Extubation in the E mergency

Department and
R e s u s c i t a t i v e U n i t Se t t i n g
a, b,c
Chidinma C. Nwakanma, MD *, Brian Joseph Wright, MD, MPH

KEYWORDS
! ED Extubation ! Resuscitation ! Emergency Department Critical Care

KEY POINTS
! A subset of intubated patients can be extubated in the emergency department (ED).
! Appropriate physician and nurse monitoring is required for ED extubation to detect and
manage potential complications and extubation failure.
! The disease process that led to intubation should be reversed before considering extuba-
tion in the ED.
! ED physicians should select patients with a low probability of extubation failure for ED
extubation.

INTRODUCTION

Patients are placed on invasive mechanical ventilation (IMV) for many different
reasons. The common goal is to safely protect the airway while maintaining
adequate oxygenation and ventilation until the underlying disease process is
reversed. Patients should be on IMV for the shortest amount of time that is medically
necessary. Endotracheal Intubation (ETI) and IMV are life-saving interventions, but
are associated with complications like ventilator-associated pneumonia, lung injury,
venous thromboembolism, delirium, and acquired weakness. IMV also requires
expensive and scarce critical care resources, including high-intensity nursing and
intensive care unit (ICU) beds. Finally, ETI and IMV can be uncomfortable and painful.

Disclosure Statement: I have no financial disclosures to report.

a
Department of Emergency Medicine, Perelman School of Medicine at the Hospital of Uni-
versity of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; b Department of
Emergency Medicine, Renaissance School of Medicine, Stony Brook University, 101 Nicolls
Road, Health Sciences Center, Level 4, Stony Brook, NY 11794, USA; c Department of Neuro-
surgery, Renaissance School of Medicine, Stony Brook University, 101 Nicolls Road, Health
Sciences Center, Level 4, Stony Brook, NY 11794, USA
* Corresponding author.
E-mail address: [email protected]

Emerg Med Clin N Am 37 (2019) 557–568

https://doi.org/10.1016/j.emc.2019.03.004 emed.theclinics.com
0733-8627/19/ª 2019 Elsevier Inc. All rights reserved.
558 Nwakanma & Wright

Resuscitation and critical care specialists should have expertise in both initiation and
cessation of IMV.
Extubation is not a common emergency department (ED) practice. With the devel-
opment of ED-ICUs and resuscitation units, and the increased boarding of critically ill
patients managed by emergency medicine providers, ED extubation (EDEx) may
become a more common practice. This article provides a framework for determining
appropriate patients for EDEx and a practical approach on how to safely perform the
procedure.

DIFFERENCES BETWEEN EXTUBATION IN THE EMERGENCY DEPARTMENT VERSUS

INTENSIVE CARE UNIT

There is a paucity of published literature on EDEx. Weingart and colleagues1 examined

the safety of extubation in a cohort of 50 ED trauma patients cared for in a highly special-
ized ED with ICU-level nurse-patient ratios (1:2 or 1:3) and run by trauma and critical care
specialists experienced in extubation. Selected patients were intoxicated, had no signif-
icant injury after the initial trauma workup was completed, or had injuries that required
temporary deep sedation only. In carefully selected patients they found that EDEx was
safe with no unplanned reintubations. Sixteen percent of their patients were discharged
from the ED. The application of this and similar extubation studies from the ICU or Post
Anesthesia Care Unit should be applied with caution to the general ED setting. EDEx is
safe and feasible provided that certain unit logistic and patient features are met.1,2
Close monitoring after extubation is the biggest obstacle to EDEx. The clinical envi-
ronment must provide intensive monitoring by clinicians and nurses who can recog-
nize and manage extubation failure and reintubate if necessary. Continuous pulse
oximetry, telemetry, and blood pressure monitoring are a minimum. End-tidal carbon
dioxide monitoring is not standard practice but may be helpful in determining the pres-
ence of apnea, airway obstruction, hypoventilation, or hypercapnia. Dedicated staff
(1:1 or 1:2 nurse:patient) must continuously monitor a newly extubated patient, similar
to recovering a patient after procedural sedation.
There is debate in extubation literature regarding acceptable reintubation or extuba-
tion failure rates.3,4 Extubation failure is associated with significant morbidity and mor-
tality, even after correcting for the underlying disease process that led to extubation
failure.4 ED patients are early in their disease process. If there is question or concern
about extubation readiness and whether a particular disease process is resolved, then
the patient should be extubated in a traditional ICU setting.
Patients with a low risk of reintubation should be selected (excluding elective rein-
tubations) and the ED unit should have a goal of a near zero rate of reintubation. Pa-
tients should be monitored closely for an appropriate amount of time after extubation.
Based on existing evidence, 1 hour should be the minimum duration for intensive
monitoring and specific patient characteristics should also be considered after
EDEx.1 Patients with cardiac or lung disease may need to be observed for longer
than 1 hour in a monitored setting. Further evidence is needed to determine optimal
length of monitoring after EDEx.

