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AARC Clinical Practice Guideline

Removal of the Endotracheal Tube

RET 1.0 PROCEDURE
Removal of the endotracheal tube from adult, pediatric, and newborn patients.

RET 2.0 DESCRIPTION/DEFINITION:
To ensure patient safety, the patient with a temporary, artificial translaryngeal airway should have the device removed at the earliest appropriate time. Occasionally, acute airway obstruction of the artificial airway due to mucus or mechanical deformation mandates immediate removal of the artificial airway. (This guideline pertains to the decision processes surrounding the removal of an artificial translaryngeal airway, and the procedure referred to as extubation.)

2.1 Prolonged translaryngeal intubation is associated with many complications including but not limited to sinusitis,(1,2) vocal cord injury,(3) laryngeal injury,(4,5) laryngeal stenosis,(4,5) tracheal injury,(6-8) hemoptysis,(9) and pulmonary infection.(10-12)
2.2 Extubation may result in upper airway obstruction from laryngospasm,(13-15) laryngeal edema,(16-19) or supraglottic obstruction;(20) pulmonary edema;(21-23) pulmonary aspiration syndrome;(24,25) or impaired respiratory gas exchange.

RET 3.0 SETTINGS:
The endotracheal tube should be removed in an environment in which the patient can be physiologically monitored and in which emergency equipment and appropriately trained health care providers with airway management skills are immediately available.

RET 4.0 INDICATIONS/OBJECTIVES:
When the airway control afforded by the endotracheal tube is deemed to be no longer necessary for the continued care of the patient, the tube should be removed. In general, the patient should be capable of maintaining a patent airway and adequate spontaneous ventilation and should not require high levels of positive airway pressure to maintain normal arterial blood oxygenation.

4.1 Patients in whom further medical care is considered (and explicitly declared) futile may have the endotracheal tube removed despite continuing indications for the artificial airway.
4.2 Acute artificial airway obstruction mandates immediate endotracheal tube removal if the obstruction cannot be cleared rapidly. Reintubation or other appropriate techniques for reestablishing the airway must be used to maintain effective gas exchange (ie, surgical airway management).

RET 5.0 CONTRAINDICATIONS:
There are no absolute contraindications to extubation; however, some patients will require reintubation, positive pressure ventilation, continuous positive airway pressure, noninvasive ventilation, or high inspired oxygen fraction to maintain acceptable gas exchange after extubation. Airway protective reflexes are usually depressed immediately following and for some time after extubation and, therefore, measures to prevent aspiration should be considered.

RET 6.0 HAZARDS/COMPLICATIONS:

6.1 Hypoxemia after extubation may result from but is not limited to
6.1.1 failure to deliver adequate inspired oxygen fraction through the natural upper airway;
6.1.2 acute upper airway obstruction;
6.1.3 development of postobstruction pulmonary edema;
6.1.4 bronchospasm;
6.1.5 development of atelectasis, or lung collapse;
6.1.6 pulmonary aspiration;
6.1.7 hypoventilation
6.2 Hypercapnia after extubation may be caused by but is not limited to:
6.2.1 upper airway obstruction resulting from edema of the trachea, vocal cords, or larynx;
6.2.2 respiratory muscle weakness;
6.2.3 excessive work of breathing;
6.2.4 bronchospasm.
6.3 Death may occur when medical futility is the reason for removing the endotracheal tube.

RET 7.0 LIMITATIONS OF METHODOLOGY/VALIDATION OF RESULTS
Patients may need reintubation immediately or after some interval due to inappropriate extubation, progression of underlying disease, or development of a new disorder. A trial of extubation may be used in some marginal patients with the expectation that the need for reintubation is likely.

The need to reinsert an artificial airway following extubation is not necessarily an indication of poor practice. Inadequate airway maintenance and failure of reintubation may be an indication of poor practice.

The failure and complication rates of extubation can be used as quality monitors.

RET 8.0 ASSESSMENT OF NEED
The endotracheal tube should be removed as soon as the patient no longer needs an artificial airway. Patients should be capable of adequate spontaneous ventilation and should not require high levels of positive airway pressure or inspired oxygen to maintain adequate arterial blood oxygenation. (Experience suggests PEEP <=;10 cm H2O and FIO2 <=; 0.40.)

