EXTUBATION

Yes, paramedics certified by the RPPEO are authorized to perform endotracheal and nasotracheal extubation should the situation dictate. That said, extubation is a high-risk procedure in a controlled setting, let alone in the back of a moving ambulance and would rarely be indicated. Furthermore, re-intubation should it be required, is always more challenging than the first attempt. The American Society of Anesthesiologists Closed Claims Project concluded that reported that adverse respiratory events leading to death and brain injury were more common among claims relating to ехtubаtiοn than intubatiοn.

Two situations where extubation may be indicated in the pre-hospital setting are:

• Failure of the nasotracheal or endotracheal tube (ETT) (I.e., a significant cuff leak resultant from a damaged pilot balloon).
• Rapid and significant improvement of the patient’s level of awareness and/or that is non-responsive to procedural sedation.

If the paramedic notices a sudden loss of ETC02 waveform capnography or BVM compliance, troubleshooting techniques using the “DOPE” pneumonic should be performed prior to considering extubation.

• Displacement (esophageal ETT, intubation of right mainstem)
• Obstruction (Secretions, emesis, food bolus)
• Pneumothorax (Decreased compliance AND you tried suctioning AND decreased breath sounds on one side AND you have unexplained hypotension, consider needle thoracostomy).
• Equipment (Cuff leak, kinked airway tube, defective, saturated or obstructed capnography line, disconnected tubing). Start your way from the distal end and work proximal to ensure integrity of your equipment

Distress and agitation is common among intubated patients. The goal of care for these patients is to provide comfort and decrease sympathetic tone. This is best managed under the Procedure Sedation Medical Directive as opposed to extubation. ACP’s can initiate post-intubation sedation with pharmacologic agents such as fentaNYL and midazolam. Indications for procedure sedation in the intubated patient may include.

• An improving GCS.
• “Bucking” at the tube.
• Spontaneous movement of extremities.

Additionally, the intent of the directive is to administer both midazolam and fentaNYL concurrently. To mitigate adverse events (i.e. hypotension) we recommend administering conservative doses of each respective medication in the elderly and light weight individuals (i.e., midazolam 0.05mg/kg and fentanyl 25-50mcg.

In conjunction with troubleshooting using the DOPE pneumonic and treating with procedural sedation, the paramedic should carefully assess the following clinical considerations prior to extubation.

Will the patient tolerate extubation due to?

• Airway obstruction (laryngeal edema, laryngeal spasm, chronic lung disease, airway trauma, trismus, emesis)?
• Difficulty ventilating with other airway management techniques due to conditions such as; chronic lung disease, obesity, neuromuscular disease?
• Impaired oxygenation (hypotension, acidosis, ongoing hypoxia)?
• Inadequate clearing of secretions (impaired cough reflex, obtundation from opioids, benzodiazepines, anesthetics, or organic causes)?
• Inability to protect and manage the airway with other techniques (positioning, OPA/NPA, another advanced airway)?
• What is the expected clinical course? If that patient required intubation initially, what has changed?

Will the paramedic have difficulty re-establishing the airway due to:

• Anatomical challenges (the first attempt was difficult and/or required multiple attempts, the airway may be compromised by blood, secretions, stomach contents, airway trauma, or edema)?
• Physiological changes (Patients may be less tolerant of delays and persistent or prolonged intubаtiοո attempts. Patients may be hypoxic, hypercapnic, acidotic or hemodynamically unstable)?

If extubation is necessary, paramedics should adhere to the following sequence:

1. Pre-oxygenate for several minutes (if possible).
2. Position the patient in a way that will facilitate airway patency and BVM ventilations (sniffing position).
3. Optimize environment: Discuss the procedure with your team and delegate roles should support be required, prepare other airway management equipment (i.e., suction, OPA/NPA, another advanced airway, ETT).
4. Clear secretions.
5. Deflate the pilot balloon and remove the ETT at peak inspiration
6. Oxygenate/ventilate as required.
7. Closely monitor (ABC’s, HR, RR, BP, SP02, ETC02, MAP, LOA.

As mentioned above, extubation in the pre-hospital setting is extremely high risk. If in doubt, if a difficult airway, if close to hospital, treatment under the Procedural Sedation Medical Directive is the preferred approach to managing distress and agitation in the intubated patient. As always, the BHP’s are happy to take your consults to assist in weighing the risk/benefit of extubation.

In closing, any intubation that requires extubation or deep sedation due to improved mentation can sometimes be avoided by understanding the etiology of the conditions that cause coma (i.e., Patients who suffer a witnessed cardiac arrest and achieve ROSC after defibrillation often present with improved mentation quickly, post ictal patients after a single seizure tend to improve with supportive care). Rushing to intubate a patient in whom the expected clinical course is improvement of LOA can create a challenging intubation for paramedics as they may respond to direct laryngoscopy and if the tube is placed, lead to an adverse event as LOA improves. Often times, oxygenation and ventilation using BLS or other advanced airways is the most appropriate management.