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art & science clinical skills: 17

A practical guide to extubation


Scales K, Pilsworth J (2007) A practical guide to extubation. Nursing Standard. 22, 2, 44-48.
Date of acceptance: May 25 2007

Summary
This article reviews current practice in relation to extubation and
the relative merits ofthe available techniques. The procedure for
extubation is described as well as the potential complications and
nursing care of the patient following extubation.

Authors
Katie Scales is consultant nurse, critical care and Julie Pilsworth is
sister, critical care outreach, Charing Cross Hospital, Hammersmith
Hospitals NHS Trust, London. Email: kscales@hhnt.nhs.uk

Keywords
Endotracheal extubation; Mechanical ventilation; Procedure
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.

ENDOTRACHEAL INTUBATION is the


placement of an endotracheal tube (ETT) through
the larynx and into the trachea (Figure 1). Itcan
be performed orally or nasally. In the UK, the oral
route is most frequently used for intubation. To
perform elective intubation sedative agents and
muscle relaxants are administered and the patient
will require artificial ventilation until the
medications have worn off or been reversed, for
example, during a surgical operation. Emergency
intubation may be required if a patient is unable
to breathe spontaneously or if the cough and gag
reflexes are absent, for example, during cardiac
arrest or sustained loss of consciousness.
Intubation is usually performed to (Mims etal
2004): maintain a patent airway; facilitate
bronchial suction; protect the airway from
aspiration; or facilitate mechanical ventilation.
Extubation is the removal of the ETT when it is
no longer required (Mims ei a/2004).
The duration of intubation and ventilation will
depend on the patient's condition but generally
patients who undergo routine or uncomplicated
surgery will only require short-term peri or postoperative ventilation, while critically ill patients
may require long-term ventilation. Short-term
ventilation is defined as three days or less and
long-term ventilation as greater than three days
(Clement and Buck 1996, Charleboiseia/2005),
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although these are not universally agreed


definitions. Many long-term ventilated patients
will require a tracheostomy for ongoing
ventilatory management and the ETT will be
removed at the time of tracheostomy formation.
Irrespective of the duration of ventilation
the aim is to wean patients successfully from
ventilation and extubate. Ventilatory weaning is
defined as: 'the gradual reduction of ventilatory
support and its replacement with spontaneous
ventilation' (Intensive Care Society 2007).
However, the weaning process and the procedure
of extubation are two discrete and separate
processes (Epstein 2001).
Ventilatory weaning and extubation have
traditionally been medical roles, although evidence
suggests that extubation can be performed safely
by nurses using weaning and extubation protocols
(Ely ei a/2001). The implementation of local
policies relating to ventilatory weaning and
extubation has enabled nurses to take on this role
without the need for direct consultation with
anaesthetic staff (Anderson and O'Brien 1995).
The benefits of early ventilatory weaning and
extubation are reported in the field of fast-track
cardiac surgery and include more efficient use of
intensive therapy unit (ITU) facilities, fewer
cancelled operations and reduced costs ( Aps
1995, Howard 1995, Cheng 1998, Reis etal
2002, Kogan etal 2003). Nurse-led extubation is
not limited to the adult population and is
reported in neonatal care and paediatrics (Luyt et
al 2002, Lucier and Brisson 2003 ).
Post-operative extubation in theatre is primarily
performed by anaesthetists while extubation in
recovery areas or ITUs is increasingly performed
by experienced nurses. A recent study of ITUs in
England and Wales found that 35 % of extubtions
were performed by nurses, 10% by doctors and
30% were performed jointly by doctors and nurses
(Suresh and Cheesman 2006).
Nurse-led extubation has been shown to
reduce the incidence of unplanned extubation
in intensive care (Birkettei/2005). Unplanned
extubation occurs when a patient removes his or
her ETT (self-extubation) or when an ETT
is accidentally removed (de Lassence etal 2002).
Intubated patients can become restless and
agitated when waking up from sedation.

If extubation is delayed there is an increased risk


that patients may traumatically remove their
ETT while waiting to be extubated. This is
classified as an unplanned extubation and is used
asa quality marker in ITUs (Curtis ez/2006).
Nurse-led extubation protocols allow the nurse
to assess the patient's readiness for extubation
and to extubate in a timely manner as soon as the
patient is ready. Such protocols have been shown
to reduce the incidence of unplanned extubation
inITUs(Birketteifl/2005).

