Extubation without spontaneous breathing

[Pluto201]

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Anyone leave patient on ventilator until they wake up? Off course I make sure muscle relaxant is fully reversed. It seems patient wake up better this way.


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[facted]

Pts wake up far better if they're breathing and you titrate in some narcs. Also can pull the tube at the earliest sign of life. Harder to do if the pt has been on the vent until the second they're now ready to jump off the bed...

 

[Pluto201]

Why cannot we extubate ( not ICU settings) before spontaneous breathing. Are patients spontaneously breathing more awake than the ones still on the ventilator? In my opinion keeping the patient on ventilator will wash out more inhalation agent and have less CO2 narcosis, also less likely to have negative pressure pul edema if they go into larygospasm because they are not forcefully trying to breath.


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[Mikkel]

I do both, and I think the switch from controlled ventilation to patient driven ventilation wakes patients up prematurely when they're still in stage 2.

Transitioning to stage 1 without them bucking then pulling the tube tends to be the smoothest.

I think it's brainstem mediated, like how OSA patients wake themselves when hypoxic, or when hypercapnic patients can get tachycardia and sympathetic surge.

 

[surgndoc]

The best wake up is a spontaneously breathing patient who is appropriately narcotized, some nitrous in addition also helps the wakeup too.
Pts can be what you refer to as “transitioned” (vent to spontaneous) at any depth of anesthesia, since this is a function of PaCO2. Therefore it’s often best to achieve this at some time towards the end of the case but not during the high flow wakeup phase. At that point you should ride the vent until time to extubate. Yes the pt will buck but usually only once.

 

[facted]

Why cannot we extubate ( not ICU settings) before spontaneous breathing. Are patients spontaneously breathing more awake than the ones still on the ventilator? In my opinion keeping the patient on ventilator will wash out more inhalation agent and have less CO2 narcosis, also less likely to have negative pressure pul edema if they go into larygospasm because they are not forcefully trying to breath.


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No one said no breathing. I get them breathing early with Pressure support of 10ish. Usually gets me nice TV and washes out the gas and keeps CO2 low.

 

[woopedazz]

Are patients spontaneously breathing more awake than the ones still on the ventilator?

Generally yes?

 

[Aether2000]

I don't use opioids unless necessary, and use adjuncts instead such as nerve blocks, ketorolac, acetaminophen, etc. This allows easy awakening without introducing another element of hypercarbia. Pressure support mode is my preference.

 

[PieOHmy]

No one said no breathing. I get them breathing early with Pressure support of 10ish. Usually gets me nice TV and washes out the gas and keeps CO2 low.

I stopped getting people spontaneous breathing upon waking up. The rate limiting step to wake up ALWAYS is getting the gas off. SO it behooves you to blow the gas off as quick as possible and that is accomplished using Controlled ventilation. Once the gas is off, they are following commands, out comes the tube. I no longer check to see if they are reg breathing because in my estimation, if you are following commands, by default you are breathing.

This pressure support business, never learned it. The ventilator for me has 2 modes, controlled and using my hand (spontaneous_)

 

[psychbender]

This pressure support business, never learned it. The ventilator for me has 2 modes, controlled and using my hand (spontaneous_)

It's real easy. You push the button marked PSV, set a pressure of 5, and call it a day. I go PSV at the end of the case, and minute ventilation remains able the same as it was with me controlling the ventilation. Hence, gas comes off at the exact same rate. Keeping the patient on CMV until extubation provides no benefit to me, unless I overshot with the analgesics, and they're just not breathing on their own at all tried the end of the case.

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[facted]

I stopped getting people spontaneous breathing upon waking up. The rate limiting step to wake up ALWAYS is getting the gas off. SO it behooves you to blow the gas off as quick as possible and that is accomplished using Controlled ventilation. Once the gas is off, they are following commands, out comes the tube. I no longer check to see if they are reg breathing because in my estimation, if you are following commands, by default you are breathing.

This pressure support business, never learned it. The ventilator for me has 2 modes, controlled and using my hand (spontaneous_)

When you use PS properly, the minute ventilation is very similar to if you used controlled ventilation. Except now you can titrate in narcs, and pull the tube before they are "following commands", ie: before they're bucking like crazy.

