1. Sahar Elkaradawy Assistant Professor in Anaesthesia and Intensive Care Unite.

2. Weaning from ventilation Weaning process is a liberation of patient from ventilator, after resolution of illness.

3. Role of physiotherapist after extubation Physiotherapists are often involved in the weaning from ventilation to:  assist patients to maintain a good respiratory function  prevent re-intubation.

4. Standardized weaning protocol Mechanical ventilation should be discontinued under the direction of one of three board,  certified critical care physicians  respiratory therapists  nursing staff.

5. Criteria for weaning from ventilation Cooperative and pain free Good cough reflex to tracheal suctioning Minimal secretion PaO2to FIO2 ratio >24 kPa > 300, minute ventilation ≤12 l PEEP <5 cm H2O Hb >7 g dl±1 Axillary temperature between 36 and 38.5°C Plasma K+ concentration >3.0 and <5.0 mmol litre±1 Plasma Na+ concentration >128 and <150 mmol litre±1 Inotropes reduced or unchanged over previous 24 h Spontaneous ventilatory frequency >6 min

6. Evaluation of the cough strength The cough strength on command (0 to 5) and amount of endotracheal secretions (none to abundant). Patients are asked to cough onto a white card through the endotracheal tube. If secretions were propelled onto the card, it is termed a positive white card test (WCT). Patients with weak (grade 0 to 2) coughs and abundant secretions were more likely to fail extubation.

7. Extubation failure Extubation failure-need for reintubation within 72 h of extubation, is common in intensive care unit (ICU). The impact of extubation faliure :  increased morbidity, higher costs, higher ICU and hospital length of stay (LOS) and mortality.

8. Risk factors for re-intubation Patients with advanced age. High severity of illness at ICU admission and extubation. ICU factors: o Deconditioned muscles, poor nutrition, upper airway edema due to prolonged translaryngeal intubation, inability to clear secretions, decreased level of consciousness due to persistent effects of sedative and analgesics and polyneuropathy

9. Physiotherapy after extubation Upper and lower limb active exercises Deep breathing exercises Chest percussion and vibrations Huffing and assisted cough

10. The Effect on respiratory mechanics Improvement of vital capacity maximum inspiratory pressure immediately after exercise in ICU in extubated patients.

11. Management of failed extubation A strategy to prevent failed extubation, if anticipated,: Treatment of causes of muscle weakness and excessive secretions and daily assessment for readiness to extubate, until predictors become more favorable. If there is no hope for extubation, non- invasive ventilation and prophylactic steriods are alternative option.

12. Thank you