EXTUBATION OF ENDOTRACHEAL TUBES
PROCEDURE
To standardize the procedure for extubating patients with endotracheal tubes.
SCOPE
It is the policy of the Department of Respiratory Care Services to maintain artificial airways
and removal of artificial airways upon physician prescription.
Extubation will be done by a Licensed Respiratory Care Practitioner with
understanding of age specific requirements of the patient population treated under
general supervision of the Supervisor.
A physician must be present or in the immediate area during the extubation procedure
so that the physician can take the necessary action, should a complication arise that
would warrant reintubation.
EQUIPMENT
Suction catheter of appropriate size
Normal Saline
Scissors
10cc syringe (for cuffed endotracheal tubes)
Appropriate oxygen delivery system
Hand held nebulizer with racemic epinephrine (if ordered)
Manual Resuscitator with face mask
PROCEDURE
Oral Tubes:
Step
1 Verify physician's order and patient using two patient identifiers. Wash hands.
2 Verify the presence of emergency resuscitation equipment at the bedside.
3 The procedure must be explained to the patient; in the degree of detail they can
comprehend. It is desirable to have the patient's cooperation during and after the extubation.
Position the patient as upright as possible.
4 Increased inspired oxygen should be administered. This is done by increasing the FIO2 to
100% (In the ISCU, hyper oxygenation to 20% above the baseline FiO2 appropriate unless
otherwise directed by physician or practitioner).
5 Secretions must be aspirated from the trachea, if indicated, the oropharynx (in that order).
Nasopharyngeal suctioning is not advocated unless indicated, due to the increased risk of
nose bleed.
6. For Cardiothoracic (CT) patients, remove patient's nasogastric/ oro-gastric tube prior to
extubation, per CT protocol
7 The lungs should be hyper inflated, so that the patient will be exhaling as the tube is
withdrawn and adequate oxygenation and ventilation is maintained. For adult patients (and
some paediatric patients), positive pressure is administered with a manual resuscitator. At the
end of peak inspiration, the tube is removed rapidly but gently. This occurs immediately after
cuff deflation. For infants (and some paediatric patients), the tube is removed rapidly but
gently while the patient continues on mechanical ventilation.
8 Appropriate oxygen is immediately administered as per physician order.
9 The patient is immediately evaluated for signs of obstruction, stridor, difficulty breathing
and ability to speak. The patient should be encouraged to take deep breaths and to cough.
10 The patient must not be left unattended, while there is doubt of his ability to function
without the artificial airway.
Nasotracheal Tubes:
Step
1 Standard procedure is followed except after cuff deflation slowly remove tube from nares
allowing patient to cough during removal. This decreases potential trauma to nasopharyngeal
tissues and facilitates removal of oral and nasal pharyngeal secretions.
Adverse Reactions
Laryngospasm
• Definition: Spasmodic contraction of the larynx.
• Signs and Symptoms: Crowing sound on inspiration dyspnea, shortness of breath,
tachypnea and cyanosis.
• Action: Administer oxygen, maintain ventilation, and administer appropriate emergency
care if necessary. Alert physician; do not leave patient unattended, and complete appropriate
documentation.