PS is super easy, and VERY helpful. Some vents don't offer it, I'll grant you that, but many do.. If you vent offers it, look into using it. You'll be surprised how useful it is.

 

[surgndoc]

When you use PS properly, the minute ventilation is very similar to if you used controlled ventilation. Except now you can titrate in narcs, and pull the tube before they are "following commands", ie: before they're bucking like crazy.

I usually switch to PSVpro during closure to maintain a good MV and blow off gas but rarely extubate straight off PSV. I feel this to be somewhat unsafe, since if they haven’t coughed at all or fought the tube they haven’t gone through stage 2 and may spasm. Usually as soon as the pt bucks I’ll turn the vent off, waitto see a few good TVs or normal respiratory pattern then pull the tube. I don’t care much for following commands as long as they were previously triggering PS ventilation or fully off the vent.

 

[facted]

I usually switch to PSVpro during closure to maintain a good MV and blow off gas but rarely extubate straight off PSV. I feel this to be somewhat unsafe, since if they haven’t coughed at all or fought the tube they haven’t gone through stage 2 and may spasm. Usually as soon as the pt bucks I’ll turn the vent off, waitto see a few good TVs or normal respiratory pattern then pull the tube. I don’t care much for following commands as long as they were previously triggering PS ventilation or fully off the vent.

I do it for almost every case. Haven't had an issue. Not every extubation needs to end start with bucking... especially if pt is well narcotized.

 

[deleted875186]

PSV is nice if the patient will synch to it and breath adequately.

I prefer keeping them on controlled ventilation for a faster wake up. Usually aggressively blow off the gas on the vent, keep their etCO2 near 35. They won’t start to breath or cough on the tube til ready to wake up. Watch them like a hawk, as soon as they cough or become dysynchrknous, manual mode and check MV and then quickly out with the tube. Obviously only for people who yoj are not concerned about respiratory mechanics.

 

[surgndoc]

If they’re making effort they should sync to it no problem. Can also lower the trigger so weaker efforts still trigger a pressure support breath.

change the support level to make the etco2 whatever you want.

 

[vector2]

Has anyone else noticed that the respiratory rate on PSV (even at something low like 5-8 and with a low flow trigger) is many times wildly different than the rate on the bag? I've had quite a few instances where the RR on PSV is 8 but the RR on the bag is like 25, thus narcotic titration would've been inaccurate on PSV. I've seen this phenomenon both before and after nmb reversal. Assuming the pt is reversed, I'd rather just put them on the bag, close the pop off so they have 5 of peep and just see what rate/pco2 the pt's brainstem really wants.

 

[drmwvr]

Has anyone else noticed that the respiratory rate on PSV (even at something low like 5-8 and with a low flow trigger) is many times wildly different than the rate on the bag? I've had quite a few instances where the RR on PSV is 8 but the RR on the bag is like 25, thus narcotic titration would've been inaccurate on PSV. I've seen this phenomenon both before and after nmb reversal. Assuming the pt is reversed, I'd rather just put them on the bag, close the pop off so they have 5 of peep and just see what rate/pco2 the pt's brainstem really wants.

If your machine has a flow trigger, have you tried adjusting that?

 

[Robotic Wis-Hipple]

Why cannot we extubate ( not ICU settings) before spontaneous breathing. Are patients spontaneously breathing more awake than the ones still on the ventilator? In my opinion keeping the patient on ventilator will wash out more inhalation agent and have less CO2 narcosis, also less likely to have negative pressure pul edema if they go into larygospasm because they are not forcefully trying to breath.


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Spontaneously breathing patients make it easier to confirm adequate reversal, and tidal volumes and almost certainly is easier to verify that they are more awake. It also is more comfortable.

You can use the vent to “wash out” volatile more quickly by increasing minute ventilation but then you haven’t verified their own drive if you extubate straight from the vent.

And your thought on negative pressure Pulm edema makes little sense to me, they aren’t laryngospasm-ing with an ETT in place either way. They could bite the tube in either case however.

