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## Complete Summary

#### GUIDELINE TITLE

Removal of the endotracheal tube---2007 revision & update.

#### BIBLIOGRAPHIC SOURCE(S)

American Association for Respiratory Care (AARC). Removal of the
endotracheal tube\--2007 revision & update. Respir Care 2007
Jan;52(1):81-93. \[189 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). Removal of the endotracheal tube. Respir Care
1999 Jan;44(1):85-90.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Pulmonary disease or other condition where use of endotracheal tube is
necessary

#### GUIDELINE CATEGORY

Evaluation\
Management\
Risk Assessment

#### CLINICAL SPECIALTY

Critical Care\
Emergency Medicine\
Internal Medicine\
Pediatrics\
Pulmonary Medicine

#### INTENDED USERS

Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

To focus on the predictors that aid the decision to extubate, the
procedure referred to as extubation, and the immediate postextubation
interventions that may avoid potential reintubation

**Note**: This review will not address weaning from mechanical
ventilation, accidental extubation, nor terminal extubation.

#### TARGET POPULATION

Adult, pediatric and neonatal patients with endotracheal tubes

#### INTERVENTIONS AND PRACTICES CONSIDERED

Removal of the endotracheal tube (extubation) including

-   Assessment of extubation readiness as determined by established
    readiness criteria

-   Assessment of risk factors for extubation failure

-   Prophylactic medication prior to extubation to avoid or reduce
    complications

-   Assessment of outcome (physical examination, auscultation,
    postextubation respiratory support, postextubation medical therapy)

-   Patient and equipment monitoring

-   Standard precautions

#### MAJOR OUTCOMES CONSIDERED

-   Clinical outcome as assessed by physical examination, auscultation,
    invasive and noninvasive measurements of arterial blood gas values,
    and chest radiography

-   Extubation complications and the need for reintubation

-   Sensitivity and specificity of tests

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This guideline was approved by the 2006 Clinical Practice Guidelines
Steering Committee.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Environment**

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 (see \"Resources\" and
\"Monitoring\" sections below).

**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. Subjective or objective determination of improvement
of the underlying condition impairing pulmonary function and/or gas
exchange capacity is made prior to extubation (MacIntyre et al., 2001).
To maximize the likelihood for successful extubation, the patient should
be capable of maintaining a patent airway and generating adequate
spontaneous ventilation. In general, this requires the patient to
possess adequate: central inspiratory drive, respiratory muscle
strength, cough strength to clear secretions, laryngeal function,
nutritional status, and clearance of sedative and neuromuscular blocking
effects.

-   Occasionally, acute airway obstruction of the artificial airway due
    to mucus or mechanical deformation mandates immediate removal of the
    artificial airway. Reintubation or other appropriate techniques for
    reestablishing the airway (i.e., surgical airway management) must be
    used to maintain effective gas exchange (Cohen et al., 1988; Skoulas
    & Kountakis, 2003; Kapadia et al., 2001).

-   Patients in whom an explicit declaration of the futility of further
    medical care is documented may have the endotracheal tube removed
    despite failure to meet the above indications (\"Consensus report,\"
    1990; Truog et al., 2001).

**Contraindications**

There are no absolute contraindications to extubation; however, to
maintain acceptable gas exchange after extubation some patients may
require one or more of the following: noninvasive ventilation,
continuous positive airway pressure, high inspired oxygen fraction, or
reintubation. Airway protective reflexes may be depressed immediately
following and for some time after extubation (Leder, Cohn, & Moller,
1998; Ajemian et al., 2001). Therefore, measures to prevent aspiration
should be considered.

**Hazards/Complications**

Refer to the Potential Harms field for information on hazards and
complications of extubation.

