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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

Today’s tip is about, “When a trial extubation should be done?” This is a question we’re having from a member. By the way, we have a membership for families of critically ill patients in intensive care where you can get access to the membership at intensivecarehotline.com by clicking on the membership link or you go to intensivecaresupport.org directly.

Back to our member who’s asking, “When should the trial extubation be done?” Now, for some context, our member’s husband has been in intensive care for about 10 days. Now, he’s very slowly coming out of an induced coma after aspiration pneumonia. He’s coming off sedation. He’s having his first couple of days with spontaneous breathing trials and they’re going okay. But he’s probably not quite ready for extubation yet.

Now, what does extubation mean? Extubation means the removal of a breathing tube and the disconnection from the ventilator. Now, generally speaking, extubation should be done when a patient is ready for extubation. That means they need to be hemodynamically stable. They need to be breathing spontaneously for a couple of days on spontaneous breathing trials on CPAP (Continuous Positive Airway Pressure) pressure support. Their arterial blood gases need to be good. Their chest X-rays need to be clear. Patients need to be neurologically responding. Then, there’s a very good chance that an extubation will actually be successful.

Now, there are borderline situations where you can’t be sure whether an extubation will be successful and that is then called a trial extubation. That is when a patient is maybe not quite awake yet, maybe when their breathing rate is a little bit on the high side, maybe they’re simply exhausted, maybe they have been in a prolonged induced coma.

Should that stop people from extubating a patient in an intensive care if it’s sort of borderline situation? It really depends, you don’t want to extubate someone and then reintubate them because that has certain risks attached as well.

By the same token, you don’t want to not try either because if you’re successful with an extubation, you can avoid the tracheostomy, and that should always be the goal to successfully extubate someone, to successfully get them off the ventilator, and so forth.

Now, I’ll come in a minute to, “How you can prepare for trial extubation, and what should be put in place?”

But coming back to, “When would you do a trial extubation?” So, I explained when the patient is not quite ready. Another situation is when there’s airway swelling. So, for example, there’s swelling around the trachea and you are actually worried that when you take out the breathing tube, that the airway will swell further and then there could be an airway blockage and then the patient can’t breathe. That could be another reason why someone wants to do a trial extubation. But you actually need to make sure that the airway isn’t swelling all the way up so then the patient could potentially suffocate, literally suffocate.

So, when a trial extubation is done, one thing that you need to prepare for is often BIPAP (Bilevel Positive Airway Pressure) or CPAP (Continuous Positive Airway Pressure) ventilation with the mask. So, if it fails, you have to back up with BIPAP or CPAP.

Also, important that you keep a patient NIL by mouth, that you stop the nasogastric or a gastric feed for at least 4 to 6 hours, making sure you’re not extubating on a full stomach because that could get a patient to vomit and could get a patient to aspirate.

Other very important factors when it comes to extubation or trial extubation is chest physiotherapy and mobilization deep breathing exercises, coughing exercises, mobilization, is absolutely critical, sitting on the edge of the bed, getting out in a tilt table in a chair, in a reclining chair, so important. A lot of work, a lot of physical work that needs to go into that, but it is so important to do that to keep a patient off the ventilator or wean a patient off the ventilator.

Lastly, we could also look at high-flow nasal prongs and oxygen via the high flow nasal prongs. The high-flow nasal prongs give a little bit of PEEP (Positive End-Expiratory Pressure) similar to the BIPAP or CPAP. It gives up to 5 of PEEP apparently, whereas with the BIPAP or CPAP, you can go up with a PEEP to 15 or even higher, but hopefully you don’t need that.

So, there are ways to manage a trial extubation and keep a patient off the ventilator. There’s no guarantee. The safest option is not to do a trial extubation but to do a tracheostomy. But then, it is a surgical procedure, and then you’ve got an artificial airway. If you can avoid that, you should.

I’ve done plenty of videos about, “How to wean a critically patient off the ventilator and the breathing tube?” I’ve done videos about, “How long can a breathing tube stay in?” Done videos about, “When should the tracheostomy be done?” and so forth. But today, it was really about trial extubation.

Now, if you want your questions answered as part of our membership in real-time, I encourage you to go to intensivecarehotline.com and click on the membership link. We have a membership for families of critically ill patients in intensive care where 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 also or you can go to intensivecaresupport.org directly for access to the membership.

Also, I offer one-on-one consulting and advocacy over the phone, via Skype, WhatsApp, Zoom, or whichever medium works best for you. I talk to doctors and nurses directly and I ask all the questions you haven’t even considered asking but must be asked so that you can make informed decisions, have peace of mind, control, power, and influence.

I also represent you in family meetings with intensive care teams. I have been in hundreds of family meetings with intensive care teams, and I know how to represent you there. It’s critically important that you have advocacy and clinical representation when you go to a family meeting with intensive care teams, and I can help you with all of that.

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

Why am I offering all of that all of the services that we are providing? Well, I am a critical care nurse, having worked in critical care for over 20 years in three different countries where I also worked as a nurse unit manager for over five years in intensive care and I’ve been consulting and advocating for families in intensive care for the last 10 years is part of intensivecarehotline.com and I’ve been advocating for families in intensive care all over the world.

Now, if you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care, click the like button, click the notification bell, comment below what you want to see next or what questions and insights you have and share the video with your friends and families.

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.