 

[vector2]

If your machine has a flow trigger, have you tried adjusting that?

Yes, in my post you quoted I said even with a low flow trigger.

 

[facted]

Has anyone else noticed that the respiratory rate on PSV (even at something low like 5-8 and with a low flow trigger) is many times wildly different than the rate on the bag? I've had quite a few instances where the RR on PSV is 8 but the RR on the bag is like 25, thus narcotic titration would've been inaccurate on PSV. I've seen this phenomenon both before and after nmb reversal. Assuming the pt is reversed, I'd rather just put them on the bag, close the pop off so they have 5 of peep and just see what rate/pco2 the pt's brainstem really wants.

Probably has something to do with the fact that off PS, they're breathing through a straw without any help (you're actually making it more difficult for them to breathe than it will be for them once extubated) and need to compensate by increasing RR. Try it yourself. Put an ETT between your lips, close your nose and start breathing. Now ask yourself why you would want to do that to your patient?

PS of ~8 supposedly is equal to the resistance of breathing through a 7.0 tube (or thereabouts). In my experience, extubating off of PS around 8 gives me VERY similar TV with mask after extubation. I extubate from this level of PS almost every case.

 

[vector2]

Probably has something to do with the fact that off PS, they're breathing through a straw without any help (you're actually making it more difficult for them to breathe than it will be for them once extubated) and need to compensate by increasing RR. Try it yourself. Put an ETT between your lips, close your nose and start breathing. Now ask yourself why you would want to do that to your patient?

PS of ~8 supposedly is equal to the resistance of breathing through a 7.0 tube (or thereabouts). In my experience, extubating off of PS around 8 gives me VERY similar TV with mask after extubation. I extubate from this level of PS almost every case.

I'm not arguing thats it's ?maybe more difficult to breathe unassisted through a smallish ETT, but it still doesnt explain a discrepancy I've seen between a reversed pt breathing 250-300cc x 24 unassisted vs 400cc x 8 on PSV.

 

[deleted162650]

Try it yourself. Put an ETT between your lips, close your nose and start breathing. Now ask yourself why you would want to do that to your patient?

This tells me that you haven’t actually tried yourself. If you had, you’d know that resistance through a 7.0 is minimal. For many, it’s less than the resistance of breathing through your nasal passages. Tube resistance isn’t really limiting until you get below a 6.0. There’s a nice table in Benumof’s airway book about this.

 

[surgndoc]

Has anyone else noticed that the respiratory rate on PSV (even at something low like 5-8 and with a low flow trigger) is many times wildly different than the rate on the bag? I've had quite a few instances where the RR on PSV is 8 but the RR on the bag is like 25, thus narcotic titration would've been inaccurate on PSV. I've seen this phenomenon both before and after nmb reversal. Assuming the pt is reversed, I'd rather just put them on the bag, close the pop off so they have 5 of peep and just see what rate/pco2 the pt's brainstem really wants.

I have never noticed this but will keep it in mind. Think if it were happening to me I wouldn’t noticed. Don’t understand why this would be and the subsequent explanations offered. My preference as well is to usually turn off the vent completely from PSV mode and leave the popoff to 5 or so For CPAP

 

[Ronin786]

As this thread clearly demonstrates. There's only one way to do it.

 

[nimbus]

I do all my EP ablations and ICDs under GA/ETT with no narcotics. Over the last few months I’ve been keeping them on the vent until the end, then I extubate before giving sugammadex and it has been working very well. No coughing, strong ventilation almost instantly, and wide awake and conversant before leaving the room.

 

[Pluto201]

Spontaneously breathing patients make it easier to confirm adequate reversal, and tidal volumes and almost certainly is easier to verify that they are more awake. It also is more comfortable.

You can use the vent to “wash out” volatile more quickly by increasing minute ventilation but then you haven’t verified their own drive if you extubate straight from the vent.

And your thought on negative pressure Pulm edema makes little sense to me, they aren’t laryngospasm-ing with an ETT in place either way. They could bite the tube in either case however.

You can confirm adequate reversal with twitch monitor. Checking tidal volumes never practical in anesthesia setting.

