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

So today, I want to talk about risky extubation and what that means and what our strategies to manage risky extubation.

So, let’s just clarify the terminology. Extubation means the removal of the breathing tube, and it comes after someone has passed spontaneous breathing trials while they are on a ventilator with the breathing tube often coming out of an induced coma.

So, some extubations in ICU are very straightforward. Someone is passing the spontaneous breathing trial. They are awake, they are alert, they can obey commands. they can have a good cough, they can take deep breaths, they have a good gag reflex, and they can swallow. That is what I would refer to a straightforward extubation or removal of the breathing tube.

Keep in mind, I have worked in critical care and nursing for nearly 25 years in three different countries where I worked as a nurse manager for over 5 years and where I have been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com as part of my consulting and advocacy.

I can very confidently say that we have saved many lives with our consulting and advocacy. You can verify that on our testimonial section at the intensivecarehotline.com or on our podcast section at the intensivecarehotline.com where we have done client interviews.

So, let’s come back to “risky extubations”. So, we’ve clarified what is a straightforward extubation. 

What is a risky extubation? A risky extubation could be if there’s airway swelling. So, let’s just say a patient is ready to breathe. They passed spontaneous breathing trials, their blood gases are good, their X-rays look good, they are awake, they can obey commands, they have a good strong cough, but they’ve got an airway swelling, which means that if the breathing tube is taken out, there might be airway swelling, potentially closing the airway and people would literally suffocate.

So, how can you check for that and how can you manage that? So, the first thing that intensive care teams need to do is they need to take the cuff down on the breathing tube to see whether a patient can breathe spontaneously whilst the cuff is down and see whether there’s an air leak.

If there’s no air leak, then that could be a risk of airway swelling. The risk of taking out the breathing tube might be too high, because if the airway closes, you can’t get a breathing tube back in, and then you’re literally left with no airway unless you establish an emergency tracheostomy but all of that is too risky.

One way to manage the extubation before extubation when there’s airway swelling is with adrenaline nebulizer, steroids, get the airway swelling down. That’s one way to manage it, but you don’t want to take it out and then notice and then realizing that the airway is closed and collapsed and then start adrenaline nebulizers or give steroids because by then, it could simply be too late.

Next, other “risky extubations” could be if someone is not quite awake yet, but they’ve passed some spontaneous breathing trials, but the Glasgow Coma Scale might be an 8 or 9, they’re not fully awake, there is some brain damage or some delayed brain activity, there could be some neurological event such as seizures, epilepsy, et cetera. That could be risky to extubate someone. Other issues could be around if someone has no cough reflex, no swallow reflex. They are also risky extubation. 

Or another situation is if someone still has a pneumonia, which often happens when someone is on a ventilator, they end up with ventilator-associated pneumonia, also known as VAP.

So, how do you manage that? Well, again, one way to manage it is potentially with high flow nasal prong oxygen, or with BIPAP (Bi-level Positive Airway Pressure), CPAP (Continuous Positive Airway Pressure), with a cough assist is another strategy, a cough assist machine. Other strategies are mobilization, physical therapy, breathing exercises, coughing exercises, nebulizers, humidified oxygen or humidified air. Those are all strategies to manage “risky extubation”.

Now, just one more comment. When it comes to “risky extubation” about nutrition, most patients in ICU that are ventilated with a breathing tube have a nasogastric tube. With that nasogastric tube, nutrition can be established. Enteral feeding can be established. Now, pre and post extubation feeds are often off for a few hours, making sure there’s an empty stomach. The risk of aspiration is reduced and so forth, but feeds should be started as quickly as possible again after extubation. 

A critically ill patient needs nutrition. Studies have shown that without nutrition in critical care, the risk of complications is increased. So, nutrition is not negotiable.

So, I hope that explains to you what risky extubations are and how to manage them.

Because we get so many questions from families of critically ill patients in intensive care, that’s why we created a membership for families of critically ill patients in intensive care. 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 a membership area and via email, and we answer all questions intensive care related.

In the membership, you also have exclusive access to 21 e-books and 21 videos that I have personally written and recorded, helping you to make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always.

I also 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 handhold you through this once in a lifetime situation that you simply can’t afford to get wrong. I also talk to doctors and nurses directly. When I talk to doctors and nurses directly with you, 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.

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

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, share this video with your friends and families, and comment below what you want to see next, what questions and insights are from this video.

I also do a weekly YouTube live where I answer your questions live on the show. You will get notification for the YouTube live if you are a subscriber to my YouTube channel or if you are a subscriber to my intensivecarehotline.com email newsletter at intensivecarehotline.com.

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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