FIGURE 1
Endotracheai intubation
Laryngoscope

Pilot balloon

Trachea
Endotracheal tube

Extubation criteria
The patient should be clinically ready to be
extubated. Howard (1995) proposed specific
nursing extubation criteria following fast-track
cardiac surgery:
The patient should have a good respiratory
pattern.
Pain should be well controlled.
The patient should be awake enough to
maintain his or her own airway.
The patient should have satisfactory arterial
blood gases (ABGs) on 50% oxygen or less:
Partial pressure of oxygen in arterial blood
(PaO2)of 10 kilopascals (kPa) or greater.
Partial pressure of carbon dioxide in arterial
blood (PaCO2) of 7kPa or less.
Oxygen saturation (SpO2) 94% or greater.
Base excess of -5 or less (unless
deteriorating).
These objective criteria can be easily applied to
the post-operative cardiac surgical patient.
Aps (1995) suggested less specific medical
criteria for the extubation of fast-track cardiac
surgical patients:
Circulation satisfactory and stable.
Patient awake, neurologically intact and
co-operative.
Patient centrally normothermic, peripherally
warm and well perfused.
Sensible gas exchange.
These criteria require the application of clinical
judgement and are less prescriptive. While
specific criteria may help nurses to decide that
extubation is appropriate, clinical judgement
remains an important element in the decision to
extubate. Leitchei a/(1996) concluded that
bedside clinical judgement produced satisfactory
outcomes in relation to weaning and extubation,
and that mechanical predictive indices such as
vital capacity, respiratory rate and tidal volume
had limited practical use.
NyRSI^3G STANDARD

In a survey by Suresh and Cheesman (2006),


41 % of ITUs had a written protocol for extubation
but it was unclear whether the protocols were
nurse or doctor led. Published protocols appear to
focus on decision making before extubation and
assessing readiness for extubation, rather than the
procedure of extubation (Anderson and O'Brien
1995, Howard 1995).
In general adult patients who are ready for
extubation usually meet the following broad
system-based criteria (adapted from Anderson
and O'Brien 1995):
Neurology: the patient should be alert and
co-operative.
Cardiovascular: the patient should be stable,
with systolic blood pressure of lOOmmHg or
greater. There should be minimal inotropic
support and the patient should not be bleeding
or have any major metabolic disturbance.
Respiratory: the patient should have an
adequate cough and ability to clear secretions,
satisfactory ABGs on minimal oxygen,
effective spontaneous breathing and should
not be tachypnoeic.
Pharmacology: muscle relaxants should be
discontinued and the effects worn off.
Sedation should usually be stopped. Pain
should be adequately controlled to facilitate
coughing and deep breathing.
Extubation is not always successful. The strength
of the patient's cough and the volume of
respiratory secretions have been shown to be a
predictor of extubation failure. In a study by
Khamiees etal (2001 ) patients who were
recovering from respiratory failure and who still
required suction of respiratory secretions two
hourly, or more frequently, were 16 times more
likely to have a failed extubation than patients
with minimal or no secretions. Patients with a
September 19 :: vol 22 no 2 :: 2007 45

art & science clinical skills: 17


weak cough were shown to be four times more
likely to have a failed extubation than patients
with a strong cough (Khamieeseia/2001). Once
the ETT has been removed patients must be able
to cough and expectorate. An ineffective cough
may result in retained secretions, which will
impair gas exchange and predispose them to
pneumonia. If patients cannot manage their
secretions they will require re-intubation and
their extubation will have failed.
Preparation for extubation
It is important to ensure a safe environment at all
times. Emergency equipment should be available
to re-intubate the patient if extubation fails
(American Association for Respiratory Care
( AARC) 2007) or to manage any complications
of extubation. Equipment should be checked to
ensure that it is working correctly. Consideration
should be given to the timing of extubation. Postoperative extubation will take place when the
operation is complete, however, elective
extubation of critical care patients is usually
carried out during normal working hours when
senior medical assistance is available. Extubation
should be planned in relation to the workload
of the rest of the unit. Following extubation a
member of staff should be available to observe
the patient closely on a one-to-one basis.
The extubation procedure should be
explained to the patient. Patients are usually
positioned upright in a Fowler's position (head of
the bed is raised 45-60 degrees and the patient's
knees are elevated slightly), however, obese
patients or patients with a large abdomen may
Equipment for extubation
Cardiac and respiratory monitoring devices, for example,
electrocardiogram (ECG) and puise oximetry (SPO2).
iHigh vacuum suction equipment
Yani<auer sucker - a rigid, hoiiow tube with a curve at the distai end
to mai<e it easier to remove thici< pharyngeai secretions.
Steriie suction catheters.
Non-steriie gioves.
lOmi syringe.
Scissors.