I mean when you extubate when patient is awake but apneic it will be unlikely to have NPPE simply because patient is not trying to forcefully breath. While if patient is breathing and had a laryospam he will be at risk of NPPE. This is in theory. I am just challenging the conventional teaching, may be there is a better way to do things in anesthesia that we never tried.


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[Pluto201]

I do all my EP ablations and ICDs under GA/ETT with no narcotics. Over the last few months I’ve been keeping them on the vent until the end, then I extubate before giving sugammadex and it has been working very well. No coughing, strong ventilation almost instantly, and wide awake and conversant before leaving the room.

I delay the sugammadex to just before extubation. Do you mean you extubate deep then reverse?


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[vector2]

I delay the sugammadex to just before extubation. Do you mean you extubate deep then reverse?


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I routinely extubate deep then give sug the second the tube is out

 

[PieOHmy]

I don’t care much for following commands

I think you should reconsider.

IN my opinion, as a general rule of thumb, you should ALWAYS wait til one follows commands prior to extubation. Unless of course you have a good reason NOT to.

 

[PieOHmy]

I do all my EP ablations and ICDs under GA/ETT with no narcotics. Over the last few months I’ve been keeping them on the vent until the end, then I extubate before giving sugammadex and it has been working very well. No coughing, strong ventilation almost instantly, and wide awake and conversant before leaving the room.

I agree with this, THis is why we should LIMIT narcotics to the bare minimum that keeps patient pain free. Titrating narcotics to Resp Rate will invariably lead to over-dose. ALmost ALWAYS

 

[Morzh]

I usually switch to PSVpro during closure to maintain a good MV and blow off gas but rarely extubate straight off PSV. I feel this to be somewhat unsafe, since if they haven’t coughed at all or fought the tube they haven’t gone through stage 2 and may spasm. Usually as soon as the pt bucks I’ll turn the vent off, waitto see a few good TVs or normal respiratory pattern then pull the tube. I don’t care much for following commands as long as they were previously triggering PS ventilation or fully off the vent.

I agree with most of what you said but the bolded is simply untrue.. stage 2 does not have to be ugly. Using the right combination of narcotic titration, small propofol boluses in the final minutes of a case, and +/- nitrous, it is pretty easy to routinely have patients wake without bucking.

My general strategy, which seems to work pretty well, is to get the end tidal volatile to basically 0 at least 10-15 minutes before skin closure is finished. This is the key. If you are "waking up" from volatile you buck and cough and feel miserable. If you "wake up" from a small propofol bolus wearing off you don't buck and you feel good.

Once fascia is closed I typically turn off volatile completely - even if there's still a massive skin incision to close. Turn up FGF to be > than their MV so they don't rebreath volatile, and get them reversed and triggering spontaneously on PSV - titrating PS and narcotic to achieve a goal EtCO2 around 40 with RR 8-14. I agree with others who have cautioned about getting too aggressive using narcotics to control their RR - I prefer to use as much regional anesthesia and non-opioid adjuncts as possible. When I "feel" stage 2 nearing (if using Sevo I expect this around the time end tidal % gets to 0.3-0.5), I'll prophylactically push 10-30mg propofol and repeat q6-8 min until case is done. Suction while they're stunned - not when they're light or it will trigger bucking. Same with removing OG tube, etc. With some practice, Once the dermabond or dressing is going on I gently call the patient's name and they'll open their eyes, which is a good enough sign of "following commands" to me for most patients. I flip from PSV to manual only for a few seconds, enough to see 3 or 4 good TVs, then pull. Super smooth. It's fun to pull the drapes down a minute later and the surgeons see a comfortable extubated patient looking at them - half the time I'm so sneaky they don't even realize I've extubated.

 

[nimbus]

I delay the sugammadex to just before extubation. Do you mean you extubate deep then reverse?


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No not deep. I’ll often have them on 0.8% of sevo on the dial while they pull sheaths. When the techs tell me they are finished holding pressure, I turn the dial to zero, turn up the O2 flow, suction an extubate. Then I give the sugammadex and they take their first breath shortly thereafter. It’s something I wouldn’t have tried before sugammadex.