SELECTION OF PATIENTS FOR EXTUBATION IN THE EMERGENCY DEPARTMENT AND

RESUSCITATIVE UNIT

Patient selection for EDEx is highly dependent on the original indication for intubation,
and should be more stringent than in the ICU (Table 1). For most patients intubated in
the ED, a prolonged ventilatory course and ICU admission are necessary. A subset of
patients may require only transient IMV.
 Extubation in the Emergency Department 559

Table 1
Suggested clinical presentations for emergency department extubation (EDEx) consideration/
avoidance

EDEx Can be Safely EDEx Can be Considered EDEx Should Not be

Attempteda with Cautiona Considered
! Intoxicated or drug ! Anaphylaxis/laryngeal ! Hemodynamically unstable
overdose with clinical edema with improved ! Need for high ventilatory
sobriety symptoms and resolution support
! Airway protection for of airway edemac ! Expected prolonged
procedural sedation ! Severe asthma/chronic clinical course (eg,
(ie, endoscopy) obstructive pulmonary drowning, pneumonia)
! Head trauma with disease with significant ! Expected need for
improving mental improvement repeated invasive
status and negative ! Undifferentiated altered procedures, transfer or
neuroimaging mental statusd surgery
! Palliative/Terminal ! Cardiogenic pulmonary ! Significant neuromuscular
extubationb edema with significant disease (eg, myasthenia
improvement and resolved gravis, multiple sclerosis)
hypoxia/hypercarbia after ! Trauma/Injury to cervical
aggressive management spine, oropharynx, larynx
(eg, diuresis, afterload or lung
reduction) ! Cerebrovascular Accident
(pons or brainstem lesions
can affect airway
maintenance)
a
Assuming all extubation criteria are achieved.
b
Extubation in this setting can be performed without meeting criteria.
c
Anaphylaxis may have biphasic distribution, thus despite initial improvement a secondary phase
may occur even up to 24 h after primary presentation.
d
Undifferentiated altered mental status is a clinical challenge, as prediction of clinical course is
difficult.

Indications for IMV must be resolved in the ideal EDEx candidate. Selected patients
should meet ALL of the following criteria before consideration (Box 1).2

Resolution of Initial Indication for Intubation

Ventilator liberation will rely on the resolution of the condition that led to necessitation of
IMV. This should be the first consideration of EDEx candidacy. The clinician should have

Box 1
Suggested inclusion criteria for emergency department extubation

! Resolution of initial indication for intubation

! Able to oxygenate and ventilate on minimal ventilator settings
! Awake and able to follow commands
! Hemodynamically stable
! Uncomplicated initial intubation
! Expected to maintain airway patency postextubation
! Anticipated hospital course does not require mechanical ventilation

From Gray SH, Ross JA, Green RS. How to safely extubate a patient in the emergency depart-
ment: a user’s guide to critical care. CJEM 2013;15(5):303–306; with permission.
560 Nwakanma & Wright

