After Coming Off the Ventilator, Is There a Chance to Go Again Ventilated?

Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!

This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was

My Mom is Admitted to the Hospital with an Infection. Why Do the Doctors Keep on Convincing me to Put my Mom into a “Do Not Resuscitate” (DNR) status? Help!

You can check out last week’s question by clicking on the link here.

In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions that we get quite frequently as part of my 1:1 consulting and advocacy service!

After Coming Off the Ventilator, Is There a Chance to Go Again Ventilated?

Taking patient off a ventilator is usually a gradual process, often referred to as weaning. There are numerous articles that describe this process in detail, and clear protocols have been developed. Assessment of a patient’s readiness for removal of the endotracheal tube in the ICU is based on:

ability to maintain a patent upper airway

ability to cough and clear secretions

ability to follow 4 simple tasks (ie, open eyes, track with eyes, grasp with hands, and stick out tongue)

adequate ABG (Arterial Blood Gas)

sitting up in bed

Reintubation is common following extubation and discontinuation of mechanical ventilation. The extubation failure rate considered acceptable has empirically been set at 10–15%, but avoiding reintubation remains an important clinical goal.

Extubation failure-need for reintubation within 72 h of extubation, is common in intensive care unit (ICU). It can cause increased morbidity, higher costs, higher ICU and hospital length of stay (LOS) and mortality.

Due to the high economic and personal costs of prolonged weaning and extubation failure, it is imperative that the critical care nurse monitor factors such as patient discomfort, fatigue, sweating, work of breathing, mental status, and vital signs during weaning. In addition, measures such as these can be taken prior to the start of a Spontaneous Breathing Trial (SBT) to encourage successful breathing:

Optimizing muscle strength by providing adequate nutrition, avoiding neuromuscular blockers that paralyze the muscles that are necessary for breathing like cisatracurium or rocuronium , decreasing corticosteroids, and normalizing electrolytes.

Decreasing respiratory work by placing the patient in an upright position, decreasing respiratory demand and resistance, and increasing compliance.

Optimizing ventilator drive by reducing or stopping sedative medications.

Increasing oxygen-carrying capacity by avoiding factors that cause atelectasis or collapse of the lung, correcting anemia and blood gases imbalances.

Addressing cardiac dysfunction and oxygen-carrying capacity.

Promoting sputum clearance.

Mobilization as appropriate. (6)

HOW TO WEAN A CRITICALLY ILL PATIENT IN INTENSIVE CARE OFF THE VENTILATOR AND THE BREATHING TUBE!

WHO ARE AT RISK FOR EXTUBATION FAILURE? (3)

Patients with advanced age

High severity of illness at ICU admission and extubation

Preexisting chronic respiratory and cardiovascular disorders

Unresolved illness

Development and progression of organ failure during the time from extubation to reintubation

Prolonged sedation and prolonged induced coma

*Reintubation itself have been proposed as reasons for increased mortality and morbidity*

PARAMETERS USED TO PREDICT EXTUBATION FAILURE CAN BE CATEGORIZED INTO:

assessing respiratory mechanics

assessing airway patency and protection

cardiovascular reserve

*The intensivist needs to identify patients at high risk of extubation failure and be prepared to reinstitute ventilation early to prevent adverse outcomes*

NECESSARY FOR SUCCESFUL EXTUBATION:

Adequate cough strength

Minimal secretions

Alertness

Stable vital signs

Acceptable blood gas results and chest x rays

HOW LONG DOES IT TAKE TO COME OFF A VENTILATOR/ RESPIRATOR IN INTENSIVE CARE?

FAILED EXTUBATION CONSEQUENCES

To predict “extubation failure” is essential, as both delayed and failed extubation have detrimental consequences such as:

prolonged ventilation and ICU stay

need for tracheostomy

increased cost of treatment and mortality

CAUSES OF EXTUBATION FAILURE

poor nutrition

decreased level of consciousness due to persistent effects of sedative and analgesics

neurological impairment due to primary illness

respiratory failure which manifests with increased work of breathing, accessory muscle use, hypoxia

failure to maintain airway patency due to upper airway edema seen in patients with prolonged translaryngeal intubation and evident as stridor

Excessive secretions, coupled with inadequate muscle strength and glottic incompetence

Prolonged sedation and induced coma

WHAT IS AN UNPLANNED EXTUBATION?

Endotracheal intubation is always being done in the hospital for patients who have and may have problems with their airway and it is very important to monitor closely these patients to always secure the breathing tube in place to avoid unplanned extubation.

An unplanned extubation occurs when a patient is on mechanical ventilation and their endotracheal tube is removed when it was not supposed to be.

If the patient themselves intentionally removes their own tube, this is known as self-extubation or deliberate unplanned extubation, whereas if the tube is removed by health professionals, or a patient removes it by accident, it is referred to as accidental extubation. (4)

Unplanned extubation can increase the amount of time a patient must remain on mechanical ventilation, the duration of the patient’s hospital stay, and the patient’s medical costs. It is also estimated that 60% of patients who experience an unplanned extubation require re-intubation, which may increase the risk of ventilator-associated pneumonia.

MANAGEMENT OF FAILED EXTUBATION

A reasonable strategy to prevent failed extubation, if anticipated, can be:

continued ventilation

treatment of remediable causes of muscle weakness and excessive secretions

daily assessment for readiness to extubate

Specific therapies can be used only when the cause for failed extubation is known.

If extubation failure is due to cardiac failure adequate anti-failure with diuretics and vasodilators can be instituted and then extubation attempted.

Performing tracheostomy is another option; however, the problem of removing artificial airway still remains and tracheostomy has its own complications.

Only two options seem promising in failed extubation, non-invasive ventilation and prophylactic steroids

Intubation is one of the integral parts of the hospital procedures as it is considered as an emergent life support measure. Being able to successfully remove the breathing tube of your loved one or wean them from a ventilator requires prompt and proper implementation of the successful extubation recommendations to avoid getting your loved one again ventilated. Such circumstance needs that the critical care nurses and the team serve as leaders in the adoption of the above recommendations to ensure that patients receive the highest quality of care during mechanical ventilation, weaning and successful extubation.

REFERENCES:

Factors Associated With Reintubation in Intensive Care https://www.researchgate.net/publication/11841633_Factors_Associated_With_Reintubation_in_Intensive_Care

Predictors of Reintubation in Critically Ill Patients http://rc.rcjournal.com/content/59/2/178

Extubation failure in intensive care unit: Predictors and management https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760915/#sec1-1title

Unplanned Extubation https://en.wikipedia.org/wiki/Unplanned_extubation

Unplanned Extubation in Adult Critical Care: Quality Improvement and Education Payoff https://aacnjournals.org/ccnonline/article-abstract/24/1/32/891/Unplanned-Extubation-in-Adult-Critical-CareQuality?redirectedFrom=fulltext

Mechanical Ventilation Weaning: An evidence-based review https://journals.lww.com/nursingcriticalcare/Fulltext/2018/11000/Mechanical_ventilation_weaning__An_evidence_based.2.aspx

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