1. J. Prince Neelankavil, M.D.
Extubation Criteria
J. Prince Neelankavil, M.D.

2. Case
71 y.o. male s/p laparascopic surgery presents to the PACU intubated. Pt. remained intubated secondary to residual neuromuscular blockade
H/O HTN, DM
When should we extubate?

3. General Principles
Why was the patient intubated in the first place? Inadequate oxygenation/ventilation/airway protection.
Patient should have adequate respiratory drive, respiratory muscle strength, cough reflex to clear secretions, laryngeal function and clearance of sedative and neuromuscular blocking medications.

4. Adequate Gas Exchange?
Adequate arterial partial pressure of oxygen: [PaO2/FIO2] ratio >
Appropriate pH (pH >7.25) and arterial partial pressure of carbon dioxide during spontaneous ventilation

5. Pass a Breathing Trial?
30–120 minute spontaneous breathing trial with low level of CPAP (e.g. 5 cm H2O) or low level of pressure support (e.g. 5-7 cm H2O)
Show gas exchange (ABG), hemodynamic stability, and subjective comfort

6. Pass These Numbers? RR < 35 Vital capacity > than 10 mL/kg
NIF > -20
Tidal Volume > 5mL/kg
Minute ventilation < 10L/min
Thoracic compliance > 25 mL/cm H2O

7. Able to Protect Airway? Appropriate level of consciousness
Adequate airway protective reflexes (cough, swallow, vocal cord movement)
Adequate managed secretions

8. All Systems Go? Hemodynamic Stability (+/- 20%)
Nutritional status allowing for respiratory muscle strength

9. Risk Factors for Failed Extubation
ICU patient
Age > 70 or < 24 months
Hemoglobin <10 mg/dL
Longer duration of mechanical ventilation
Medical or surgical airway condition
Frequent pulmonary toilet
Loss of airway protective reflexes

10. What do you need to extubate?
Oxygen source
Suction
Oral/Nasal airways
Face masks
Endotracheal tubes
LMA
Pulse ox
Cardiac Monitors
CO2 detectors
Ambu bags

11. What did we do before we extubated our patient?
Ensured proper equipment needed for reintubation
Monitoring BP, HR, Sat, RR
Used a twitch monitor to demonstrate no fade on TOF/sustained tetany
Turned off the propofol sedation

12. What did we do before we extubated our patient?
We did not quantitatively evaluate his tidal volume, thoracic compliance, pH, NIF, breathing trial, etc…
We qualitatively evaluated several things Stable hemodynamics
2. Able to protect airway
3. Able to exchange gases

13. Stable Hemodynamics His preoperative BP and HR were 134/77 and 68
Prior to extubation his BP and HR were 126/72 and 61

14. Able to protect airway
Patient was gagging on the ETT and would gag when we suctioned him
Patient was coughing

15. Able to exchange gases
Patient was spontaneously breathing for 30 minutes
Good ventilatory effort
Maintained oxygen saturation

16. Case Our patient was extubated and had an uneventful PACU stay.
Another satisfied customer

17. References
American Association for Respiratory Care (AARC). Removal of the endotracheal tube revision & update. Respir Care 2007 Jan;52(1):81-93
Nir Hoftman, M.D.’s PACU extubation criteria