Minimizing Unplanned Extubation Failures: Adhering to Standard Protocols

The provided content discusses unplanned extubation failures in patients with certain conditions. Two best practice interventions should be adhered to when carrying out a weaning test, as per the DAS extubation guideline and selected criteria. These protocols can help reduce the associated comorbidities significantly.

Running head: CRITICAL EVALUATION OF AIRWAY COMPLICATION
Critical evaluation of airway complication
Name of the student:
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Table of Contents
Introduction: 2
Critical evaluation: 3
Critical observation: 7
Conclusion: 9
References: 10

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Introduction:
One of the greatest complications that arise in the post operative patients residing in the
coronary Care Unit is related to respiratory distress and Airway blockage. These postoperative
complications include laryngospasm aspiration and hypoxemia, and these complications are very
common after any bypass graft surgery. 1 mechanism to avoid patients at wearing these
complications in a post operative stage is performing endotracheal intubation which is one of the
most abundantly utilised intervention techniques for management of airway complication in
postoperative cardiac patients (Villafranca et al., 2013).
However, as beneficial as intubation methods are for reviving the postoperative cardiac
patients struggling with airway complication, variety of different risks are associated with the
extubation procedure. The clinical decision to perform extubation is based on the reading
readiness test performed on the bed sheet that involves spontaneous breathing on 80 piece or low
levels of ventilator reassessed. Naturally this procedure is associated with a lot of risk and failure
in distribution mechanism is also very common affecting 10 to 20% of the cardiac patient
popularity. However, it has to be mentioned that mortality rates associated with extubation
failure in post- op patients is 20 to 25% which is relatively high. Different studies suggest that
adhering to a step-by-step standardized protocol before carrying out the extubation is known to
help reduce the rate of extirpation failure and increases the recovery chances of the patient
reduces the rate of extirpation failure and increases the recovery chances of the patients
drastically (Villafranca et al., 2013). This assignment will focus on exploring the extubation
criteria and associated interventions performed in ICU patients suffering with Airway clearance
and attempts to determine whether it adheres to the best practice procedures or not taking the
help of critically evaluate in relevant and authentic article published on this issue

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Critical evaluation:
In case of any complications the most important intervention to be performed is Airway
patency, and tracheal intubation serves that purpose. However after the purpose is served the
removal of the tracheal tube is extremely necessity and this is the process of extubation.
However the estimation procedure can sometimes result in mobility and mortality, one of the
most frequent complications that are associated with the process of airway complication
management by tracheal tubes, is the unplanned extubation (Anderson et al., 2011). In most
cases specifically in the critical care units or coronary care unit at the patients the severity of the
complication is escalated than the normal cases, unplanned extubation followed by re- intubation
procedure is a necessary intervention. However, there are few literature that emphasizes on the
challenges associated with exhibitions and the criteria based on which extubation intervention is
carried out. It has to be understood that extirpation is a meticulous and highly risky procedure
which can result in severe consequences if the protocol is not followed step by step. Hence the
importance of standardizing the criteria based on which extubation will be carried out is
extremely important for the safety and reducing the morbidity associated with this procedure.
The purpose of this assignment is to evaluate the literature available on the Internet and explore
how efficient these literature articles are in defining the criterion for extubation and how helpful
excavation methods are in airway complication management.
First and foremost, the extubation procedure and its risks should be taken into account, and
the article “Difficult Airway Society Guidelines for the management of tracheal extubation” by
Mitchel and coauthors, the information regarding extubation is hazardous and how extirpation
management can help in treating critical patients is explained excellently (Mitchell et al., 2012).
Problems related with extubation are the challenges that airway reflexes pose. For instance

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exaggerated laryngeal reflexes is the most contributing factor for extubation complications.
Along with that reduced airway reflection and dysfunctional reflexes are also few instances that
complicate the intubation and extubation procedure for a critical patient. another very important
complication that can arise after incubation on extubation procedure is airway injury. It has to be
mentioned in this context that these periglottic trauma are resultant from any transoesophageal
echocardiography probes or nasogastric tubes being inserted during the entire procedure. And
these complications not only make the procedure of insertion and extraction of tracheal tube
extremely meticulous but also reduce the recovery chances of the patients and increase the
hospital stay statistics exponentially. Apart from the clinical manifestations of the tracheal
intubation and extubation intervention, there are some management flaws that result in
complicating the intubation procedure and demanding unplanned extubation as well. This article
explains the severe lack of compelling general principles available for the extirpation strategies
that would fit all patients. According to the authors extubation is considered to be an electric
process which makes the planning and execution part very important. The purpose of extubation
management is to ensure that the patient’s lungs receive an interrupted flow of oxygen. 1 highly
appreciated context of this particular article is that it has very helpful provided a detailed
acceleration and explanation of b a s activation guidelines. It has to be understood that this
particular Framework provides 4 step action plan for the execution of the activation procedure.
In the first step the extubation is plant followed by the steps two where the peri- operative
preparations for extubation is carried out. In the steps three extubation is performed in real time
and in the steps four a thorough and extensive post extubation care is planned and carried out for
the patient. As explained by the authors of this article 20 step by step actions questions each and
every action before it is performed, hence this particular guideline is extremely precise and to the

