Reducing Re-Intubation Rates - One Protocol....
Getting intubated ICU patients extubated in a timely fashion is the goal for most ICU nurses. However, there can be issues that result in re-intubation. Here is one protocol based on a recent study to prevent post-extubation stridor.
ICU patients are sicker than ever. Many patients in the ICU are intubated and getting them extubated can sometimes be problematic. Delayed extubation or re-intubations are costly in terms of healthcare dollars but more importantly in increased mortality and morbidity. A recent study conducted in a large neurocritical care unit (NCCU) explored stridor as a predictor of unsuccessful extubation.
"Some degree of laryngeal edema develops in all patients undergoing prolonged intubation. In serious cases, the tracheal lumen can narrow by greater than 50%, impairing ventilation and necessitating reintubation.3 An objective marker used as the clinical indicator for severe laryngeal edema is stridor, an audible high-pitched inspiratory whistle caused by increased airflow velocity. Postextubation stridor (PES) affects 1.5% to 26.3% of patients after extubation.4 These patients require monitoring and rapid intervention, leading to increased care needs and associated nursing time."
This study encompassed 43 extubations in an urban NCCU. 12 had post-extubation stridor and 9 patients were reintubated, 6 of these were due to post-extubation stridor.
"Risk factors that require the consideration of prompt treatment include female sex, age less than 18 years, duration of intubation more than 5 days, body mass index greater than 26.5 (calculated as the weight in kilograms divided by height in meters squared), prehospital intubations, and difficult intubations requiring multiple attempts. Additional risk factors include previous self-extubation, recurrent intubations, and extreme agitation."
With a screening tool involving the above criteria, it was determined that a single dose of methylprednisolone 40mg IV four hours prior to planned extubation. "Additionally, someevidence15,16 supports the use of inhaled budesonide immediately before extubation, although larger studies are necessary to support these findings."
The "aim was to affect institutional practice, not to create generalizable knowledge. Implementation of the pathway was successful in reducing rates of post-extubation stridor and reintubation; however, these findings are limited by the short implementation period and small sample size."
"Research on risk factors for PES and appropriate prophylactic treatment is limited. A few studies focused on trauma, medical, and surgical critical care patients. No studies focused on NCC patients. The latter patients are associated with a unique set of challenges and require further investigation. Additionally, research findings have long supported the use of steroids in patients at high risk for PES, but consensus on the definition of high risk has not been achieved.17-19 Further research is necessary to better aid in understanding patient characteristics and practices contributing to PES prevalence in NCC patients. The clinical pathway we implemented incorporated the best available research to create consistency in evaluation of patients before extubation and to guide management. Multidisciplinary input into the creation of the pathway was critical to obtain support from everyone involved in its implementation and was key to the success of the quality improvement project. The pathway was safe and effective in reducing rates of PES and reintubation in a single NCCU.
What is your experience extubating patients successfully? Do you find the use of steroids in one dose or multi-doses to be helpful in reducing the risk of reintubation?
What is your ICU doing to reduce reintubations?
Here is the link to the study discussed in this article - it will be available October 15-25, 2018.Last edit by traumaRUs on Oct 15
About traumaRUs, MSN, APRN, CNS Admin
Joined: Apr '00; Posts: 53,565; Likes: 26,643
allnurses Asst Community Manager, APRN; from US
Specialty: 25 year(s) of experience in Nephrology, Cardiology, ER, ICUOct 15Specialty: CVICU, MICU, Burn ICU ; From: US ; Joined: Nov '16; Posts: 337; Likes: 790This is a great topic, TraumaRUs! Deciding when to extubate can be tricky. I think there is definitely a case to be made for steroid use in the peri-extubation period. I like the idea of having a more systematic approach to extubation.Oct 15Joined: Apr '06; Posts: 889; Likes: 1,977Great article. Interesting.
I think a lot of getting "off the vent" depends on how they "got on the vent" and then the "intrinsics".
The ease of intubation (upper airway trauma from difficult intubation plus the local tissue trauma from the tube makes for badness). Underlying disease process is a huge factor.
In my experience, I was surprised at just how SMALL (almost tiny) some teen/young adult airways were. Yep folks they kinda look grown (like adults), but I was thinking 7ETT (cause that's my adult mindset) and ended up grabbing a 5.5!
So, it's not unthinkable that an inexperienced practioner could have unanticipated issues leading to a very difficult intubation if UNPREPARED.
When I teach airway classes, I impart this pearl of wisdom.
It's disconcerting to only be able to pass a 6.5 ETT on a 16yo 6'4" 200# football player that sustains traumatic injury post celebration, but gosh-darn it, IDK most kids just have small airways.
I find a good mindset, a couple of down ETT sizes and a Miller 2/3 helped me and saved my patients.
If the unprepared EMS'er gets a small airway and it becomes "difficult" with prolonged or multiple attempts that will create local trauma that could lead to edema in the upper airway. It's best avoided.
And let's be honest, some EMS'ers do not maintain accurate records of the attempt numbers.
Traumatic or difficult intubations MUST be ACCURATELY reported in order to assure CONTINUITY of care.
As for steroids, at that point, for that reason - "I'm in the prolly can't hurt, might help" camp. Try it. Airway over all.
Anyway, just wanted to add this. Teens end up in the Neuro ICU often. It's important that prehospital folks think this over and it be accurately documented and even better prepared for - and perhaps the difficult airway made less so by preparation. Be ready.