a definitive understanding of the initial indication for IMV. This will indicate the likelihood
of extubation failure. For example, the intoxicated patient (with no significant trauma) that
is now exhibiting clinical sobriety is an ideal candidate for extubation. A drowning victim
who may worsen in the next 24 hours would not be a good candidate (see Table 1).
Pulmonary Assessment: Ability to Oxygenate and Ventilate on Low Ventilator
Settings
A patient’s ability to oxygenate and ventilate on minimal ventilatory settings (contin-
uous positive airway pressor [CPAP] alone or minimal pressure support [PS]) may
be able to risk stratify the patient as low-risk for a failed extubation. Generally, a spon-
taneously breathing patient should be able to generate a tidal volume "5 mL/kg on
CPAP or minimal PS and adequate oxygenation with a FiO2 less than 40% on a positive
end-expiratory pressure (PEEP) #8.5 An arterial blood gas on minimal ventilator set-
tings can support the decision to extubate in patients with cardiac or pulmonary pa-
thology but may not be necessary in patients without cardiovascular or pulmonary
pathology. Adequate oxygenation can be defined as oxygen saturation greater than
92% and PaO2 greater than 70 mm Hg. Adequate ventilation can be defined as a
PaCO2 between 38 and 42 mm Hg.2,5
A spontaneous breathing trial (SBT) can be helpful for clinicians to determine extu-
bation readiness, especially if the patient was intubated for pulmonary or cardiovascu-
lar pathology. SBTs have been studied heavily and implemented in most ICU ventilator
weaning strategies. Patients should be clinically and hemodynamically stable for an
SBT. There are 3 potential approaches to an SBT (Box 2).4,6
PS provides the most ventilatory assistance during the SBT and the T-piece pro-
vides the least.4 Current extubation guidelines recommend that a PS SBT is an
acceptable screening for extubation readiness and may be more sensitive than the
other methods.7–9 A CPAP-only or T-piece strategy may be more specific, but can
incorrectly classify patients as SBT failures that may otherwise be extubated
safely.4,10 CHEST and the American Thoracic Society7 recommend using a PS strat-
egy in patients who have been on the ventilator for more than 24 hours.
Patients extubated in the ED setting should have an exceedingly low rate of reintu-
bation. As a result, we recommend using a low PS trial or CPAP-only trial as it provides
a good estimation of extubation readiness and does not require additional equipment.
The SBT should be conducted for at least 30 minutes and no longer than 120 mi-
nutes.4,6 Box 3 includes successful SBT criteria.2
The rapid shallow breathing index (RSBI) is a dynamic measurement that can be used
during an SBT to determine extubation preparedness.9,11 RBSI is defined as follows:

Box 2
Ventilator setting options for spontaneous breathing trial

! Pressure support spontaneous breathing trial: pressure support (PS) of 5 cm H2O

(to overcome the resistance of the endotracheal tube [ETT]) with positive end-expiratory
pressure (PEEP) #5 cm H2O
! Continuous positive airway pressure only: PEEP #5 cm H2O, no PS
! T-piece trial: Supplemental oxygen only through the ETT

Data from Thille AW, Richard JCM, Brochard L. The decision to extubate in the intensive care
unit. Am J Respir Crit Care Med 2013;187(12):1294–1302. http://doi.org/10.1164/rccm.201208-
1523CI; and Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous
breathing trials; an educational review. Emergency 2016;4(2):65–71. https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC4893753/pdf/emerg-4-065.pdf.
 Extubation in the Emergency Department 561

Box 3
Predictors of a successful spontaneous breathing trial

! Respiratory rate <30 breaths per minute and more than 8 breaths per minute
! Heart rate <140 beats per minute and more than 60 beats per minute
! Systolic blood pressure less than 200 mm Hg and more than 90 mm Hg or less than 20%
change from baseline
! Oxygen saturation greater than 92%, PaO2 greater than 70 mm Hg (on FiO2 <0.4 and PEEP
#8 cm H2O)
! Spontaneous tidal volume >5 mL/kg
! No signs of increased work of breathing, severe anxiety, or altered mental status

Data from Weingart SD, Menaker J, Truong H, Bochicchio K, Scalea TM. Trauma patients can be
safely extubated in the emergency department. J Emerg Med 2011;40(2):235–239. http://doi.org/
10.1016/j.jemermed.2009.05.033; and Gray SH, Ross JA, Green RS. How to safely extubate a pa-
tient in the emergency department: a user’s guide to critical care. CJEM 2013;15(5):303–306.

