Policies and Procedures Title: ENDOTRACHEAL TUBES (ADULT, PEDIATRIC) EXTUBATION Number: 1162 Authorization: [x] SHR Nursing Practice Committee Source: Nursing / Respiratory Therapy Cross Index: SHR Region-Wide Policies & Procedures Manual: #7311-60-017 Verification of Patient/Resident/Client Identification Before the Initiation of Treatment, Procedure or Therapy Date Revised: November 2012 Date Approved: February 2004 Date Effective: March 2004 Scope: SHR Acute Any PRINTED version of this document is only accurate up to the date of printing 8-Feb-13. Saskatoon Health Region (SHR) cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for the most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or organization not associated with SHR. No part of this document may be reproduced in any form for publication without permission of SHR. Definition: Extubation is the removal of an endotracheal tube (ETT) 1. PURPOSE 1.1 To safely remove oral or nasal endotracheal tubes. 2. POLICY Who may extubate Physician order required Special considerations Registered respiratory therapists (RRT) will extubate. If RRT coverage is not available (such as an unplanned extubation or in Urban Acute Care PACU), the extubation can be performed by a: - Registered Nurse or Nurse Practitioner (RN-NP) certified in ETT extubation - Physician - Intermediate Care / Advance Care paramedic Yes NOTE: if patient is receiving enteral nutrition, an order is required to temporally stop the nutrition if necessary. A second qualified health care professional must be available in case help is needed. A person skilled in intubation must be immediately available for reintubation if necessary. Pediatrics: NPO status or stop gastric feeds 4 hours prior to extubation. If jujenal feeds, stop immediately prior to extubation. Supplies Suction setup oral and tracheal Personal protective equipment Bag-valve-mask (BVM) device with oxygen source and appropriately sized mask Scissors (for cutting adhesive tapes or twill tapes) Page 1 of 5
3. PROCEDURE Supplemental oxygen delivery device for post-extubation 12 ml syringe Absorbent pad Readily available: reintubation supplies, crash cart Patent vascular access Direct ECG rhythm (if available) and SpO2 monitoring 3.1 If appropriate, assess readiness for extubation (see Appendices) 3.2 Check physician s order 3.3 Verify patient identification (see SHR policy 7311-60-017) 3.4 Ensure appropriate monitoring in place (ECG, SpO2) 3.5 Ensure the necessary equipment is in place 3.6 Explain the procedure to the patient / family if applicable and importance of deep breathing and coughing. 3.7 Position patient with head of bed elevated, if not contraindicated. Pediatrics: 45 degrees unless contraindicated. 3.8 Perform hand hygiene. Don PPE (face shield, clean gloves) 3.9 Suction the ETT, if necessary. 3.10 Suction oropharynx if necessary. 3.11 Hyperoxygenate patient if condition warrants. Note: Hyperoxygenation with 100% oxygen not recommended for children with certain congenital heart defects. 3.12 Unfasten or cut endotracheal tube securing device. Maintain firm grip on ETT 3.13 If a cuffed ETT is insitu, deflate the cuff by inserting a 12ml syringe into one way valve of pilot balloon and aspirate all the air from the cuff. If there is any concern regarding presence of laryngeal edema, ensure patient can breathe around the ETT by auscultating over the trachea. If there is no air leak, DO NOT PROCEED. Notify MRP. 3.14 If patient can cooperate, ask patient to take in a deep breath then quickly and gently remove ETT at peak inspiration. Pediatrics: apply positive pressure with BVM and remove tube during peak inspiration NOTE: If the ETT does not come out easily, do not attempt removal and notify MRP promptly. 3.15 Encourage deep breathing and coughing. Suction oral and nasopharyngeal secretions prn. 3.16 Apply oxygen and humidity as required. 3.17 Assess patient s respiratory status (i.e. rate, rhythm, presence of secretions, SpO2). 3.18 If an unplanned Extubation (patient self-extubation or blocked ETT): Page 2 of 5
