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Intubating and extubating ventilated patients are not risk-free procedures. Both are associated with morbidity and mortality when performed on patients in the intensive care unit (ICU). Patients with an unstable respiratory or cardiovascular system are at a particularly high risk of life-threatening complications during intubation. Extubation represents another risk period, which, according to studies, has a 10 % failure rate and is linked with a poor prognosis.
Endotracheal intubation is a lifesaving procedure routinely performed throughout hospitals in the United States and worldwide. The process involves guiding an endotracheal tube (ETT) into the mouth or nose and then the patient's trachea to keep the airway open and allow air to flow to the lungs. The two most common clinical scenarios when doctors intubate patients are during emergencies or before surgeries.
Whether the intubation is for surgery or due to an emergency, it is important to note that not all intubated patients are ventilated. Once the endotracheal tube is successfully inserted into the windpipe, the clinician then hooks the tube to a device that delivers air. The device can be a bag to manually push air into the patient's airway or a ventilator that blows oxygen into the lungs.
Extubation is the removal of the endotracheal tube. Although the process sounds simple, the preparation for extubation is a long process, which starts on the day of the patient's intubation and continues through the acute management of the primary issue which caused respiratory failure.
Two terms associated with extubation are weaning and liberation. Weaning means gradually transitioning a patient from full invasive ventilatory support to spontaneous ventilation with minimal support. Liberation, on the other hand, means the complete discontinuation of mechanical ventilation.
Clinicians should assess ventilated ICU patients daily for readiness to wean by carefully weighing the benefits of early weaning against the risks of morbidity and mortality associated with failed extubation.
Although intubations are lifesaving procedures, complications can occur, including:
Thanks to the introduction of video laryngoscopy (VL) and modern extra-glottic devices, emergency airway management has improved over the years. However, the instruments used are only one of the factors in intubation success. Instead, the totality of the intubation process determines whether a clinician can successfully intubate a patient, including one with a potentially difficult airway. Besides the glottic view and anatomic obstacles in placing the tracheal tube, these factors include:
Here are the steps of the intubation process:
After the patient successfully passes the spontaneous breathing trial (SBT), the clinician should proceed with extubation. It is critical to ensure that all equipment is available for extubation management, including those needed when extubation does not go as planned.
Here are the steps of the extubation process:
Intubation and extubation are routine procedures, yet complications can occur. Clinicians frequently perform intubation for surgery or during medical emergencies. Considering the lifesaving nature of intubation, the benefits generally outweigh the risks. Physicians should strive for 100% first-pass success by considering the entire intubation process and ensuring the availability of necessary devices and personnel. Extubation should only be performed after carefully assessing the patient's readiness to wean.
Have you heard of QuickSteer™ - the latest innovation in airway management designed to reduce overall intubation time and improve first-pass success rate in patients with difficult airways?
Watch this video to see QuickSteer™ in action.
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