Mechanical Ventilation - Liberation and Extubation
Requirements ...
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Mechanical Ventilation - Liberation and Extubation

Requirements for Extubation: 

   (1) Adequate oxygenation and ventilation: PaO2/FiO2 >150-200, PEEP ≤5-8 mmHg, FiO2 <0.5, pH >7.2

   (2) Sufficient mental status (3) Ability to cough (4) Able to manage secretions (5) Hemodynamically stable

      o Rapid Shallow Breathing Index (RSBI) RSBI = RR/VT; RSBI > 105 predicts extubation failure (sp>>sn)

Liberation Protocol - Daily Spontaneous Awakening Trial (SAT) + Spontaneous Breathing Trial (SBT)

 • SAT: ↓ ventilator time, ICU LOS, and mortality if paired with SBT 

 • SBT: ~30 min daily trials with little/no vent support (≤ 5 of PEEP on PSV, generally 0 PEEP unless COPD) = ↓ vent time

 • Ways to fail SBT: Hypoxemia (SaO2 <90%, PaO2<60), hypercarbia (PaCO2 ↑ by >10), respiratory distress (↑HR/RR, accessory muscle, diaphoresis, dyspnea, anxiety), arrhythmia, hemodynamic instability, AMS

Extubation Strategies:

 • Extubation to NIPPV or HFNC in patients with hypercarbia / risk factors for reintubation→ ↓ post-extubation respiratory failure (NB: worse outcomes if NIPPV used as rescue therapy during post-extubation respiratory failure vs. re-intubation) (Lancet 2009;374:1082)

 • Early tracheostomy if expect intubation >14 days→ ↑comfort, allows ↓sedation, ↓risk of tracheal stenosis

 • Check for absence of cuff leak / laryngeal edema before extubation → consider methylpred 20mg IV Q4H during 12hr prior to extubation if concerned for laryngeal edema

 • If agitation is limiting ability to extubate, consider dexmedetomidine → may improve odds of extubation



#Liberation #Extubation #Mechanical #Ventilation #management #pulmonary #criticalcare
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