3.18.1 Apply oxygen adjunct to maintain SPO2 as ordered. 3.18.2 Call qualified physician or RRT stat for possible reintubation. 3.19 Documentation 3.19.1 patient's tolerance of procedure 3.19.2 oxygen therapy presently in use 3.19.3 problems encountered during procedure and interventions done 3.19.4 patient s respiratory status (i.e. rate, rhythm, presence of secretions, SpO2) 4. REFERENCES: AARC Clinical Practice Guideline: Removal of the Endotracheal Tube. Downloaded February 2, 2012. http:www.rcjournal.com/cpgs/rotectcpg.html. Binck, A. C. (2008), Extubation: perform. In J. Trivits Verger & R. M. Lebet (Eds). AACN Procedure Manual Pediatric Acute and Critical Care. (pp. 89-93). St. Louis: Saunders Elsevier. Irwin, R. S, Rippe, J. S. (2009). Respiratory Adjunct Therapy in Irwin and Rippe's Intensive Care Medicine. 9 th ed. Philadelphia: Lippincott, Williams & Wilkins. Pg. 691. Levine, W. C. (sr. ed). (2010). Emergence from General Anesthesia In: Clinical Anesthesia Procedures of the Massachusetts General Hospital8 th ed. Philadelphia: Lippincott, Williams & Wilkins. Pg. 205. McMillan, J. A.; Feigin, R. D.; DeAngelis, C.; Jones, M. D. (eds). (2006). Extubation In: Oski's Pediatrics 4th ed. Philadelphia: Lippincott, Williams, & Williams. Pg. 25773-2574 Morton, P. G. et al. (2008). Endotracheal Tube Intubation In: Critical Care Nursing: a Holitisic Approach. 8th ed. Lippincott, Williams, Wilkins. Pg. 449-451. Nettina, S. M. ed. (2009). Non-invasive Positive Pressure Ventilation In: Lippincott Manual of Nursing Practice. 9 TH ed. Philadelphia: Lippincott, Williams & Wilkins. Pg 265 276 Stein, F., Karam, J. M (2006). Extubation in Oski's Pediatrics 4 th ed. Philadelphia: Lippincott, Williams & Wilkins. Pg. 2573-2574. Urden, L.D., Stacy, K. M., and Lough, M E. (2006) Thelan s Critical Care Nursing: diagnosis and treatment. 5 th Ed. St. Louis: Mosley Elsevier. Pg 669 670. Wachter, R. M., (ed). (2005). Weaning and Extubation in Hospital Medicine. 2 nd ed. Philadelphia: Lippincott, Williams & Wilkins. Pg. 180 182. Weigand, D. L., (ed.) (2011) Endotracheal tube and oral care in AACN Procedure Manual for Critical Care. (6th ed). St. Louis: Elsevier Saunders. pp. 43-47. Wilkins, R. L., Stoller, J. K. (2009). Egan's Fundamentals of Respiratory Care, 8th Edition,. St. Louis. Mosby Elsevier Page 3 of 5
Criteria for Extubation Adult Appendix A These are guidelines only. The decision to extubate is not dependant on the patient meeting all of the following criteria. Patient is weaned to minimal ventilatory support and able to maintain the following parameters: o Acceptable PaCO2 with a spontaneous respiratory rate 10-30 breaths/min o SpO2 greater than / equal to 92% or PaO2 greater than / equal to 60 mmhg with FiO2 less than / equal to 0.40 and CPAP less than / equal to 8 cmh20 Return of gag reflex Able to effectively remove secretions from airway - capable of generating an effective cough Adequate air leak past deflated ETT cuff see Respiratory Therapy Policy: Assessment of Endotracheal Tube Cuff Leak - Adults Awake and can follow commands Able to hold head or leg lift for a sustained period of time Stable vital signs Post Extubation Patient to remain NPO until ordered otherwise by physician Page 4 of 5
Criteria for Extubation Pediatric Appendix B These are guidelines only. The decision to extubate is not dependant on the patient meeting all of the following criteria. Intact airway protective reflexes (gag and cough and swallow). Spontaneous respiratory rate within age appropriate norms. Minimum sedation to level that does not affect respiration Muscular strength present to sustain work of breathing NPO x 4 hours prior to extubation or gastric contents emptied Acceptable blood gases or SpO2, and/or end-tidal CO2 while on minimal ventilatory support ventilation with FiO2 less than / equal to.40 and CPAP less than / equal to 8 cmh20 Cardiovascular and metabolic stability Page 5 of 5