secretions, cardiovascular stability, and specific weaning parameters such as rapid shallow breathing index (RSBI), maximal inspiratory pressure (MIP), and minute ventilation.

Before Extubation Care

Before extubation, hyperoxygenate and suction the patient. Ensure all necessary equipment, including an alternative O₂ delivery device, are readily available. Loosen the ET tapes or commercial holder. Have the patient take a deep breath and deflate the ET tube cuff at the peak of inspiration.

After Extubation Care

Immediately after extubation, encourage the patient to cough and take deep breaths. Suction the oropharynx as needed. Assess their ability to speak. Provide supplemental O₂ and oral care.

In the post-extubation phase, ensuring adequate oxygenation, managing secretions, encouraging coughing and deep breathing, and maintaining airway hydration are crucial. Patients should be closely monitored for extubation failure or post-extubation stridor signs.

Carefully monitor vital signs, respiratory status, and oxygenation immediately after extubation and for the first 2 to 3 hours (per agency policy). If the patient does not tolerate extubation (e.g., decreased SpO2 levels, tachypnea or bradypnea, tachycardia, decreased Loss of consciousness (LOC), decrease in PaO2, increase in PaCO2), immediate reintubation or a trial of noninvasive ventilation may be needed.