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point if for exhibition procedures to be carried out in critical conditions. For instance in the step
1, presence of general and special airway risk factors is questioned meticulously, before carrying
out the activation procedure in itself. Along with that during and post extubation care and
management techniques are extensively explained in this particular article as well with answers
the main question that this assignment represents. However we must not ignore that this article is
based on a specific clinical framework and does incorporate only theories lacking any practical
observations which significantly reduces the relatability of the article.
A different viewpoint is provided by the article ‘Unplanned extubation in the ICU: a
marker of quality assurance of mechanical ventilation” , Where extubation procedure is viewed
as a unnecessary complications and which can be seen as a significant and visible quality marker
for the winning care that the patients receive in intensive care unit (Peñuelas, Frutos-Vivar &
Esteban, 2011). The authors argue that the main criteria for carrying out unplanned extubation is
the complications that arise with previous intubation procedure. And a better every complication
management technique will be ensuring that the initial intubation procedure is flawless and it
does not require emergency unplanned extubation process to be carried out on the patients which
has severe risk of complicating the condition of the patient further. The authors further argue that
in order to reduce the need for unplanned exhibition, understanding all the associated factors of
extubation is extremely important. The office describe that along with the clinical implications,
the floors in the Healthcare staff like nursing workforce burnout, lack of a detailed and
standardized protocol, lacking use of protective Gear on the patience to secure the tracheal tube,
even minor mis- placements are significant contribution factors behind the need or criteria of
extirpation to be carried out (Peñuelas, Frutos-Vivar & Esteban, 2011). The authors propose that
strategies for reducing these flaws like detecting short displacement, using safety gears on the

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patient, etc can reduce the need for extubation exponentially. All the while, critically evaluating
the relevance of this article in this assignment, that despite providing a novel viewpoint to the
study, it must not escape noticed that this article only emphasizes on strategies that can identify
the disc for activation and eliminate that altogether, while not paying any attention show how the
complications associated with extubation can be managed with adequate interventions.
Another article under evaluation here is by Nolan and Kelly, emphasizing on the broad
Topic of airway complication management (Nolan & Kelly, 2011). The article discusses the
incidences of difficult intubation and complications and providing possible intervention
strategies that can successfully manage those complications. For instance this article discusses
use of capnography, tracheostomy, anaesthesia induction for critically ill patients, and the
challenges associated with these strategies are discussed in detail. Now one of the solutions
discussed in the article to overcome the challenges that application brings forth in the ICU,
intubation bundle is discussed significantly (Liu et al., 2010). According to this article
intubation reduces the application by 21 to 34 %, however the discs on complications associated
with field intubation procedure resulting in unplanned extubation is also considered as one of the
most influential confounding factors in this intervention strategy. However the author suggest
that at heading to a particular standardized Framework protocol can significantly reduce the
flaws in the intubation procedure and in turn eliminate the need for unplanned extubation all
together. Among the other Airway management techniques that are utilized in such scenarios, the
authors describe a successful captain atrophy after intubation to verify proper ventilation to be
the most effective one. Authors discuss that category is the most reliable and relevant method of
intervention to confirm tracheal tube positioning and eliminate the risk of unplanned extubation.
Cricothyroidotomy is another intervention that the authors suggest to be useful in airway

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management, along with managing human factors by training and skill improvement procedures
(Maggiore et al., 2014).
The article “Unplanned Endotracheal Extubations in the Intensive Care Unit: Systematic
Review, Critical Appraisal, and Evidence-Based Recommendations” by Da Silva unplanned
extubation and its consequences in detail as well (da Silva & Fonseca, 2012). This article it is a
systematic review conducted on the rate of unplanned Expectations and the need for preventative
strategies in the Airway management techniques to avoid and plant exhibition. Authors
performed extensive and critical research from the database is like MEDLINE, EMBASE,
CINAHL, LILACS etc. The main where did that the systematic review provides is that the
existing literature only emphasizes on the occurrences of unplanned x 2 patients and the
computing factors that lead to add how that where there is a significant lack of research studies
that focus on preventative strategies and reccomendation.
Critical observation:
According to the article “The Decision to Extubate in the Intensive Care Unit”, the
emphasis of the authors is on the decision to activate in the ICU (Thille et al., 2013). It has to be
mentioned in this context that this article co-aligned perfectly with the question been asked in the
assignments and their house recognition for providing such relevant and transferable data. In my
own professionl experience I have observed that the most important factor regarding unplanned
extubations are associated with not identifying the exact need of the patient, and in most cases
the patient the patient worsen more after the extubation and intubation. It has to be understood,
the major questions being asked in the assignment apart from proper and improvised Airway
management techniques, is the criteria based on which exhibition procedures are carried. From
my professional experience , the lack of a proper demarketed guideline standardizing both