**Limitations of Methodology/Validation of Results**

Predicting extubation outcome is of significant clinical importance as
both extubation delay and unsuccessful extubation are associated with
poor patient outcomes (Epstein, 2002; MacIntyre et al., 2001). However,
the literature on this topic is limited by few validated objective
measures to accurately predict the extubation outcome for an individual
patient (Epstein, 2002; MacIntyre et al., 2001; Epstein, 2000; Davis &
Henderson-Smart, 2001; Sinha & Donn, 2002; Epstein, 2001). Failed
extubation, or the need to reinsert an artificial airway following
extubation, is not necessarily an indication of failed medical practice.
Patients may need reintubation immediately or after some interval due to
inappropriately timed extubation, progression of underlying disease, or
development of a new disorder. Therefore, a trial of extubation may be
used in some marginal patients with the expectation that the need for
reintubation is likely. Clinical practice standards for endotracheal
tube removal include attentive postextubation monitoring, prompt
identification of respiratory distress, maintenance of a patent airway
and, if clinically indicated, attempts to successfully establish an
artificial airway by reintubation or surgical technique. The failure and
complication rates of extubation can be used as quality monitors.

**Assessment of Extubation Readiness**

The endotracheal tube should be removed as soon as the patient no longer
needs an artificial airway. Patients should demonstrate some evidence
for the reversal of the underlying cause of respiratory failure and
should be capable of maintaining adequate spontaneous ventilation and
gas exchange. The determination of extubation readiness may be
individualized using the following guidelines.

1.  Patients with an artificial airway to facilitate treatment of
    respiratory failure should be considered for extubation when they
    have met established extubation readiness criteria (DeHaven, Hurst,
    & Btanson, 1986; Leitch, Moran, & Grealy, 1996). Examples of these
    criteria include but are not limited to

    -   The capacity to maintain adequate arterial partial pressure of
        oxygen (arterial oxygen pressure/fraction of inspired oxygen
        \[PaO~2~/FIO~2~\] ratio \> 150-200) on inspired oxygen fractions
        provided with simple oxygen devices (FIO~2~ [\<]{.underline}0.4
        to 0.5 and with low levels of positive airway pressure \[PEEP\]
        [\<]{.underline}5 to 8 cm H~2~O) (MacIntyre et al., 2001)

    -   The capacity to maintain appropriate pH (pH
        [\>]{.underline}7.25) (MacIntyre et al., 2001) and arterial
        partial pressure of carbon dioxide during spontaneous
        ventilation (Berman et al., 1976; Kim & Boutwell, 1987)

    -   Successful completion of 30--120 minute spontaneous breathing
        trial (SBT) performed with a low level of continuous positive
        airway pressure (CPAP) (e.g. 5 cm H~2~O) or low level of
        pressure support (e.g. 5-7 cm H~2~O) demonstrating adequate
        respiratory pattern and gas exchange, hemodynamic stability, and
        subjective comfort (Farias et al., 2001; Esteban et al., 1997;
        Esteban et al., 1999; Vallverdu et al., 1998; Ely et al., 1999)

    -   In adults, respiratory rate \< 35 breaths per minute during
        spontaneous breathing (Cohen et al., 1982); in infants and
        children, the acceptable respiratory rate decreases inversely
        with age and can be measured with good repeatability with a
        stethoscope (Rusconi et al., 1994)

    -   Adequate respiratory muscle strength (Bellemare & Grassino,
        1982; Jubran & Tobin, 1997; Roussos & Macklem, 1982)

    -   Maximum negative inspiratory pressure \> -30 cm H~2~O (Sahn &
        Lakshminarayan, 1973; Hess, 1989; Marini, Smith, & Lamb, 1986;
        Belani et al., 1980) although current clinical practice may
        accept a maximum negative inspiratory pressure \> -20 cmH~2~O
        (Yang & Tobin, 1991; Martin, Bratton, & Walker, 1996)

    -   Vital capacity \> than 10 mL/kg ideal body weight (Bendixen et
        al., 1965) or in neonates \>150 mL/m^2^ (Belani et al., 1980)

    -   Pressure measured across the diaphragm during spontaneous
        ventilation \< 15% of maximum (Aubier et al., \"Bilateral,\"
        1985; Tobin, Laghi, & Jubran, 1998)