Respiratory Rate (breaths per minute)/tidal volume (L)

Optimal breathing is slow and deep with a low RSBI. A patient with an inability to
tolerate independent breathing will tend to breath fast and shallow generating a
high RSBI. A threshold RSBI of less than 75 breaths per min/L (on PS ventilation) or
less than 100 breaths per min/L (with T-piece) predict successful weaning and are
more accurate than other accepted RSBI values.12 RSBI less than 105 is wildly cited
as an acceptable criterion for extubation success.4,12 We recommend using an RSBI
of less than 75 breaths per min/L using the PS or CPAP trial technique in the ED. A
lower RSBI cutoff is more specific and will potentially reduce the risk of extubating
borderline patients.
Despite the common use of RSBI, it is important to remember that extubation eval-
uation is a global assessment and RSBI should not be used as a singular benchmark
for success. In addition to the RSBI formula, the interpretation of SBT failure/success
should also consider work of breathing, ability to clear secretions, and clinical appear-
ance. Blood gas analysis is not always necessary to make this determination, espe-
cially if the patient was intubated for nonpulmonary indications. An arterial blood
gas may be helpful for borderline cases or patients who were intubated for pulmonary
indications, particularly if the clinician is concerned about effective oxygenation and
ventilation at the end of the trial. If the SBT is successful, proceeding with extubation
is encouraged as long as airway, hemodynamic, and neurologic criteria are met. In the
setting of SBT failure, the patient should remain on full ventilatory support and the
EDEx attempt should be aborted and deferred to the ICU.

Neurologic Assessment: Awake and Able to Follow Commands

When assessing a patient for extubation, it is important to ensure that the patient is
fully awake and able to participate in independent breathing. Sedation should be
weaned and time should be given to allow the patient to regain full consciousness.
Small doses of analgesia or anxiolytic agents may be necessary to maintain patient
comfort while sedation is discontinued. Dexmedetomidine (DMT) is an excellent anxi-
olytic that does not affect respiratory drive and may facilitate extubation in patients
with agitation from pain or discomfort due to the endotracheal tube. DMT should
not be given in bolus doses, as this is associated with significant bradycardia. The
562 Nwakanma & Wright

onset of therapeutic effect is usually reached in 15 to 40 minutes.13 DMT use to facil-

itate safe extubation should be used only if the clinician is certain that the increased
respiratory rate is from agitation due to the endotracheal tube and not from a respira-
tory or cardiovascular derangement. Clinically, the patient should spontaneously
achieve normal or high tidal volumes. A blood gas may help discriminate tachypnea
due to agitation versus ventilatory insufficiency. A high respiratory rate secondary to
agitation will be associated with a respiratory alkalosis and low PCO2. A normal or
elevated PCO2 with a high respiratory rate should trigger the clinician to consider
that the patient’s agitation and tachypnea is a compensatory mechanism. Once the
patient is awake, he or she should have a consistent neurologic examination, and
be able to follow commands. Asking a patient to lift his or her head should always
be included in the neurologic assessment, as cervical mobility and strength are vital
for clearing secretions and maintaining a patent airway.

Cardiovascular Assessment: Hemodynamic Stability

Ensuring hemodynamic stability before extubation is a critical component of assess-
ing readiness for extubation. An extubation candidate should be liberated from the use
of inotropes and vasopressors. One suggested criterion for hemodynamic stability in-
cludes the following2,5:
1. Oxygen saturation greater than 92% (on FiO2 <0.4)
2. Heart rate less than 100 beats per minute
3. Respiratory rate less than 30/min
4. Systolic blood pressure greater than 90 mm Hg unassisted by vasopressors
5. No active cardiac ischemia or unstable arrhythmia
Good clinical judgment would likely include these recommendations, along with the
patient’s hemodynamic baseline. Weaning-induced cardiovascular dysfunction is a
well-described phenomenon, and a common cause for extubation failure.4,14,15 Risk
factors include volume overload, depressed left ventricular dysfunction, diastolic
dysfunction, structural heart disease, obesity, and chronic obstructive lung disease.14

Procedural Considerations
It is important to review initial airway assessment and documentation before extuba-
tion. Airway trauma may increase the risk of postintubation stridor and respiratory fail-
ure from airway compromise. Aspiration can lead to delayed airway compromise and
progressive hypoxemia. Knowledge of a difficult airway, multiple ETI attempts, and
airway trauma should lead to a more comprehensive assessment of airway patency.
A cuff leak (CL) test may be indicated in certain patients.9

