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How to Avoid Reintubation after Extubation! Quick Tip for Families in Intensive Care!
Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.
So, one of the questions that we get quite frequently is, “How to avoid reintubation after extubation, i.e., if your loved one has a breathing tube in their mouth and they get extubated, how can you avoid being reintubated?” And I have seen in over 20 years of ICU, plenty of reintubations after extubation, and it’s rarely good. Often patients end up with a tracheostomy if you need to reintubate them. So, let’s focus on today, how to avoid reintubations?
So, number one is, make sure that you’re following all the right steps when you extubate someone that you are choosing the right window of opportunity when to extubate someone. How do you know when is the right time? How do you know when the right window of opportunity is there? Well, I’ve written an article and made a video about, “How to wean someone off a ventilator and a breathing tube?” and I have put a link below this video.
So, certain boxes need to be ticked, such as patient needs to be awake, needs to be breathing in pressure support or CPAP (continuous positive airway pressure) with a pressure support of less than 10 and a PEEP (positive end expiratory pressure) of 5, less than 35% of FiO2 (fraction of inspired oxygen), arterial blood gases need to be good, patient needs to be obeying commands and have a good, strong cough. That’s it in a nutshell. But there’s more information in the article and video that I’ll link to underneath this video.
Next, make sure once the patient is extubated, or your loved one is extubated, again, they do deep breathing exercises. They get physiotherapy or physical therapy. They get mobilized as quickly as possible. They get good pain relief if they are in pain. Ideally, no opiates such as morphine or fentanyl because they have respiratory depression as a side effect. So, you certainly don’t want to go in with the big guns and have medications being given that have respiratory depression as a side effect. But sometimes, that is the only way. So, it needs to be finely titrated and finely balanced.
Next, make sure the patient stays awake because they can be quite comatose when they come out of an induced coma. Keep talking to them. Give them good nursing care. Give them a good bed bath, make sure they’re getting good mouth care, eye care, nose care. Very important. You wash their back quite frequently. Ideally, get them to a shower, and a good ICU, we’ll take them to a shower. That’s assuming there’s no fractures or surgical wounds that’s holding them back, but there’s plenty of patients in ICU that don’t have any surgical wounds, or no fractures and they can still have a shower.
Now also, how you can also avoid reintubation is to monitor the patient very, very closely. Monitor their respiratory rate, their breathing rate. Monitor, again their pain threshold. Monitor their heart rate. Monitor their oxygen saturation. Do an arterial blood gas after extubation. Do them frequently, at least for the first 24 to 48 hours to make sure that breathing is physiological, is adequate so that the patient can move forward and can eventually leave ICU.
Next, if things don’t go as planned, a patient might start with some high flow nasal prongs. High flow nasal prongs give humidified air and humidified oxygen with a little bit of PEEP. They’re just nasal prongs in the nose, but they are really comfortable for most patients, that’s at least what patients described. They’re sitting quite comfortably in the nose and they’re delivering, again, humidified, warm air or oxygen and a little bit of PEEP. So, that can help.
Again, deep breathing exercises, coughing regularly, making sure that someone is listening to the chest with a stethoscope, making sure there’s air entry going in and making sure there’s no fields in the lung where there’s no air entry, follow up with the chest x-ray after extubation as well.
Now, if all of that fails, you also need to look at the next level is BIPAP or CPAP. So, with a mask that’s non-invasive ventilation, ventilation with a breathing tube is invasive ventilation because the tube goes down into the lungs. And ventilation with a BIPAP or CPAP mask is non-invasive ventilation, but it’s nevertheless mechanical ventilation. So, that might help as well. But again, BIPAP or CPAP is more uncomfortable. There’s more aspiration risk you certainly don’t want to aspirate. That’s another thing, especially in the first 12 to 24 hours, slow oral intake. Just some sips of water, maybe. Some ice, some crushed ice, maybe some ice cream. If your loved one is up for it. But certainly, no solid foods to begin with, because of aspiration risk, especially if someone has been intubated for quite some time. They need to start to learn to talk again. Their vocal cords have been paralyzed. So, those are things that need to be considered as well.
Last but not least long time ago, when I first started in ICU nearly 25 years ago, there was also a machine called the cough assist machine. And whilst we’re using the cough assist machine in the community for our clients at Intensive Care at Home, it hasn’t been used in ICU much in the last 25 years, but it used to be used, especially after cardiac surgery or open-heart surgery, very effective. That’s another way to potentially avoid reintubation by using a cough assist machine. Cough assist machine gives a positive and a negative PEEP, makes patients cough, and really clears the airway and avoids atelectasis and pneumonia and chest infections.
And before I forget about it, just one more tip, how to avoid reintubation, especially when patients are immobile and you’re turning them to the side, make sure you give them some chest percussions. Wash their back, put some cream on their back, and give them some nice chest percussions. Rub up any secretions that might be there that the patient can’t get up yet. And also, again, seat them up, seat them to the edge of the bed, give them some chest percussions. Make sure they’re sitting up straight and do deep breathing exercises and coughing exercises. Very, very, very important to avoid reintubation.
So, that’s my quick tip for today.
If you have a loved one in intensive care, go to intensivecarehotline.com. Call us on one of the numbers on the top of our website, or simply send us an email to [email protected].
Also, have a look at our membership for families in intensive care at intensivecaresupport.org. There, you have access to me and my team, 24 hours a day, and we answer all questions intensive care related, and Intensive Care at Home related.
Also, if you need a medical record review for your loved one in intensive care, we review medical records in real time when your loved one is in intensive care, but also after intensive care, especially if you suspect medical negligence.
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This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.