    -   In adults, spontaneous exhaled minute ventilation \< 10 L/min
        (Sahn & Lakshminarayan, 1973)

    -   In adults, a rapid shallow breathing index (RSBI, respiratory
        rate-to-tidal-volume ratio) of [\<]{.underline} 105 breaths/min
        (positive predictive value \[PPV\] of 0.78) (Yang & Tobin,
        1991); in infants and children, variables standardized by age or
        weight proved more useful. Modified CROP index (compliance,
        resistance, oxygenation, and ventilating pressure) above the
        threshold of [\>]{.underline} 0.1 to 0.15 mL x mm
        Hg/breaths/min/kg) (sensitivity of 83% and specificity of 53%)
        may be a superior screening tool than a modified RSBI
        [\<]{.underline} 8--11 breaths/min/mL/kg (sensitivity of 74% and
        specificity of 74%) (Farias et al., 1998; Baumeister et al.,
        1997; Thiagarajan et al., 1999)

    -   Thoracic compliance \> 25 mL/cm H~2~O (Peters et al., 1972)

    -   Work of breathing \< 0.8 J/L (Lee et al., 1994; Krieger et al.,
        1997; Lewis et al., 1988; Levy, Miyasaki, & Langston, 1995;
        Kirton et al., 1995; Shikora et al., 1990)

    -   Oxygen cost of breathing \< 15% total especially for those
        patients with chronic respiratory insufficiency requiring
        long-term mechanical ventilation (sensitivity 100%; specificity
        87%) (Shikora et al., 1990; Harpin et al., 1987; Shikora,
        Benotti, & Johannigman, 1994)

    -   Dead-space-to-tidal-volume ratio (V~D~/V~T~) \< 0.6; in
        children, V~D~/V~T~ [\<]{.underline} 0.5 equates to 96%
        successful extubation, 0.51-0.64 equates to 60% successful
        extubation, 0.65 equates to 20% successful extubation
        (Tahvanainen, Salmenpera, & Nikki, 1983; Hubble et al., 2000)

    -   Airway occlusion pressure at 0.1 seconds (P~0.1~) \< 6 cm H~2~O
        and when normalized for maximal inspiratory pressure (MIP), as
        indicated by \[P~0.1~/MIP\], accurately predicts successful
        extubation 88% and 98% of the time, respectively (Capdevila et
        al., 1995; Montgomery et al., 1987; Gandia & Blanco, 1992).
        (This measurement is primarily a research tool.)

    -   Maximum voluntary ventilation \> twice resting minute
        ventilation (Sahn & Lakshminarayan, 1973)

    -   In preterm infants, minute ventilation testing vs. standard
        clinical evaluation resulted in shorter time to extubation
        (Gillespie et al., 2003)

    -   Peak expiratory flow (PEF) ≥ 60 L/min after 3 cough attempts
        measured with an in-line spirometer (Smina et al., 2003; Bach &
        Saporito, 1996)

    -   Time to recovery of minute ventilation to pre-spontaneous
        breathing trial baseline levels (Martinez, Seymour, & Nam, 2003)

    -   Sustained maximal inspiratory pressures (SMIP) \> 57.5 pressure
        time units (sensitivity and specificity of 1.0) predicted
        extubation outcome (Bruton, 2002)

    -   In neonates, total respiratory compliance (C~rs~, derived from
        V~T~/PIP-PEEP) ≤ 0.9 mL/cm H~2~O was associated with extubation
        failure, whereas a value ≥ 1.3 mL/cm H~2~O was associated with
        extubation success (Balsan et al., 1990)

    -   Preterm infants extubated directly from low rate ventilation
        without a trial of endotracheal tube continuous positive airway
        pressure (CPAP) demonstrated a trend to increased chance of
        successful extubation (Davis & Henderson-Smart, 2001)

