Extubation is the process of removing a patient’s endotracheal tube after mechanical ventilation, either due to their medical condition or general anesthesia for surgery. Successful extubation requires careful assessment, preparation, and post-extubation monitoring to ensure that patients continue to breathe effectively on their own. Respiratory support can be utilized to manage and prevent post-extubation respiratory failure and reduce the need for re-intubation.1,2
The placement of an endotracheal tube requires full sedation and relaxation of a patient’s entire body. Patients undergoing general anesthesia for surgery may receive medication to temporarily paralyze them during the procedure, while patients receiving ventilatory support due to a critical condition may still be weak and have an impaired respiratory system. Therefore, after extubation, patients may experience respiratory distress due to factors like muscle weakness and impaired cough reflex and require support. Underlying health conditions, such as congestive heart failure or obstructive pulmonary disease, can also increase the likelihood that a patient will need respiratory support to help with spontaneous breathing.
There are several different modalities that can be used to support patients’ breathing post-extubation.2 Numerous factors influence the decision on the type of support needed,3 and healthcare providers must tailor the support to the individual patients’ needs. For example, providers should consider factors like blood oxygenation levels, blood pH and carbon dioxide pressure, underlying health conditions, the duration the patient was intubated, and mental status.
Supplemental oxygen therapy can be provided in various forms to meet different levels of respiratory needs. For patients with mild respiratory requirements, a nasal cannula can be used to deliver low-flow oxygen at rates between 1 to 6 liters per minute. For those needing more substantial support, a simple face mask can deliver moderate-flow oxygen at rates between 6 to 10 liters per minute. In cases where significant support is necessary, a non-rebreather mask can provide high-flow oxygen at rates between 10 to 15 liters per minute.
For some patients experiencing respiratory distress, oxygen flow of 10-15 liters per minute may not be adequate enough. In these cases, High-Flow Nasal Cannula (HFNC) therapy delivers heated and humidified oxygen at high flow rates of up to 60 liters per minute.2 This modality provides a comfortable and effective means of support, ensuring more adequate oxygenation and reducing respiratory effort.
If additional support is needed, there are two forms of non-invasive ventilation (NIV) with a machine and mask that utilize pressure to maintain an open airway and increase oxygenation. Firstly, Continuous Positive Airway Pressure (CPAP) provides continuous positive airway pressure throughout the entire respiratory cycle (both inhalation and exhalation). This contributes to keeping the airways open by preventing airway collapse, improving oxygenation, and reducing the work of breathing. If constant positive pressure is not sufficient, Bi-level Positive Airway Pressure (BiPAP) can be used. This modality provides two levels of pressure: a high-pressure during inhalation and a lower pressure during exhalation. The different pressure levels help facilitate better gas exchange. Overall, BiPAP is the most aggressive form of respiratory support post-extubation that is not as invasive as re-intubation. 1
Generally, effective respiratory support with close monitoring after extubation is crucial to ensure patients continue to breathe effectively and avoid complications. As there are several different modalities to provide support, healthcare providers must assess patients’ level of respiratory distress, underlying respiratory function, and previous medical history to choose the most appropriate interventions. Each patient requires individualized care, and ongoing assessment is key to successful outcomes.
References
- Kacmarek RM. Noninvasive Respiratory Support for Postextubation Respiratory Failure. Respir Care. 2019;64(6):658-678. doi:10.4187/respcare.06671
- Thille AW, Wairy M, Pape SL, Frat JP. Oxygenation strategies after extubation of critically ill and postoperative patients. J Intensive Med. 2021;1(2):65-70. Published 2021 Jun 29. doi:10.1016/j.jointm.2021.05.003
- Hryciw BN, Hryciw N, Tran A, et al. Predictors of Noninvasive Ventilation Failure in the Post-Extubation Period: A Systematic Review and Meta-Analysis. Crit Care Med. 2023;51(7):872-880. doi:10.1097/CCM.0000000000005865