Extubation To Permit Self-Weaning From Ventilator Support When Possible:
Older Children and Adults
Intubation involves passing an invasive airway (endotracheal) tube through the nose or mouth and into the windpipe (trachea) to ventilate the lungs using a ventilator (respirator). This becomes necessary when people have long surgical procedures or when patients develop pneumonia because their ability to cough is inadequate to effectively clear airway secretions. Once intubated, ventilatory support normalizes breath volumes, which in turn normalizes blood CO2 levels and sometimes blood O2 sat levels. Patients with respiratory tract infections also usually need antibiotics and other supportive therapies such as chest percussion and are routinely suctioned through the tube. Unfortunately, for anatomical reasons, suctioning misses the left airways over 90% of the time, so over 80% of pneumonias are in the left lung.
Once the lungs are recovered, many physicians think that they must “wean” the patient from ventilatory support and that the patient must demonstrate that they can breathe without ventilator use for a period of time before the endotracheal tube can be removed (termed extubation). When the physician feels that patients are not strong enough to breathe on their own and would stop breathing if extubated, then they say that the only option for survival is to undergo tracheotomy. If the physician is unsure whether a patient will be able to breathe after extubation, then they may extubate the person to CPAP or bi-level PAP or maintain oxygen supplementation instead of extubating to noninvasive ventilatory support (NVS) on room air. When extubation fails, patients are re-intubated and told that they need tracheostomy tubes.
Very few intensive care physicians know how to extubate anyone unless they are clearly strong enough to breathe even though this is completely unnecessary for most patients with neuromuscular disease (see applicable conditions). In fact, most conventional extubation or “weaning” criteria reflect the patient’s ability to breathe and cough, both of which are irrelevant for successful extubation using continuous CNVS and mechanical insufflation-exsufflation (MIE). Indeed, no cooperative person with a normally patent (open) airway needs a tracheostomy tube because they are too weak to breathe or cough. Ventilators that are all too often being used for invasive tracheostomy mechanical ventilation (TMV) can also be used for NVS, and they can deliver the air through simple mouthpieces or nasal interfaces when set up on “noninvasive ventilation modes.” We consider it best and most practical to extubate people to the portable ventilators that they will be using when they return home.
Over 80% of the intubated patients who fail multiple extubation attempts at other hospitals and are transferred for extubation to CNVS arrive with residual pneumonias and other lung problems that cause their O2 sats to be less than 95%. Even though they may have awaited transfer to us while intubated for weeks or months, their local physicians never resolved the pathology that caused their O2 sats to be less than normal. Since we cannot extubate them until their baseline O2 sat is normal on room air, we use MIE via the tube hourly for 24 or more hours until their O2 sat baseline is normal (≥95%), which permits us to extubate them successfully. The use of MIE while patients are intubated is as important as it is after extubation.
After extubation, the family is employed to use MIE up to every 20-30 minutes and for every O2 sat <95% to maintain the O2 sat baseline normal and the extubation successful.