    -   Integrated indices of measured vital capacity (VC, threshold
        value = 635 mL), respiratory frequency to tidal volume ratio
        (f/V~T~, threshold value = 88 breaths/min/L) and maximal
        expiratory pressure (MEP, threshold value = 28 cm H~2~O)
        (Vallverdu et al., 1998; Zeggwagh et al., 1999)

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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

    1.  Appropriate level of consciousness (Redmond et al., 1996; Harel
        et al., 1997; Coplin et al., 2000)

    2.  Adequate airway protective reflexes (Harel et al., 1997; Coplin
        et al., 2000)

        -   Reduced cough strength (grade 0 to 2) measured by the white
            card test and increased secretion burden predicted
            unsuccessful extubation (Khamiees et al., 2001)

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    3.  Easily managed secretions (Epstein, 2002; Epstein, 2001; Harel
        et al., 1997; Coplin et al., 2000)

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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

    1.  No immediate need for reintubation anticipated

    2.  Known risk factors for extubation failure

        -   Patient features of high risk for extubation failure
            include: admission to medical intensive care unit (ICU), age
            \> 70 or \< 24 months, higher severity of illness upon
            weaning, hemoglobin (Hgb) \<10 mg/dL, use of continuous I.V.
            sedation, longer duration of mechanical ventilation,
            presence of a syndromic or chronic medical condition, known
            medical or surgical airway condition (Epstein, 2001;
            Kurachek et al., 2003), frequent pulmonary toilet (Khamiees
            et al., 2001), and loss of airway protective reflexes (Harel
            et al., 1997; Coplin et al., 2000)

        -   Risk factors for a known history of a difficult airway:
            syndromic or congenital conditions associated with cervical
            instability (i.e., Klippel-Feil or Trisomy 21); limited
            physical access to the airway (i.e., halo-vest or anatomic
            hindrances); multiple failed direct laryngoscopy attempts by
            an experienced laryngoscopist, or a failed laryngoscopy
            attempt followed by tracheal intubation using fiberoptic
            bronchoscopy or nasal lightwand, or requiring placement of a
            laryngeal mask airway (Deem & Bishop, 1995; American Society
            of Anesthesiologists \[ASA\] Task Force on Management of the
            Difficult Airway, 2003; Cork & Monk, 1992; Van Boven et al.,
            1996; Mort, 2003; Loudermilk et al., 1997; Hartmannsgruber,
            Loudermilk, & Stoltzfus, 1997; Hartmannsgruber & Rosenbaum,
            1998)

        -   In the pediatric cardiothoracic surgery population, presence
            of one or more of these variables increases the likelihood
            of failed extubation: age \< 6 months, history of
            prematurity, congestive heart failure, and pulmonary
            hypertension (Davis et al., 2004)

        -   For pediatric patients, validated bedside measures of
            respiratory function identifying low (\< 10%) and high risk
            (\> 25%) threshold values of extubation failure which may be
            useful in generating discussion, but do not apply to
            individual risk (Venkataraman, Khan, & Brown, 2000)

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    3.  Presence of upper airway obstruction or laryngeal edema as
        detected by diminished gas leak around the endotracheal tube
        with positive pressure breaths (Mhanna et al., 2002; Fisher &
        Raper, 1992; Potgieter & Hammond, 1988; De Bast et al., 2002;
        Miller & Cole, 1996; Jaber et al., 2003; Marik, 1996; Sandhu et
        al., 2000; Engoren, 1999)

        -   Percent cuff leak or the difference between expiratory tidal
            volume measured with the cuff inflated and then deflated in
            a volume-controlled mode of ≥15.5% (sensitivity 75%,
            specificity 72%) (Fisher & Raper, 1992; Potgieter & Hammond,
            1988; De Bast et al., 2002; Miller & Cole, 1996; Jaber et
            al., 2003; Marik, 1996; Sandhu et al., 2000). Yet this test
            was found not to be predictive in a study of cardiothoracic
            surgery patients (Engoren, 1999).