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intubation procedure and weaning test interpretation is a major concern. The authors here suggest
that extubation failures and complications that arise for extubation are mainly concerned with the
inability of the health care staff to purchase the results of the winning readiness test properly.
The authors rightfully propose that understanding the pathophysiology of the winning test are
extremely essential as it takes place in instrumental role in the discussion for excavation which
can possibly result in further complications for the patient is carried out imperfectly or without a
proper need. Agreeing with previous studies discussed in this assignment the authors of the study
also suggest that most of the extubation procedures are in fact and plan activation and result in
need for reintubation. The author suggest that strategies should be identified planned and
executed for both extubation management and weaning readiness test management, so that you
better clinical decision making can be facilitated (Thille et al., 2013).
The authors here propose an international consensus panel that has instructed meaning
readiness test for extirpation to be performed only with the patients fulfills the following criteria,
resolution for the primary reason for intubation, cardiovascular stability and close to no need of
vasopressors, no need for continuous sedation, and continuous oxygenation (Thille et al., 2013).
Hence this can be considered as the standardized protocol on criteria based on which winning
readiness test and following extubation should be performed to confirm the absolute needed the
patient for excavation and avoid associated with extubation and Reintubation. Help it can be
concluded that this particular article has provided the answer to the first part of the question
asked in the assignment perfectly and the criteria mentioned in the article can be considered the
best best possible solution to the conundrum of unplanned extubation (White, 2014).

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Conclusion:
Hence on a concluding note, it can be stated that extubation is an undoubtedly necessary
procedure, however unplanned extubation is not the best practice for proper airway management
to be carried out. Instead care should be taken to avoid unnecessary unplanned extubation when
it follows a reintubation further complicating the condition of the patient. In such cases two best
practice interventions should e adhering to the DAS extubation guideline and the criteria selected
before carrying out a weaning test. And it can be hoped that adhering to these two standard
protocols can effectively reduce the co morbidities associated with unplanned extubation failures
significantly.

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References:
Anderson, C. D., Bartscher, J. F., Scripko, P. D., Biffi, A., Chase, D., Guanci, M., & Greer,
D. M. (2011). Neurologic examination and extubation outcome in the neurocritical care
unit. Neurocritical care, 15(3), 490-497.
Brotfain, E., Zlotnik, A., Schwartz, A., Frenkel, A., Koyfman, L., Gruenbaum, S. E., &
Klein, M. (2014). Comparison of the effectiveness of high flow nasal oxygen cannula vs.
standard non-rebreather oxygen face mask in post-extubation intensive care unit
patients. The Israel Medical Association journal: IMAJ, 16(11), 718-722.
da Silva, P. S. L., & Fonseca, M. C. M. (2012). Unplanned endotracheal extubations in the
intensive care unit: systematic review, critical appraisal, and evidence-based
recommendations. Anesthesia & Analgesia, 114(5), 1003-1014.
Devor, R., Wellnitz, C., Kang, P., Siddiqui, M., Nigro, J., Velez, D., & Willis, B. (2016).
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Iyer, N. P., Dickson, J., Ruiz, M. E., Chatburn, R., Beck, J., Sinderby, C., & Rodriguez, R. J.
(2017). Neural Breathing Pattern in Newborn Infants Pre and Post‐Extubation. Acta
Paediatrica.
Jung, B., Moury, P. H., Mahul, M., de Jong, A., Galia, F., Prades, A., ... & Jaber, S. (2016).
Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on
extubation failure. Intensive care medicine, 42(5), 853-861.

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Liu, Y., Wei, L. Q., Li, G. Q., Lv, F. Y., Wang, H., Zhang, Y. H., & Cao, W. L. (2010). A
decision-tree model for predicting extubation outcome in elderly patients after a
successful spontaneous breathing trial. Anesthesia & Analgesia, 111(5), 1211-1218.
Lu, C. H., Wu, Z. F., Lin, B. F., Lee, M. S., Lin, C., Huang, Y. S., & Huang, Y. H. (2016).
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total surgical suite time after propofol-based total intravenous anesthesia compared with
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Maggiore, S. M., Idone, F. A., Vaschetto, R., Festa, R., Cataldo, A., Antonicelli, F., ... &
Antonelli, M. (2014). Nasal high-flow versus Venturi mask oxygen therapy after
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340.
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Peñuelas, Ó., Frutos-Vivar, F., & Esteban, A. (2011). Unplanned extubation in the ICU: a
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Thille, A. W., Harrois, A., Schortgen, F., Brun-Buisson, C., & Brochard, L. (2011).
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