8.1 Patients receiving an artificial airway to facilitate treatment of respiratory failure should be considered for extubation when they have met traditional weaning criteria.(26) Examples of weaning criteria include but are not limited to
8.1.1 the capacity to maintain adequate arterial partial pressure of oxygen on inspired oxygen fractions provided with simple oxygen devices and with low levels of positive airway pressure;
8.1.2 the capacity to maintain appropriate pH and arterial partial pressure of carbon dioxide during spontaneous ventilation;(27,28)
8.1.3 adequate respiratory muscle strength;
8.1.4 maximum negative inspiratory pressure > 30 cm H2O;(29-33)
8.1.5 vital capacity greater than 10 mL/kg ideal body weight;(34)
8.1.6 pressure measured across the diaphragm during spontaneous ventilation less than 15% of maximum;
8.1.7 spontaneous exhaled minute ventilation < 10 L/min.(29)
8.1.8 in adults, respiratory rate < 35 during spontaneous breathing;(35) in infants and children, acceptable rate decreases with age and can be predicted and measured with good repeatability when determined by stethoscope.(36)
8.1.9 in adults, a rapid shallow breathing index (RSB, respiratory rate-to-tidal-volume ratio) of <=; 98-130;(37-40) in infants and children, neither a modified CROP index (derived from compliance, resistance, oxygenation, and ventilating pressure) nor a modified RSB has been shown to be a superior discriminator between successful and unsuccessful extubation.(41,42))
8.1.10 thoracic compliance > 25 mL/cm H2O;(43)
8.1.11 work of breathing < 0.8 J/L;(38,39,44-46)
8.1.12 oxygen cost of breathing < 15% total;(47-49)
8.1.13 dead-space-to-tidal-volume ratio < 0.6;(50)
8.1.14 absolute tracheal pressure in the first 0.1 second of occlusion < 6 cm H2O;(51,52) (This measurement is primarily a research tool.)
8.1.15 maximum voluntary ventilation > twice resting minute ventilation.(29)
8.2 In addition to treatment of respiratory failure, artificial airways are sometimes placed for airway protection. Resolution of the need for airway protection may be assessed by but is not limited to
8.2.1 normal consciousness,(53)
8.2.2 adequate airway protective reflexes,(54)
8.2.3 easily managed secretions.
8.3 In addition to resolution of the processes requiring the insertion of an artificial airway, issues that should be considered in all patients prior to extubation are
8.3.1 no immediate need for reintubation anticipated;
8.3.2 no previously identified difficulties with intubation;(55-58)
8.3.3 presence of gas leak around the deflated cuff with positive pressure breaths;(59,60)
8.3.4 evidence of stable, adequate hemodynamic function;(61-64)
8.3.5 evidence of stable nonrespiratory functions;(65-67)
8.3.6 electrolyte values within normal range.(68,69)

RET 9.0 ASSESSMENT OF OUTCOME
Removal of the endotracheal tube should be followed by adequate spontaneous ventilation through the natural airway, adequate oxygenation, and no need for re-intubation.

9.1 Clinical outcome may be assessed by physical examination, auscultation, invasive and noninvasive measurements of arterial blood gas values, and chest radiography.
9.2 Quality of the procedure can be systematically assessed by monitoring extubation complications and the need for reintubation.

RET 10. RESOURCES

10.1 Equipment:
10.1.1 Oxygen source
10.1.2 Devices to deliver oxygen-enriched gas mixtures
10.1.3 High-volume suction source
10.1.4 Pharyngeal and tracheal suction catheters
10.1.5 Self-inflating or non-self-inflating manual ventilation system
10.1.6 Oral and pharyngeal airways
10.1.7 Endotracheal tubes of various sizes
10.1.8 Translaryngeal intubation equipment (laryngoscope blades, handles, batteries, stylettes)
10.1.9 Equipment for establishing an emergency surgical airway (scalpel, lidocaine with epinephrine, appropriately sized endotracheal or tracheostomy tubes)
10.1.10 Pulse oximeter
10.1.11 Supplies for arterial puncture and blood gas analysis.
10.2 Personnel
10.2.1 Level-II personnel, credentialed and/or licensed health care personnel with documented knowledge and demonstrated skills specific to patient assessment and airway management, should determine the appropriateness of extubation, be available to assess success, and begin appropriate interventions should immediate complications occur. Personnel skilled in endotracheal intubation and the insertion of invasive airways should be immediately available whenever extubation is performed.
10.2.2 Level-I personnel, credentialed and/or licensed health care personnel with documented knowledge and demonstrated skill in providing oxygen administration devices and suctioning the airway, may provide support to Level-II personnel during the extubation procedure.
10.2.3 In the event of acute obstruction of the artificial airway, anyone with airway maintenance skills may remove the endotracheal tube to save the patient's life.(70)

RET 11.0 MONITORING
The success of removal of the endotracheal tube can be monitored by examining the frequency of reintubation and frequency of complications. When a patient experiences an unplanned self-extubation and does not require reintubation, this suggests that planned extubation should have been considered sooner.(71-76)

RET 12.0 FREQUENCY
The timing of extubation is determined by improvement in the patient's condition that mandated an artificial airway. Acute, artificial airway obstruction may occur at any time and must be recognized and treated immediately.

RET 13.0 INFECTION CONTROL Caregivers should exercise Standard Precautions for all patients, follow CDC recommendations for control of exposure to tuberculosis and droplet nuclei,(77,78) and, in addition, institute appropriate precautions empirically for airborne, droplet, and contact agents pending confirmation of diagnosis in patients suspected of having serious infections.(77)

Endotracheal Tube Removal Working Group

Charles G Durbin Jr MD, Chairman Charlottesville VA
Robert S Campbell RRT, Cincinnatti OH
Richard D Branson RRT, Cincinnati OH

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