        -   Air leak may be an age-dependent predictor of postextubation
            stridor in children. An air leak \> 20 cm H~2~O was
            predictive of postextubation stridor in children ≥ 7 years
            of age (sensitivity of 83%, specificity of 80%), but was not
            predictive \< 7 years of age (Mhanna et al., 2002)

        -   Air leak test has been predictive of postextubation stridor
            or extubation failure for children with upper airway
            pathology: trauma patients (Kemper et al., 1991), croup
            (Adderly & Mullins, 1987), after tracheal surgery (Seid et
            al., 1991).

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    4.  Evidence of stable, adequate hemodynamic function (MacIntyre et
        al., 2001; Morganroth et al.,1984; Clochesy, Daly, & Montenegro,
        1995; Biery et al., 1990; Hammond et al., 1990)

    5.  Evidence of stable nonrespiratory functions (Rothaar & Epstein,
        2003; Sapijaszko et al., 1996; Smith & Shneerson, 1995;
        Scheinhorn et al., 1995)

    6.  Electrolyte values within normal range (Cerra, 1987; Aubier et
        al., \"Effect of hypophosphatemia,\" 1985; Aubier et al.,
        \"Effects of hypocalcemia,\" 1985)

    7.  Evidence of malnutrition decreasing respiratory muscle function
        and ventilatory drive (Pingleton & Harmon, 1987; Lewis et al.,
        1986; Doekel et al., 1976; Larca & Greenbaum, 1982; Bassili &
        Deitel, 1981)

    8.  Anesthesia literature indicates the patient must have no intake
        of food or liquid by mouth for a period of time prior to airway
        manipulation. The continuation of transpyloric feedings during
        an extubation procedure remains controversial (Lyons et al.,
        2002; ; American Academy of Pediatrics \[AAP\], 1992)

    9.  Prophylactic medication prior to extubation to avoid or reduce
        the severity of postextubation complications such as

        -   Consider use of lidocaine to prevent cough and/or
            laryngospasm in patients at risk (Gefke, Andersen, &
            Friesel, 1983; Staffel et al., 1991)

        -   Prophylactic administration of steroids may be helpful to
            prevent reintubation rates in high-risk neonates, but not in
            children (Davis & Henderson-Smart, 2001; Markovitz &
            Randolph 2000)

        -   Prophylactic administration of steroids may help reduce the
            incidence of postextubation stridor in children, but not in
            neonates or adults (Davis & Henderson-Smart, 2001; Markovitz
            & Randolph 2000)

        -   Prophylactic administration of steroids for patients with
            laryngotracheobronchitis (croup) correlates with reduced
            rates of reintubation (Freezer, Butt, & Phelan, 1990;
            Tibballs, Shann, & Landau, 1992)

        -   Caffeine citrate reduced the risk of apnea for infants, but
            did not reduce the risk of extubation failure (Steer &
            Henderson-Smart, 2000)

        -   Methylxanthine treatment stimulates breathing and reduces
            the rate of apnea for neonates with poor respiratory drive,
            especially extremely low birth-weight infants
            (Henderson-Smart & Davis, 2003)

**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 reintubation.

-   Clinical outcome may be assessed by physical examination,
    auscultation, invasive and noninvasive measurements of gas exchange,
    and chest radiography.

-   Quality of the procedure can be systematically assessed by
    monitoring extubation complications and the need for reintubation.

-   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 earlier (Listello & Sessler, 1994; Epstein,
    1995; Whelan, Simpson, & Levy, 1994; Tindol, DiBenedetto, & Kosciuk,
    1994; Vassal et al., 1993; Franck, Vaughan, & Wallace, 1992).

-   Some patients may require postextubation support or intervention to
    maintain adequate gas exchange independent of controlled mechanical
    ventilation.