breathe more effectively in a reverse


Trendelenburg position (head is higher than the
body and legs) (Winslow 1996). Box 1 lists the
equipment required for extubation.
Methods of extubation

There are two main methods of extubation. The


first is the traditional method of placing a suction
catheter through the ETT and into the trachea.
When suction is applied the cuff of the ETT is
deflated and the ETT and catheter are removed
together. This is the trailing suction catheter
technique (Suresh and Cheesman 2006). The
advantage of this technique is that secretions in
the chest or pharynx are removed by suction, but
disadvantages include the risk of hypoxia and
atelectasis.
The positive pressure breath technique is the
second method. A re-breathing bag delivers a
positive pressure breath using 100% oxygen and
simultaneously the cuff on the ETT is deflated.
Once the breath has been delivered the tube is
immediately withdrawn without suction (Suresh
and Cheesman 2006). Consequently the first
post-extubation event should be a cough. This
enables the patient to clear his or her airway and
provides improved oxygnation.
Cuglielminotti etal (1998) studied the effects
ofthese two techniques on arterial oxygen
saturation in children. They concluded that
trachal extubation greatly impairs oxygnation
and that this was more marked when suction was
used during the extubation procedure. They
recommended lung inflation with 100% oxygen
before routine trachal extubation.
In Suresh and Cheesman's (2006) audit of ITU
extubation practice in England and Wales, 215
questionnaires were sent to the nurse in charge
of all ITUs registered with the acute hospitals
register. The response rate was 82%. The results
revealed that 85% of ITUs used the trailing
suction catheter technique while 15% used the
positive pressure breath technique. Although the
trailing suction catheter technique has been the
traditional method for many years in the UK, a
change in practice is required to reduce the
recognised complications of extubations.
Extubation should be performed by two
competent practitioners. Whether extubation is
nurse-led, protocol led or medically led depends
on local unit practices. A step-by-step guide to
positive pressure breath extubation is provided
in Box 2.

Re-breathing bag (Water's circuit or Mapleson C circuit).


Self-infiating resuscitation bag v>/ith valve and masi<.

Nursing care following extubation__

Oxygen delivery device, face masi< or nasai cannuiae.

Respiratory and cardiovascular observations


should be performed following extubation to
assess the success of the procedure and to detect

Cardiac arrest troiley with intubation equipment.


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WRSING STA^3DRD

early complications. Respiratory observations


are summarised in Box 3.
If breathing is difficult the sympathetic nervous
system will produce a stress response. The heart
rate will increase, the blood pressure may also
increase and the patient's peripheries will begin to
cool as vasoconstriction occurs (Lowe etallOOl).
Routine cardiovascular observations of pulse,
blood pressure and peripheral skin temperature
and patient assessment should detect these
changes before a crisis occurs.
After extubation the patient should be able to
talk and this may be the first opportunity to assess
the patient's neurology. Neurological evaluation
using the Glasgow Coma Scale (GCS) should take
place regularly after extubation ( AARC 2007). If
the patient retains carbon dioxide (CO2) postextubation he or she may become drowsy. This
can be detected by a GCS assessment. An ABG
will confirm this complication. In post-operative
patients CO2 retention may be the result of recent
anaesthesia rather than respiratory failure,
patients should be encouraged to deep breathe
until they are properly awake. Patients may also
need assistance to cough and to clear secretions.
Many patients are thirsty and request oral
fluids post-extubation. The nurse may feel
confident to decide when to start oral fluids or
may seek advice from the anaesthetist. Howard
(1995) stated that there was no mandatory nilby-mouth period after extubation. Patients can
start to drink as soon as they wish provided that
the nurse is satisfied that the individual can
maintain and protect the airway. Short-term
ventilated post-operative patients have little risk
of impaired swallowing but patients who have
sustained head injury or stroke or who have been
on long-term ventilation may have impaired
swallowing and may be at risk of aspiration on
reintroduction of oral fluids. If there is any doubt
about the safety of a patient's swallow reflex the
patient should remain nil by mouth and a formal
swallow test should be performed. Regular
mouth care will be necessary if the patient
remains nil by mouth.
Complications of extubation
Major airway and respiratory complications of
extubation are common. Rassamei<3/(2005)
conducted an anonymous postal survey of
consultant anaesthetists to investigate extubation
techniques. Their retrospective survey revealed
that 37% of anaesthetists had experienced
post-extubation complications in the three
months leading up to the survey. Laryngeal spasm
accounted for 25 % of all reported extubation
complications. Desaturation was the next most
frequently reported complication, which was
defined as an SpO2 of less than 94% and
WURSING STANDARD