Maintenance of Airway Patency Postextubation

The ability to cough and adequately clear secretions is paramount in maintaining
airway patency. Moderate to copious secretion volume is an independent predic-
tor of extubation failure.16 The patient should be able to generate enough
strength to lift his or her head off of the bed and produce a strong cough before
extubation.
It is important to avoid extubation in patients with suspected ongoing laryngeal
edema.17,18 Patients with brainstem strokes and cervical spine injuries have a high
risk for reintubation.19 Extreme caution should be used in these patients and they
are probably better served to be extubated in an ICU.
 Extubation in the Emergency Department 563

Anticipated Hospital Course Does Not Require Mechanical Ventilation

It is important to anticipate the patient’s hospital course before considering extuba-
tion. Additional need for high-risk diagnostic testing where limited monitoring is avail-
able (ie, MRI), interhospital transfer, or need for future procedural sedation/general
anesthesia should be considered. Patients with diseases that classically get worse
during the early hospital stay, drowning, acute respiratory distress syndrome, pneu-
monia, spinal cord injury, ischemic and hemorrhagic cerebrovascular accidents,
should remain intubated.

PHYSIOLOGICAL ASPECTS OF EXTUBATION AND MANAGEMENT OF CLINICAL

COMPLICATIONS
Postextubation Hypoxemia
The transition from positive pressure ventilation (PPV) to negative-pressure ventilation
can lead to significant physiologic cardiopulmonary challenges. Postextubation car-
diac dysfunction is one of these well-described complications. Significant increases
in left ventricular transmural pressure and afterload can occur after extubation. This
can clinically present as an increased work of breathing, hypertension, pulmonary
edema, hypoxemia, and progressive recurrent respiratory failure. Postextubation hy-
pertension and new B-lines on lung ultrasound are both concerning signs of postex-
tubation cardiac dysfunction. Myocardial ischemia, arrhythmias, and sudden
cardiac death are rare but potential events that require clinical vigilance.15
Postextubation hypoxemia can also be the result of compromised pulmonary func-
tion and gas exchange. Significant de-recruitment, atelectasis, changes in work of
breathing, increased airway resistance and shunt can all contribute to new onset hyp-
oxemia or recurrent respiratory dysfunction after extubation. Soummer and col-
leagues20 prospectively evaluated 86 ICU patients with lung ultrasound before
extubation after a successful SBT. Of the patients who developed postextubation res-
piratory distress (more than 30%), there was a higher incidence of loss of lung aeration
(indicated by development of new B-lines or consolidation on lung ultrasound) during
their SBT. Lung ultrasound may be a clinically useful tool in assessing patients during
SBT or after extubation with respiratory distress.
Management of postextubation cardiac dysfunction is similar to management of a
patient with sympathetic crashing pulmonary edema. Intravenous nitroglycerin is an
excellent agent to reduce cardiac preload and afterload. Diuretics also may be helpful,
as negative fluid balance is associated with less extravascular lung water, better pul-
monary function, and decreased ventilator time.21 The reinstitution of PPV with a trial
of noninvasive ventilation (NIV) may be a valuable temporary intervention to allow time
for aggressive medical management. However, similar to the use of NIV for other
causes of acute respiratory failure, reintubation should not be delayed if the patient
is not rapidly improving with these interventions.

Altered Mental Status and Agitation

The standard approach to extubation assessment includes pausing sedation to
assess mental status and perform a neurologic examination. Agitation and delirium
are common conditions in critical illness and may be either secondary to the primary
underlying pathology or the clinical interventions (ie, intubation, sedative agents).
Delirium is characterized as fluctuating alteration in consciousness with impaired
cognition. It can present as hyperactive, hypoactive, or mixed. Delirium in ICU patients
is associated with prolonged mechanical ventilation, extended hospitalization, and
increased risk of mortality.22 Delirium in the ED is usually a result of the underlying
564 Nwakanma & Wright

presenting condition given the relatively short in-hospital time and ventilator duration
compared with an inpatient ICU. Given the fluctuating course of delirium, if present,
these patients should not be extubated in the ED.

