Extubation Evaluation/Checklist

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1. Spontaneous Breathing Trial (SBT) Parameters: (To be routinely performed between 0800 and noon)
   • Vent Settings Low (FIO² ≤ 40%, PEEP ≤ 8)
   • ABG adequate PaO² and PaCO²
   • Negative Inspiratory Force (NIF) < -30 cm H₂O
   • Tidal Volume (VT) > 5 cc/kg
   • Vital Capacity (Vcap) > 10 ml/kg
   • Respiratory Rate < 30
   • Frequency Tidal Volume Index or Rapid Shallow Breathing Index (RSBI) < 104
2. Difficult/High Risk Airway:
   • Difficult or impossible face mask ventilation
   • Difficult laryngoscopy
   • Difficult or failed tracheal intubation
   • Known/History of Difficult Airway
     • Oral, pharyngeal, laryngeal, or tracheal abnormality (e.g. subglottic stenosis, tracheomalacia, peritonsillar deep space neck and retropharyngeal abscess, craniofacial abnormalities, Down's Syndrome, macroglossia, teratomas, lymphangiomas)
     • Oral, pharyngeal, laryngeal, or tracheal surgery requiring special airway management (wired jaw)
     • Limited neck movement (prior cervical fixation, immobilization, halo, cervical collar, or physically limited)
     • Small mouth opening (less than 2 fingerbreadths)
     • Inability to see uvula with the mouth open, tongue fully protruded
     • Steven’s Johnsons Syndrome (SJS) or TENS
3. Routine Extubation:
   • Notify attending prior to extubation
   • Perform extubation between 0800 and 1500, unless exempted by attending
4. Heated High Flow (HHF) Recommendations
   • Consider HHF in the following scenarios or any patients at high risk for reintubation:
     • ≥ 65 years old
     • Prolonged mechanical ventilation or difficult liberalization from mechanical ventilation
     • BMI > 30
     • Inadequate secretion management
     • Patients with rib fractures
     • Underlying chronic cardiac disease
       • LV dysfunction
       • LV EF ≤ 45%
       • History of cardiogenic pulmonary edema
       • Ischemic heart disease
       • Permanent A-fib
     • Underlying chronic lung disease
       • COPD
       • Obesity-hypoventilation syndrome
       • Restrictive pulmonary disease
   • Relative contraindication:
     • Craniofacial/skull base fractures at risk for pneumocephalus (discuss whether heated high flow/positive pressure is safe with the trauma/face team)
5. Indicators a patient is failing extubation
   • Respiratory distress
   • Dyspnea
   • Increased work of breathing (eg “belly breathing”)
   • Increased or decreased respiratory rate
   • Somnolence
   • Hypercapnea (CO₂ retention)
   • Hypoxia
   • Increased suction requirements
   • Feeling of inability to breath or “impending doom”
   • Inability to protect airway