see also: [[Airway|Intubation]]
#procedures
> The fundamental criterion for extubation in any location is that the circumstance that lead to the intubation in the first place is now resolved.
## Clinical scenarios where ED extubation may be indicated
- intubated to facilitate ix/compliance with spinal precautions
- intubated to permit procedure in ED
- unplanned intubation during procedural sedation
- resolved, short-duration overdose
- patient transitioning to palliation
## Clinical scenarios where ED extubation would be contraindicated
*patient factors* - ongoing path, ongoing sedation, difficult airway/difficult intubation, need for OT
*department factors* - time of day, acuity
*staffing factors* - lack of skilled staff to safely manage potential complications
## Extubation Clinical Criteria
patient factors, staffing, skill, equipment, ventilator
| factor | parameters |
| ---------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| ventilator | - weaned from mandatory mode and taking *spontaneous* breaths for 15-30 minutes <br>- low supports: fiO2 < 0.4, O2 sats >95%, PEEP ≤ 5, PS < 10, RR 8-25<br>- FVC > 12 mL/kg ; VC ~ 500 mL |
| patient | - reason for intubation resolved<br>- expected re-intubation<br>- difficult airway<br>- otherwise medically stable<br>- good cough<br>- is not a palliative or potential [[Organ donation]] case |
| sedation | - patient understands and follows commands<br>- eye opening, hand squeeze and head lift |
| drugs | - sedation and paralysis have weared off<br>- +/- sugammadex to reverse rocuronium if needed<br>- re-intubation drugs available<br>- alternative reversal would be 2.5mg neostigmine + 400mcg glycopyrolate (or atropine 1.2) to prevent cholinergic effects from neostigmine |
| staffing | - clinician experienced enough to re-intubate patient if required |
| department | - ED resus cubicle<br>- nurse available for 1:1 post intubation<br>- avoid overnight extubation |
> [!warning] none of:
> - RR > 35
> - SpO2 < 90
> - HR > 140
> - HR ↑ > 20%
> - systolic <90 or > 180
> - excessive airway secretions
## Extubation steps
1. sit up to 45 deg
2. re-oxygenate with FiO2 100%
3. have equipment for reintubation / NIV ready
4. bite block or gauze roll
5. suction oropharynx after ETT removal
6. apply hudson and give O2 8L/min
7. close observation in resus ~ 60 min
## Difficult ventilation after extubation
- obstruction
- aspration
- [[Laryngospasm]]
- no obstruction
- ? drug effects
- spinal cord injury
## cuff leak test
See [EM Crit - cuff leak](https://emcrit.org/pulmcrit/cuff-leak/)
Deflate cuff prior to extubation and check for leak; absence of leak suggests possible oedema , for consideration of steroids