Airway Assessment and Management of Postextubation Stridor

Careful airway assessment and management is paramount for anticipated extubation
success. Often the clinician considering extubation was not present during the pa-
tient’s initial presentation. Before proceeding with any extubation, all initial intubation
documentation and airway evaluations should be reviewed to prepare for potential
postextubation complications. For example, documentation of the presence of edema
before intubation informs the clinician that this condition was not a result of the pres-
ence of the endotracheal tube (ET) tube. Resolution of preexisting edema should occur
before extubation. Of note, ET-induced laryngeal edema usually occurs after the first
36 hours8,17,18 and this is usually greater than the average length of stay in an ED.
The CL test is used to predict postextubation stridor and is a surrogate marker of
laryngeal edema.8 To perform a CL test, first document the patient’s inspiratory and
expiratory tidal volumes (TV) before ET tube cuff deflation on Volume Control IMV.
While on Volume Control IMV, TV should temporarily be up titrated to 8 to 10 mL/kg
ideal body weight, as lower TV may fail to show a CL when one is present.23,24 After
the ET tube cuff is deflated, the difference between the inhaled and exhaled tidal vol-
ume represents the CL, or volume lost around the tube. The volume of air lost should
be >110 mL.18,23,24 The CL can also be measured by an audible leak or volume loss
approximately more than 24% tidal volume.24 A small or absent CL (volume
<110 mL) suggests laryngeal edema and is associated with an increased risk of post-
extubation stridor and respiratory distress.
Risk factors for postintubation laryngeal edema include traumatic intubation, intu-
bation more than 6 days, large ET, female sex, and reintubation after unplanned extu-
bation.8,24 Without these factors, a patient can be deemed low risk and extubated
without a CL assessment.8,24 Higher-risk patients may benefit from a CL test, and if
present likely safe to extubate. If CL is absent, initiation of intravenous (IV) glucocor-
ticoid therapy may reduce edema and reduce risk for postextubation stridor. It is
important to note that absence of a CL does not necessarily diagnose laryngeal
edema. An oversized ET relative to the cross-sectional area of the patient’s trachea
or secretions around the deflated cuff can also cause a negative CL.
Ultimately, EDEx should be avoided in patients with suspected laryngeal edema or
airway trauma. Peri-intubation laryngeal injuries should be viewed with great caution
and avoided when selecting for EDEx. If a difficult airway was noted on the initial intu-
bation, the patient may not be appropriate for EDEx. If the decision is made to proceed
with extubation, appropriate difficult airway equipment should be readily available at
the bedside along with a detailed reintubation plan that is discussed with the ED
team before extubation.

Postextubation Stridor Management

Unfortunately, even low-risk patients may experience postextubation stridor.8,24
Prompt assessment and management is necessary to avoid additional morbidity.
First, all equipment (including difficult airway equipment) and medications for potential
reintubation should be readily available for all extubations. Stridor management gener-
ally involves administration of nebulized epinephrine and IV steroids (Box 4).17 The
combination of steroids and epinephrine can reduce laryngeal edema by anti-
inflammatory and vasoconstriction mechanisms, respectively. Consider emergent
 Extubation in the Emergency Department 565

Box 4
Recommended pharmacologic treatment for postextubation stridor

! Steroids:
$ Methylprednisolone: 40 to 125 mg intravenous (IV) every 6 to 8 hours
$ Dexamethasone 5 mg IV every 6 hours
! Nebulized epinephrine:
$ 5 to 10 mL of undiluted “code epinephrine” (0.1 mg/mL, 1:10,000)
$ 0.5 mL of a 2.25% racemic epinephrine diluted in a volume of 2 to 4 mL

Data from Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent postextubation airway obstruc-
tion in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care
2007;11(4):R72. https://doi.org/10.1186/cc5957; and Pluijms WA, van Mook WN, Wittekamp
BH, Bergmans DC. Postextubation laryngeal edema and stridor resulting in respiratory failure
in critically ill adult patients: updated review. Crit Care 2015;19(1):295. https://doi.org/10.1186/
s13054-015-1018-2.