 

[facted]

I think you should reconsider.

IN my opinion, as a general rule of thumb, you should ALWAYS wait til one follows commands prior to extubation. Unless of course you have a good reason NOT to.

Shocking, I know, but that's lots of ways to give anesthesia. I RARELY wait for pt to follow commands, and my method works just fine. There are some pts you need more awake than others, of course, but to say you should ALWAYS wait for someone to follow commands makes no sense.

 

[facted]

I agree with this, THis is why we should LIMIT narcotics to the bare minimum that keeps patient pain free. Titrating narcotics to Resp Rate will invariably lead to over-dose. ALmost ALWAYS

What kind of overdose are we talking about? The kind where patients are awake and comfortable post-op? That's the kind I get when I titrate narcs to resp rate....

 

[DrOwnage]

I agree with most of what you said but the bolded is simply untrue.. stage 2 does not have to be ugly. Using the right combination of narcotic titration, small propofol boluses in the final minutes of a case, and +/- nitrous, it is pretty easy to routinely have patients wake without bucking.

My general strategy, which seems to work pretty well, is to get the end tidal volatile to basically 0 at least 10-15 minutes before skin closure is finished. This is the key. If you are "waking up" from volatile you buck and cough and feel miserable. If you "wake up" from a small propofol bolus wearing off you don't buck and you feel good.

Once fascia is closed I typically turn off volatile completely - even if there's still a massive skin incision to close. Turn up FGF to be > than their MV so they don't rebreath volatile, and get them reversed and triggering spontaneously on PSV - titrating PS and narcotic to achieve a goal EtCO2 around 40 with RR 8-14. I agree with others who have cautioned about getting too aggressive using narcotics to control their RR - I prefer to use as much regional anesthesia and non-opioid adjuncts as possible. When I "feel" stage 2 nearing (if using Sevo I expect this around the time end tidal % gets to 0.3-0.5), I'll prophylactically push 10-30mg propofol and repeat q6-8 min until case is done. Suction while they're stunned - not when they're light or it will trigger bucking. Same with removing OG tube, etc. With some practice, Once the dermabond or dressing is going on I gently call the patient's name and they'll open their eyes, which is a good enough sign of "following commands" to me for most patients. I flip from PSV to manual only for a few seconds, enough to see 3 or 4 good TVs, then pull. Super smooth. It's fun to pull the drapes down a minute later and the surgeons see a comfortable extubated patient looking at them - half the time I'm so sneaky they don't even realize I've extubated.

This is almost exactly what I do +/- the addition of nitrous. However you turn up the flow > than MV while they're closing fascia? Do you mean you turn it up to like 5L? You must have fast surgeons because I can usually keep the flow 0.6-1L combined and shut off gas completely at fascia and have it 0.1-0.2 by the time I'm waking the patient up. I'll also sometimes just put my extra prop on an infusion of 50-75mcg/kg/min while the gas is coming off and ET sevo is getting around 0.6 with a small 10-20mg bolus at the same time. But I find it this technique works like a charm with right amount of hydromorphone titrated in. Another trick is that you can't be hesitant to start titrating in the dilaudid too early. I find that 99% of patients will breathe just fine with up to 0.6 dilaudid before putting them on spontaneous or minimal PS. The peak effect of dilaudid is 45 minutes; I find that if you have some on board with this much time prior, you get less nausea and more comfort than if you shove it all in at the end when you realize their RR is 25.

 

[nimbus]

I think you should reconsider.

IN my opinion, as a general rule of thumb, you should ALWAYS wait til one follows commands prior to extubation. Unless of course you have a good reason NOT to.

Shocking, I know, but that's lots of ways to give anesthesia. I RARELY wait for pt to follow commands, and my method works just fine. There are some pts you need more awake than others, of course, but to say you should ALWAYS wait for someone to follow commands makes no sense.

I never wait for my patients to follow commands prior to extubation. Some of my partners wait every time. They both work fine.

 

[PieOHmy]

What kind of overdose are we talking about? The kind where patients are awake and comfortable post-op? That's the kind I get when I titrate narcs to resp rate....

