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Airway Management in Mechanical Ventilation 181

Vital signs, blood gases, and signs of tissue damage should be assessed carefully after
Aspiration, laryngo- extubation. Some immediate postextubation complications include aspiration, laryngo-
spasm, hoarseness, and
laryngeal and subglottic spasm, hoarseness, and laryngeal and subglottic edema. Other more severe complications
edema are some complica-
tions immediately after that may not be immediately apparent are mucosal injuries, laryngeal stenosis, tracheal
extubation. inflammation, dilation or stenosis, and vocal cord paralysis (Young et al., 1995).

Unplanned Extubation

Unplanned extubation or inadvertent extubation (self-inflicted or accidental) ac-
unplanned extubation: Unex-
pected removal of an endotracheal counts for about 8% to 10% of all extubations in ICU patients (Listello et al.,
or tracheostomy tube before the 1994). For patients who self-extubate the endotracheal tube, about 50% of them
patient is ready for extubation.
do not need to be reintubated (Betbese et al., 1998; Chevron et al., 1998). Whether
or not to reintubate the patient can be a difficult decision. Delayed reintubation
may lead to adverse outcomes such as hypoventilation, hypoxemia, and hypoxia.
In general, the decision to reintubate may be based on clinical observations and
the criteria for extubation (i.e., rapid shallow breathing index, blood gases, ventila-
tory reserve, and general cardiopulmonary signs). However, these measurements
may not have been done immediately before extubation since the extubation is not
planned.
To avoid this problem, other criteria based on routinely available patient in-
formation have been identified and used for the reintubation decision. They
are summarized in Table 6-11. In the model set, the presence of four or more
factors indicates the need for reintubation and the presence of three or fewer
factors reflects a satisfactory patient outcome without reintubation (Listello
et al., 1994).

TABLE 6-11 Clinical Predictors for Reintubation

Unfavorable Clinical Predictor* Rationales

1. SIMV or AC frequency . 6/min Patient is dependent on the ventilator.

2. Most recent pH $ 7.45 Oxyhemoglobin saturation curve shifts to left
( ➞ O affinity and O release to tissues).
2
2
➞
3. Most recent PaO /F O , 250 mm Hg Poor oxygenation status.
2
I
2
4. Highest heart rate in the past Cardiac compensation for poor perfusion or
24° . 120/min oxygenation.
5. Presence of $ 3 medical disorders Potential of medical complications.
6. Not alert Poor mental status; blunted drive for breathing.

7. Reason for intubation other than Presence of medical problems and potential
preoperative complications.

*Presence of four or more predictors favors reintubation. Presence of three or less predictors indicates no need for reintubation.
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