This patient is ready for extubation. Everyone has their own magic numbers they want to see on the vent before they think about extubating a patient, but mine are:
- Pressure support mode
- every breath is initiated by the patient and only supported by the vent
- Pressure support ≤ 8 cmH2O
- This will be enough support to overcome the resistance in the circuit.
- PEEP ≤ 7 cmH2O
- Physiologic PEEP of the epiglottis is 5 cmH2O
- FiO2 ≤ 40%
- No more supplemental oxygen than what would be given via nasal cannula or open face mask
- Stable ABG on these settings for at least 2 hours
- A&Ox3 and following commands
- Patients need to be able to participate in pulmonary toilet after the tube comes out
These are basic principles and there are many variables that go into deciding to extubate a patient. LITFL does a great review here and goes through a very systematic approach.
Once this is all good, then you can perform a few bedside tests or measurements that can help predict success of extubation.
- Rapid Shallow Breathing Index (RSBI)
- Respiratory Rate / Vt (L)
- < 105 predicts successful extubation
- Negative Inspiratory Force (NIF)
- Measurement of the maximal inspiratory pressure
- This is a great measurement of a patient’s ability to generate an adequate tidal volume once extubated.
- > -20 cmH2O predicts successful extubation
Prediction of Successful Extubation. The ICU Book.
Great post from Intensive Blog on “The Art and Science of Extubation”
References
- http://lifeinthefastlane.com/ccc/spontaneous-breathing-trial/
- http://lifeinthefastlane.com/ccc/extubation-assessment/
- Fadaii, A. Assessment of rapid shallow breathing index as predictor for weaning in a respiratory care unit. Tanaffos. 2012;11(3):28-31.
- Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med. 1991;324(21):1445–50. [PubMed]
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