Overdose. Give too much.. Using 0.6 mg of dilaudid when none will do. giving 250mcg of fentanyl when 50mcg will do. Just to what? wake someone up more smoothly?

 

[Mikkel]

Overdose. Give too much.. Using 0.6 mg of dilaudid when none will do. giving 250mcg of fentanyl when 50mcg will do. Just to what? wake someone up more smoothly?

And add 10 more minutes to getting the patient out of the room.

Peak in to your colleagues rooms during their emergences, you'll see a lot of people just standing around impatiently waiting for the patient to wake up from their "smooth" emergence.

 

[jwk]

Has anyone else noticed that the respiratory rate on PSV (even at something low like 5-8 and with a low flow trigger) is many times wildly different than the rate on the bag? I've had quite a few instances where the RR on PSV is 8 but the RR on the bag is like 25, thus narcotic titration would've been inaccurate on PSV. I've seen this phenomenon both before and after nmb reversal. Assuming the pt is reversed, I'd rather just put them on the bag, close the pop off so they have 5 of peep and just see what rate/pco2 the pt's brainstem really wants.

The RR when using PSVPro really only kicks in the backup mode - 45-60 seconds of apnea and it automatically changes over to the backup mode. On the newer PSVpro vent software, when in backup mode and two consecutive spontaneous breaths are sensed, it will change back to PSVPro.

 

[facted]

And add 10 more minutes to getting the patient out of the room.

Peak in to your colleagues rooms during their emergences, you'll see a lot of people just standing around impatiently waiting for the patient to wake up from their "smooth" emergence.

Eh. My patients are usually awake as the drapes are coming down. No one is saying give 250mcg of fent to slow the resp rate down. But giving 50mcg in the last 20 minutes to get the rate from 20 -> 12 works nicely.

 

[deleted875186]

I’ll agree I never understood the respiratory rate thing for opioids under anesthesia. I think it works in either extreme. Slow respiratory rate they are probably overdosed. Very fast they may be feeling some pain.

If you watch a mask induction, the respiratory rate gets fast and shallow under volatile anesthesia. How can you say that a mid 20s respiratory rate isn’t just from te volatile, even if you crank up the pressure support. The proof is in seeing how much pain thy have postop. As others have said you can give 50 mcg fentanyl rather than 250mcg and they have the same, if not less post op pain. I prefer giving hydromorphone or morphine if needed rather than fentanyl to provide analgesia when they wake up, which fentanyl does not do.

 

[DrOwnage]

Overdose. Give too much.. Using 0.6 mg of dilaudid when none will do. giving 250mcg of fentanyl when 50mcg will do. Just to what? wake someone up more smoothly?

I mean we're talking about an open abdominal procedure without an epidural and you wouldn't give any opioid (that 0.6 isnt going to be anything compared to what PACU nurses give)? I agree that volatile will increase the RR and diminish TVs but the compensatory tachypnea usually maintains MV especially when we're talking about levels of 0.5 and below. I have definitely seen a correlation with high RRs (above 18) and patient's waking up in discomfort. I've also taken to the practice of checking PACU medications on my patients the day after or at the end of the day. The patient's that I make comfortable prior going to the PACU often receive much less total opioid because the nurses aren't bolusing 1.2 mg of dilaudid within the first 45 minutes. Why be hesitant to give opioid when they will just get it 15 minutes later? I also agree with the above if you're vigilant and time things right the administration of moderate amounts of opioid will not slow your wake up.

 

[deleted162650]

It’s more reliable to use EtCO2 to titrate opioids than simply the RR.

 

[vector2]

The RR when using PSVPro really only kicks in the backup mode - 45-60 seconds of apnea and it automatically changes over to the backup mode. On the newer PSVpro vent software, when in backup mode and two consecutive spontaneous breaths are sensed, it will change back to PSVPro.

I'm aware. I've still had experiences where the pts bonafide spontaneous (not backup) rate with a sufficiently low flow trigger on PSV was significantly different than the rate after flipping them on the bag.

 

[DrOwnage]

It’s more reliable to use EtCO2 to titrate opioids than simply the RR.

Truth. I end up using ETCO2 more often