    1.  Noninvasive Respiratory Support

        -   Infants extubated to nasal intermittent positive pressure
            ventilation (NIPPV) were less likely to fail extubation than
            those infants extubated to nasal continuous positive airway
            pressure ventilation (NCPAP) (Davis, Lemyre, & de Paoli,
            2001)

        -   In neonates and premature infants, binasal prong continuous
            positive airway pressure (CPAP) is more effective at
            preventing re-intubation than single nasal or nasopharyngeal
            prongs (De Paoli et al., 2002)

        -   In adults, routine use of postextubation noninvasive
            positive pressure ventilation such as BIPAP is not supported
            (Jiang, Kao, & Wang, 1999; Meyer & Hill, 1994; Keenan et
            al., 2002)

        -   In patients with chronic obstructive pulmonary disease
            (COPD), CPAP of 5 cm H~2~O and pressure support ventilation
            (PSV) of 15 cm H~2~O have improved pulmonary gas exchange,
            decreased intrapulmonary shunt fraction, and reduced patient
            work of breathing (Kilger et al., 1999)

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    2.  Postextubation Medical Therapy

        -   Aerosolized levo-epinephrine is as effective as aerosolized
            racemic epinephrine in the treatment of postextubation
            laryngeal edema in children (Nutman et al., 1994)

        -   No randomized studies in neonates have been performed to
            evaluate the role of nebulized racemic epinephrine for
            postextubation stridor (Davies & Davis, 2002)

        -   Heliox may alleviate the symptoms of partial airway
            obstruction and resultant stridor, improve patient comfort,
            decrease work of breathing, and prevent reintubation (Kemper
            et al., 1990; Kemper et al., 1991)

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    3.  Diagnostic Therapy

        -   For patients with postextubation complications such as
            stridor or obstruction, fiberoptic bronchoscopy may provide
            direct airway inspection and therapeutic interventions
            (secretion clearance, instillation of drugs, removal of
            aspirated foreign objects) (Liebler & Markin, 2000; Walker &
            Forte, 1993).

**Resources**

Preparation for extubation includes assuring emergency reintubation
equipment and personnel are readily available. The following
equipment/supplies must be maintained in close proximity to the patient,
in sufficient quantities, and in working condition.

-   Equipment:

    1.  Oxygen source

    2.  Devices to deliver oxygen-enriched gas mixtures

    3.  High-volume suction source and catheters

    4.  Pharyngeal and tracheal suction catheters

    5.  Self-inflating or non-self-inflating manual ventilation system

    6.  Appropriately sized face masks

    7.  Oral and nasopharyngeal airways

    8.  Endotracheal tubes of various sizes, cuffed and uncuffed

    9.  Translaryngeal intubation equipment (laryngoscope blades,
        handles, extra batteries, stylettes, surgical lubricant,
        syringes to inflate cuff)

    10. Airway exchange catheter of various sizes

    11. Laryngeal mask airway (LMA) of various sizes

    12. Equipment for establishing an emergency surgical airway
        (scalpel, lidocaine with epinephrine, appropriately sized
        endotracheal or tracheostomy tubes)

    13. Nasogastric tubes of various sizes

    14. Pulse oximeter

    15. Two-channel cardiac monitor

    16. Supplies for arterial puncture and blood gas analysis

    17. Medication for sedation, analgesia, neuromuscular blockade and
        prevention of raised intracranial pressure as indicated by the
        individual situation

    18. Carbon dioxide detection devices (qualitative and/or
        quantitative devices)

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-   Personnel

    1.  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.

    2.  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 during the extubation procedure.

    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 (AAP, 1992).

**Monitoring**

Monitoring in the postextubation period includes ensuring the equipment,
personnel, and medications are readily available in the event of
emergent, postextubation phenomena (AAP, 1992).

-   Appropriately trained personnel need to be readily available to
    detect cardiopulmonary impairment

-   Frequent respiratory evaluation should include: vital signs,
    assessment of neurologic status, patency of airway, auscultatory
    findings, work of breathing, and hemodynamic status

-   Equipment

    1.  Pulse oximeter

    2.  Two-channel cardiac monitor

    3.  Sphygmomanometer and stethoscope

    4.  Capnograph

**Frequency**

No consensus exists on the appropriate timing of or requirement for
tracheostomy placement in the mechanically ventilated patient. Any
recommendation will have to consider patient population, etiology of
respiratory insult, expected or known duration of mechanical
ventilation, balance of risks and perceived benefits of continued
mechanical ventilation via tracheostomy as opposed to a
translaryngeally-placed endotracheal tube. Past recommendations have
been based upon expert consensus (MacIntyre et al., 2001; Plummer &
Gracey, 1989; Maziak, Meade, & Todd, 1998)

-   Limited data exist on the rate of successful extubation after a
    previous failed extubation.

