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If you want to know how to prepare for extubation, which is the removal of the breathing tube for your critically ill loved one in intensive care, stay tuned! I’ve got news for you.

My name is Patrik Hutzel from intensivecarehotline.com, and I have another quick tip for families in intensive care.

Today, I have an email here from Christopher who says,

“Hi, Patrik.

My 82-year-old mother is in ICU at Sharp Memorial Hospital. They may try to extubate her today. She passed a two-hour breathing trial on the 24th, which is the day before, but she’s slow to wake up. Also, her blood pressure is not stable after they stopped sedation. What do I do if there’s a problem at extubation time?”

Again, extubation is the removal of the breathing tube and taking someone off the ventilator. It is really a case of looking at the situation in more detail. So, before someone can be taken off the ventilator and the breathing tube, you got to make sure you’re maximizing chances that it’s not going to fail to begin with.

So, let’s look at some steps that the intensive care team needs to take. Switch off sedation completely, that’s number 1. Number 2, minimize opiate use. Ideally, switch it off completely, like morphine or fentanyl needs to be switched off completely.

You mentioned that your mom had a two-hour passing of a spontaneous breathing trial, I argue that’s not long enough. She needs to be breathing spontaneously for at least 24 hours, or she needs to be very awake where she’s almost ready to take the breathing tube out herself.

Next, your mom needs to have a good strong cough so that she can protect her airway when the breathing tube is out. Once again, she almost needs to cough the tube out. You almost need to be worried about that when she’s coughing, she’s coughing out that tube.

Then, next, if she is breathing spontaneously, it needs to be calm, it needs to be controlled, and it needs to be between 10 and 30 breaths per minute, it needs to be with tidal volumes. The volumes that she’s breathing in and out need to be adequate according to her weight.

Next, the PEEP (Positive End-Expiratory Pressure) on the ventilator needs to be 7.5 or less. Your mom needs to be awake to a point where she can squeeze your hands, where she can wiggle her toes if you ask her to.

Next, she needs to have arterial blood gases that are within normal limits when she’s breathing spontaneously. PO2 (partial pressure of oxygen) needs to be within normal limits and PCO2 (partial pressure of carbon dioxide) needs to be within normal limits. PH needs to be within normal limits.

Next, they may do a weaning trial on a T-piece. So basically, they take her off the ventilator, disconnect her from the ventilator and put what’s called the T-piece on the breathing tube and see whether she can breathe normally. If she breathes normally, all the parameters look fine, blood gases look fine, she’s obeying command, she’s coughing, that’s another good sign.

Now, other issues that could come up is airway swelling, especially when the tube is being removed. Airway swelling could come up, and then, God forbid, your mom would need to be reintubated and she can’t because there’s swelling. Once again, what needs to happen to prevent airway swelling and manage it is to deflate the balloon and see whether there’s a leakage. If there’s a leakage, that’s a good sign; that means it’s less likely that there is an airway swelling.

Also, physical therapy and physiotherapy is going to be important for extubation, leading up to it, and then also afterwards. Another option is that if your mom is struggling when she’s taken off the ventilator and the breathing tube, is to put her on BIPAP (Bi-level Positive Airway Pressure) or on CPAP (Continuous Positive Airway Pressure), which is ventilation with a mask.

Now, in the ideal scenario, that’s not going to happen, and I argue that if she’s only passed the 2-hour spontaneous breathing trial, that’s not enough. The risk of extubating her without being ready is too high. I don’t have all the ins and outs here, but I argue a 2-hour passing of a spontaneous breathing trial is not sufficient enough. She needs to breathe spontaneously for 24 hours, at least. Like I said, all the other things need to be in place as well.

Other things that can happen during extubation is that the extubation can cause sometimes damage to the vocal cords, so your mom might have a hoarse voice or no voice, pain, or stridor. Another risk is aspiration. There is a risk of aspiration when a breathing tube is removed, but by the same token, how to prevent that is basically making sure feeds are being stopped 4 to 6 hours before extubation, and also that the nurses aspirate from the nasogastric tube or orogastric tube, making sure the stomach is empty.

Also, if she’s hemodynamically unstable as you pointed out, once again, she might need to be more hemodynamically stable to be taken off the ventilator to avoid any hemodynamic instability. Worst case scenario here is that she needs to be reintubated after extubation. But when you extubate someone, it’s really critical that you choose the right time window; choosing the right time window of opportunity is really important.

So I hope that helps, Christopher.

Now, I have worked in critical care and nursing for 25 years in 3 different countries where I worked as a nurse manager for over 5 years. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have helped many families in intensive care to save their loved one’s life. You can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast where we’ve done many client interviews to verify that we saved their loved ones’ lives with our consulting and advocacy.  We have helped hundreds and hundreds of members and clients over the years with our consulting and advocacy to improve their lives instantly, making sure their loved ones get best care and treatment always.

That’s why I offer and do one-on-one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I talk to doctors and nurses directly. I handhold you through this once in a lifetime situation that you simply can’t afford to get wrong. When I talk to doctors and nurses directly, I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care.

I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care, and you can become a member if you go to intensivecarehotline.com, if you click on the membership link or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. We also review medical records, and you also have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded. All of that will help you to make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website, or simply send us an email to [email protected] with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com, and I will talk to you in a few days.

Take care for now.

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