reintubation if the patient is in severe respiratory distress, or if the stridor does not
improve after 1 to 2 hours after treatment.
Before reintubation, direct airway assessment via nasopharyngolaryngoscopy may
identify cause for airway obstruction; however, this may be difficult in a patient with
significant respiratory distress. Potential etiologies that are refractory to steroids
and epinephrine (eg, vocal cord paralysis, laryngeal lesions) can be identified and rein-
tubation can be reconsidered based on the findings.
Palliative Extubation
Palliative extubation refers to the intentional cessation of ventilatory support to limit
patient and family suffering. Usually palliative extubation is performed on the patient
who is unknowingly intubated against his or her prior expressed desires, or diagnosed
with a nonsurvivable medical condition after intubation that would not be consistent
with his or her goals of care or desired quality of life (ie, devastating neurologic injury).
These patients are ideal candidates for EDEx; however, extubation must be performed
in an organized and well-communicated manner.
Initially, the patient’s end-of-life wishes should be confirmed with the patient’s
health care proxy. This discussion should include a family meeting that details the pa-
tient’s current clinical status, prognosis, expected outcome, postextubation protocol,
and an offer of clergy or social work support if needed. The act of withdrawal of life
support and extubation can be emotionally and ethically taxing for a patient’s loved
ones in many instances. It is important that communication is compassionate, yet
informed and direct. If extubation is ultimately decided by the family and clinical
team, it must be accomplished in a controlled manner to avoid patient and caregiver
discomfort.
Providing comfort, alleviating patient or family distress, and effective team commu-
nication should be the cornerstone of any palliative extubation. First, the treatment
plan should be thoroughly discussed with the patient’s nurse and respiratory therapist.
Nursing staff must perform frequent patient reassessments to guide medication titra-
tion after extubation. Turning off patient alarms can reduce unnecessary patient stim-
ulation and family distress. Allow time for any paralytic to wear off (by identifying
spontaneous breaths on the ventilator) so that the clinicians and nurses can assess
for nonverbal cues of discomfort (eg, grimacing, tearing, sweating). Medications
aimed at managing dyspnea and pain should be initiated before extubation. An opioid
infusion, with additional as-needed boluses available for nursing, should be titrated for
566 Nwakanma & Wright

signs of pain or respiratory distress. Anxiety can be managed with IV boluses of loraz-
epam or midazolam. Glycopyrrolate can be used to control copious oral secretions.
These medications should be part of a standard comfort care order set available for
use in the ED.
Once optimal comfort is achieved, the respiratory therapist may deflate the ET tube
cuff and remove the tube. As the patient coughs or exhales, oral secretions should be
suctioned. Room air is generally preferred, to avoid any unnecessary patient tubing
that may cause discomfort. Supplemental oxygen may unnecessarily prolong the
dying process, but more importantly seeing their loved ones unencumbered with med-
ical devices may be more comforting to family members. Patients may expire minutes
after extubation; however, admission to a general medical floor or other private area
where palliative care can continue may be warranted in instances in which the patient
does not immediately die.

Fig. 1. Suggested EDEx pathway. bpm, beats per minute; HR, heart rate; RR, respiratory rate;
SBP, systolic blood pressure.
 Extubation in the Emergency Department 567

One of the most discomforting experiences for families is to watch their loved one
experience agonal respirations, gasping, or “death rattles.” It is often helpful to assess
the patient for these issues after extubation and before bringing the family back to the
bedside. Additional analgesia and anxiolytics are often helpful. Repositioning the airway
with pillows under the shoulders and/or head may improve respiratory mechanics.

SUMMARY

A subset of patients can safely be extubated in the ED. There is a paucity of data on
EDEx, but early extubation of carefully selected ED patients has the potential to mini-
mize the risk of preventable ventilator complications and can also save scarce inpa-
tient ICU resources. More objective data and published research in the ED setting
would be helpful to prove or disprove these assertions.
EDEx should be done with diligence and attention to detail. The ED provider should
be prepared for both common and life-threatening complications. Patients selected
for EDEx should be low-risk for complications with a unit goal of a near zero reintuba-
tion rate. Intensive nursing care, monitoring, and reintubation equipment must be
readily available. Fig. 1 provides a suggested EDEx pathway. Unfortunately, there is
no perfect predictor of extubation success, but objective risk stratification tools
such as the RSBI during an SBT trial and CL test can improve the patient selection
process.