    1.  Many clinical studies include the first extubation attempt only

    2.  In a pediatric descriptive study, 174/2794 subjects failed
        extubation (extubation failure rate 6.2%) after the first
        attempt; 27% (65/174) failed a second extubation attempt; of
        those patients, 22 extubated successfully after the third
        extubation attempt (Kurachek et al., 2003).

**Standard Precautions**

Caregivers should exercise Standard Precautions for all patients, follow
Centers for Disease Control and Prevention (CDC) recommendations for
control of exposure to tuberculosis and droplet nuclei, and institute
appropriate precautions empirically for airborne, droplet, and contact
agents pending confirmation of diagnosis in patients suspected of having
serious infections (Garner, 1996; \"Guidelines for preventing the
transmission,\" 1994; Lange, 2003; Ho, Tang, & Seto, 2003; Tablan et
al., 2004; Bolyard et al., 1998).

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=10669)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

The guideline is developed from a thorough review of the literature,
surveys of current practice, and the expertise of the members of the
Working Group.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate decision to discontinue mechanical ventilation that involved
weighing the risks of prolonged mechanical ventilation against the
possibility of extubation failure

#### POTENTIAL HARMS

-   Hypoxemia after extubation may result from but is not limited to:

    1.  Failure to deliver adequate inspired oxygen fraction through the
        natural upper airway

    2.  Acute upper airway obstruction secondary to laryngospasm

    3.  Development of post-obstruction pulmonary edema

    4.  Bronchospasm

    5.  Development of atelectasis, or lung collapse

    6.  Pulmonary aspiration

    7.  Hypoventilation

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-   Hypercapnia after extubation may be caused by but is not limited to:

    1.  Upper airway obstruction resulting from edema of the trachea,
        vocal cords, or larynx

    2.  Respiratory muscle weakness

    3.  Excessive work of breathing

    4.  Bronchospasm

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```
-   Death may occur when medical futility is the reason for removing the
    endotracheal tube.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

There are no absolute contraindications to extubation.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

No consensus exists on the appropriate timing of or requirement for
tracheostomy placement in the mechanically ventilated patient. Any
recommendation will have to consider patient population, etiology of
respiratory insult, expected or known duration of mechanical
ventilation, balance of risks and perceived benefits of continued
mechanical ventilation via tracheostomy as opposed to a
translaryngeally-placed endotracheal tube.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Association for Respiratory Care (AARC). Removal of the
endotracheal tube\--2007 revision & update. Respir Care 2007
Jan;52(1):81-93. \[189 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 Jan (revised 2007 Jan)

#### GUIDELINE DEVELOPER(S)

American Association for Respiratory Care - Professional Association

#### SOURCE(S) OF FUNDING

American Association for Respiratory Care (AARC)

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Revised by Angela T Wratney, MD and Ira M Cheifetz, MD, FAARC, Duke
University Medical Center, Durham, North Carolina

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). Removal of the endotracheal tube. Respir Care
1999 Jan;44(1):85-90.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Association for Respiratory Care (AARC) Web
site](http://www.rcjournal.com/cpgs/pdf/removal_of_endotracheal_tube.pdf).

Print copies: Available from the American Association for Respiratory
Care (AARC), CPG Desk, 11030 Ables Ln, Dallas, TX 75229-4593; Web site:
[www.aarc.org](http://www.aarc.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on April 25, 1999. The information
was verified by the guideline developer on April 25, 1999. This NGC
summary was updated by ECRI Institute on June 14, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008