accounted for 22% of all reported complications


(Rassam ei 0/2005). Complications may not
occur immediately and patients will continue to
require close observation. Nurses working in
ITUs and recovery should have basic airway skills
to enable them to manage airway problems until
help arrives (Rassam ei a/2005).
An earlier prospective survey by Asai et al
(1998) revealed a complication rate of 12.6%
immediately after extubation, with a further
9.5 % of patients experiencing complications
in the recovery room. Complication rates were

Procedure for positive pressure breath extubation


I Position the patient and check the emergency equipment
2. Ensure electrocardiogram and pulse oximeter are in place, alarm
parameters are set and alarms are activated. This provides baseline
observations and alerts the nurse to changes in vital signs.
3. Connect a re-breathing bag to an oxygen flow meter. Prepare the oxygen
that will be used after extubation on a separate flow meter.
4. Suction the chest if secretions are audible.
5. Suction the oropharynx with a Yankauer sucker to remove oropharyngeal
secretions while avoiding deep pharyngeal suctioning which may cause the
patient to gag and salivate. Keep the Yanl<auer sucker to hand.
6. The first practitioner should attach the re-breathing bag to the
endotracheal tube (ETT) and support the ETT while the second cuts or
unties the tape holding the ETT in place.
7. The second practitioner should then insert the 10ml syringe into the pilot
balloon of the ETT
8. The first practitioner delivers a 100% oxygen positive pressure breath via
the re-breathing bag, simultaneously the second deflates the cuff on the
ETT, and the first practitioner withdraws the ETT in one swift movement.
9. The second practitioner should be ready to suction the mouth when the
patient coughs and to apply the oxygen delivery device.

Respiratory observations
Inspection: observe for rate, rhythm, work of breathing (effort), use of
accessory muscles, chest symmetry, chest expansion (depth of respiration),
prolongation of exhalation, obstructive breathing pattern (see-saw
breathing) or respiratory distress.
Auscultation: listen for the presence of breath sounds to all zones, added
sounds such as retained secretions, bronchospasm and bronchial breathing.
Palpation: tactile assessment of chest wall movement usually performed to
confirm inspection findings and to assess expansion, may also detect tactile
fremitus (vibrations from secretions).
Breathlessness: assessment of ability to communicate, for example, talking
in long or short sentences, broken sentences, single words or not at all.
Stridor: a harsh 'crowing' sound on inspiration that can be heard without
a stethoscope, suggesting a degree of airway obstruction,
SpO2 (oxygen saturation) and FO2 (inspired oxygen concentration).
Arterial blood gases: usually performed 30 minutes after extubation.

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art & science clinical skills: 17

Conclusion

higher in men than in women, higher in obese


patients and higher if extubation occurred during
deep anaesthesia rather than after the patient had
regained consciousness (Asai etal 1998). Suresh
and Cheesman (2006) reported hypoxia to be the
most commonly encountered post-extubation
complication.
Extubation failure, usually defined as the need
for re-intubation 24-72 hours after planned
extubation, ranges from 2-25% with the highest
incidence of extubation failure occurring in
complex ITU patients (Epstein 2002). Medical,
paediatric and older ITU patients are most likely
to experience extubation failure. The most
common reasons for extubation failure include
inadequate cough, excessive secretions, airway
obstruction, encephalopathy and cardiac
dysfunction (Epstein 2002).

Little has been written about the practical


procedure of extubation. A review of the
hterature highlights two methods of extubation
and the limited evidence suggests that the
positive pressure breath technique is superior to
the trailing suction catheter technique (Suresh
and Cheesman 2006) and is associated with
improved oxygnation post-extubation
(Cuglielminotti etal 1998). Despite this, 85% of
ITUs use the trailing suction catheter technique.
Of extubations in ITUs, 35 % have been
shown to be nurse-led with a further 30% being
joint procedures between nursing and medical
staff (Suresh and Cheesman 2006). This suggests
that nurses are well placed to change practice in
relation to extubation. The development and
implementation of evidence-based protocols
might help to reduce the common complication
of hypoxia following extubation and support the
expansion of nurse-led extubation NS

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