REFERENCES

1. Weingart SD, Menaker J, Truong H, et al. Trauma patients can be safely extu-
bated in the emergency department. J Emerg Med 2011;40(2):235–9.
2. Gray SH, Ross JA, Green RS. How to safely extubate a patient in the emergency
department: a user’s guide to critical care. CJEM 2013;15(5):303–6.
3. Krinsley JS, Reddy PK, Iqbal A. What is the optimal rate of failed extubation? Crit
Care 2012;16(1):111.
4. Thille AW, Richard J-CM, Brochard L. The decision to extubate in the intensive
care unit. Am J Respir Crit Care Med 2013;187(12):1294–302.
5. Boles J-M, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Re-
spir J 2007;29:1033–56.
6. Zein H, Baratloo A, Negida A, et al. Ventilator weaning and spontaneous breath-
ing trials; an educational review. Emergency 2016;4(2):65–71. https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC4893753/pdf/emerg-4-065.pdf.
7. Ouellette DR, Patel S, Girard TD, et al. Liberation from mechanical ventilation in
critically ill adults: an official American College of Chest Physicians/American
Thoracic Society clinical practice guideline. Chest 2017;151(1):166–80.
8. Girard DTD, Alhazzani DW, Kress DJP, et al. An official American Thoracic Soci-
ety/American College of Chest Physicians clinical practice guideline: liberation
from mechanical ventilation in critically ill adults. Rehabilitation protocols, venti-
lator liberation protocols, and cuff leak tests. Am J Respir Crit Care Med 2016;
195(1):120–33.
9. Schmidt GA, Girard TD, Kress JP, et al. Official executive summary of an Amer-
ican Thoracic Society/American College of Chest Physicians clinical practice
guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir
Crit Care Med 2016;195(1):115–9.
10. Pellegrini J, Moraes R, Maccari J, et al. Spontaneous breathing trials with T-piece
or pressure support ventilation. Respir Care 2016;61(12):1693–703.
568 Nwakanma & Wright

11. Baptistella AR, Sarmento FJ, da Silva KR, et al. Predictive factors of weaning from
mechanical ventilation and extubation outcome: a systematic review. J Crit Care
2018;48:56–62.
12. Zhang B, Qin YZ. Comparison of pressure support ventilation and T-piece in
determining rapid shallow breathing index in spontaneous breathing trials. Am
J Med Sci 2014;348(4):300–5.
13. Yu S-B. Dexmedetomidine sedation in ICU. Korean J Anesthesiol 2012;62(5):
405–11.
14. Liu J, Shen F, Teboul JL, et al. Cardiac dysfunction induced by weaning from me-
chanical ventilation: incidence, risk factors, and effects of fluid removal. Crit Care
2016;20(1):369.
15. Tobin MJ. Extubation and the myth of “minimal ventilator settings.” Am J Respir
Crit Care Med 2012;185(4):349–50.
16. Mokhlesi B, Tulaimat A, Gluckman TJ, et al. Predicting extubation failure after suc-
cessful completion of a spontaneous breathing trial. Respir Care 2007;52:
1710–7.
17. Pluijms WA, van Mook WN, Wittekamp BH, et al. Postextubation laryngeal edema
and stridor resulting in respiratory failure in critically ill adult patients: updated re-
view. Crit Care 2015;19(1):295.
18. Wittekamp B, Van Mook W, Tjan D, et al. Clinical review: post-extubation laryngeal
edema and extubation failure in critically ill adult patients. Crit Care 2009;13:233.
19. Asehnoune K, Roquilly A, Cinotti R. Respiratory management in patients with se-
vere brain injury. Crit Care 2018;22(1):76.
20. Soummer A, Perbet S, Brisson H, et al. Ultrasound assessment of lung aeration
loss during a successful weaning trial predicts postextubation distress*. Crit
Care Med 2012;40(7):2064–72.
21. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome
(ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, et al.
Comparison of two fluid-management strategies in acute lung injury. N Engl J
Med 2006;354(24):2564–75.
22. Arumugam S, El-Menyar A, Al-Hassani A, et al. Delirium in the intensive care unit.
J Emerg Trauma Shock 2017;10(1):37–46.
23. Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent postextubation airway
obstruction in adults: a prospective, randomized, double-blind, placebo-
controlled study. Crit Care 2007;11(4):R72.
24. Farkas J. PulmCrit- Liberating the patient with no cuff leak. EMCrit Blog; 2017.
Available at: http://emcrit.org/pulmcrit/cuff-leak/. Accessed January 29, 2019.