Experts’ guidelines of intubation and extubation of the ICU patient (2)



Extubation of the ICU patient (Fig. 2 )







Prerequisite

  • R 5.1—We recommend a spontaneous breathing trial (SBT) before any extubation in an ICU patient ventilated for more than 48 h to decrease the risk of extubation failure. (Grade 1 +) Strong agreement.
  • R 5.2—The SBT is inadequate as the sole means of detecting all patients at risk of extubation failure; before extubation we should probably screen for more specific causes and risk factors of failure including ineffective cough, excessive tracheo-bronchial secretions, swallowing disorders and altered consciousness. (Grade 2 +) Strong agreement.

Extubation failure in ICU

  • R 6.1—A cuff leak test should probably be performed before extubation to predict the occurrence of laryngeal oedema. (Grade 2 +) Strong agreement.
  • R 6.2—A cuff leak test should be performed before extubation in ICU patients with at least one risk factor for inspiratory stridor to reduce extubation failure related to laryngeal oedema. (Grade 1 +) Strong agreement.
  • R 6.3—Measures to prevent and treat laryngeal pathology should probably be implemented during mechanical ventilation. (Grade 2 +) Strong agreement.
  • R 6.4—If the leak volume is low or nil, corticosteroids should probably be prescribed to prevent extubation failure related to laryngeal oedema. (Grade 2 +) Strong agreement.
  • R 6.5—Once corticosteroid therapy is decided, it should be started at least 6 h before extubation to be effective. (Grade 1 +) Strong agreement.


Respiratory therapy and extubation in the ICU

  • R 7.1—As a prophylactic measure, we suggest high-flow oxygen therapy via a nasal cannula after cardiothoracic surgery. (Grade 2 +) Strong agreement.
  • R 7.2—As a prophylactic measure, we suggest high-flow oxygen therapy via a nasal cannula after extubation in ICU for hypoxaemic patients and those at low risk of reintubation. (Grade 2 +) Strong agreement.
  • R 7.3—As a prophylactic measure, we suggest the use of non-invasive ventilation after extubation in ICU for those at high-risk of reintubation, especially hypercapnic patients. (Grade 2 +) Strong agreement.
  • R 7.4—As a therapeutic measure, we suggest the use of non-invasive ventilation to treat acute postoperative respiratory failure, especially after abdominal surgery or lung resection. (Grade 2 +) Strong agreement.
  • R 7.5—As a therapeutic measure, we suggest that non-invasive ventilation not be used to treat acute respiratory failure after extubation in ICU, except in patients with underlying chronic obstructive pulmonary disease (COPD) or when there is obvious cardiogenic pulmonary oedema.(Grade 2-) Weak agreement.
  • R 7.6—Treatment from a physiotherapist is probably required before and after endotracheal extubation following mechanical ventilation for more than 48 h to reduce the duration of weaning and the failure of extubation. (Grade 2 +) Strong agreement.
  • R 7.7—A physiotherapist should probably attend endotracheal extubation, to limit immediate complications such as bronchial obstruction in patients with high risk of extubation failure. (Grade 2 +) Strong agreement.


Pediatric specificity




Intubation

Complicated intubation in pediatric intensive care unit (PICU)

  • R 1.1 (pediatric)—All patients admitted in pediatric intensive care units must be considered at risk of complicated intubation. (Grade 1 +) Strong agreement.
  • R 1.2 (pediatric)—To reduce the incidence of complicated intubation in pediatric intensive care unit, respiratory and hemodynamic complications must be anticipated and prevented, thanks to a carefully preparation of intubation, including preservation of oxygenation and hemodynamic throughout the procedure. (Grade 1 +) Strong agreement.
  • R 1.3 (pediatric)—In pediatrics, risk factors of complicated intubation must be distinguished from predictive factors of difficult intubation. (Grade 1 +) Strong agreement.


Intubation equipment

  • R 2.1 (pediatric)—For child tracheal intubation in ICU, laryngoscopic blades suited to the habits of practitioners should be used (Miller straight blade or Macintosh curved blade). In case of exposition fail with the first blade, practitioner should change the type of blade for a new exposition. (Grade 2 +) Strong agreement.
  • R 2.2 (pediatric)—In order to limit intubation failures in children, videolaryngoscopes (VL) for intubation in intensive care must be used either directly or after failure of direct laryngoscopy. (Grade 2 +) Strong agreement.
  • R 2.3 (pediatric)—Oral intubation is probably preferred for children in intensive care units (Grade 2 +) Strong agreement.
  • R 2.4 (pediatric)—cuffed tubes are likely to be used for children in intensive care units in order to limit the number of reintubations for leakage (Grade 2 +) Strong agreement.


Drugs and intubation of the ICU patient

  • R 3.1 (pediatric)—Hypnotic agent should probably be chosen allowing rapid sequence induction (Etomidate, Ketamine, Propofol) depending on medical history and clinical situation of the patient in pediatric ICU. Grade 2 + Strong agreement.
  • R 3.3 (pediatric)—Succinylcholine is probably the first-line agent of choice for RSI in pediatric ICU patients with vital signs of distress. Rocuronium at a dose above 0.9 mg/kg [1.0–1.2 mg/kg] should be used when succinylcholine is contraindicated. (Grade 1 +) Sugammadex should probably be rapidly available when rocuronium is used. (Grade 2 +) Strong agreement.


Bundles and intubation in PICU

  • R 4.1 (pediatric)—Atropine should probably be administered before intubation during induction in PICU for children aged of more than 28 days to 8 years. Especially in children with septic shock, hypovolemia or when suxamethonium is used. (Grade 2 +) Strong agreement.


Extubation

Prerequisite

  • R 5.1 (pediatric)—A spontaneous breathing trial (SBT) should probably be performed before any extubation in PICU ventilated patient to decrease the risk of extubation failure. (Grade 2 +) Strong agreement.
  • R 5.2 (pediatric)—The SBT being not sufficient by itself to detect all patients at risk for extubation failure, more specific causes and risk factors for extubation failure including ineffective cough, excessive tracheo-bronchial secretions, swallowing disorders, altered consciousness and some pediatrics specific factors should probably be screened before extubation. (Grade 2 +) Strong agreement.

Extubation failure in ICU

  • R 6.5 (pediatric)—When a corticosteroid therapy is decided, it should be started at least 24 h before extubation to be effective. (Grade 1 +) Strong agreement.

Bundles of extubation in PICU

  • R7 (pediatric)—We should probably not use NIV after extubation in pediatric ICU in low risk patients. (Expert advice) Strong agreement.

References




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