Emergency Medicine: Open Access
Open Access
ISSN: 2165-7548
ISSN: 2165-7548
Research Article - (2022)Volume 12, Issue 5
Background: The practice of extubation is unpopular among emergency departments (EDs) worldwide, owing to numerous factors including lack of professional training required for the procedure. In addition, data on the safety of this procedure remains unavailable.
Methods: This study reviewed extubation cases in the ED of the King Fahd Hospital, Madina, with the objective of determining the safety of this procedure. Clinico-demographic details of 50 patients, who underwent extubation in the ED, over a period of 4 years, were collected manually from the hospital records and analyzed.
Results: The median patient age was 30 years, and 78% patients were male. Underlying causes included blunt trauma (72%) blunt trauma and medical experience (26%). Of the 50 patients, 20 were intubated before arrival to the ED; 72% were intubated because of decreased levels of consciousness, 20% because of hypoxia, and 8% because of combative behavior. Of the 50 patients that underwent extubation, only 2 (4%) had to undergo unplanned reintubation, while 6 (12%) were scheduled for orthopedic and neurosurgical procedures. The ICU admission rate post extubation was 16% as 8 patients’ required ICU admission, whereas the remaining 42 patients (84%) were transferred to the wards.
Conclusion: This study indicates that extubation in the ED is safe if the clinical condition necessitating airway control has resolved during hospital stay. Further studies are required to assess the impact of extubation on duration of hospital stay and to establish whether the practice of extubation allows for more a judicial use of hospital resources.
ED: Emergency Department; KFH: King Fahd Hospital; RT: Respiratory Therapist; DNR: Do Not Resuscitate; MRP: Most Responsible Physician; COPD: Chronic Obstructive Pulmonary Disease.
The Emergency Department (ED) at the King Fahd Hospital (KFH), Madina is a major trauma center in the region and can experience congestion due to heavy inflow of patients. A possible solution to alleviate this situation is the timely disposal of intubated patients. EDs worldwide are not keen on extubating patients for various reasons, including a lack of resources and relevant training. Further, sufficient data on the safety of this procedure is not available. The ED at KFH has been performing extubations for a few years. The aim of this study was to investigate the safety of the extubation procedures.
Intubation in the ED requires admission to a high-acuity bed and intensive monitoring by nurses and physicians for the entire duration of the patient’s stay [1]. This results in depletion of hospital resources and manpower and may also cause congestion of the ED. A feasible alternative would be to extubate the patients once the clinical condition necessitating airway control has resolved, as this would enable the patient to be transferred to the ward or, if highly stable, even discharged home. This will allow the hospital to save valuable resources and will also prevent congestion of ED. This study aimed to establish the safety of the practice of extubation through a retrospective analysis of extubated cases in our ED over a period of 4 years [2].
Study design and setting
This was a retrospective observational study of extubation cases among adult and pediatric patients in KFH Madinah ED. The study was conducted in the ED of KFH Madinah; patients were treated and extubation was performed in the critical area of the department. The ethical committee at the KFH approved the study. Since this was a retrospective analysis, the study did not require informed consent from the patients. Patient selection the critical area records were manually searched for patients who were extubated over the past 4 years. A standard proforma was used to record relevant information concerning various aspects of the procedure, including post-extubation sequelae. This information was collected by two qualified ED physicians with no conflict of interest [3-5].
Intervention
The ED policies at KFH, Madina advocate for extubation procedures and the ED shift supervisor plays a vital role in the process along with the Respiratory Therapist (RT). Extubation is performed only on resolution of the clinical condition that required intubation [6].
Further, the patient’s intubation history is required to be uneventful and the patient is required to have a minimum GCS above 12/15. In order to be eligible for an extubation, the patient’s stats should be as follows: Saturation >95% on FIO2 ≤ 40% PEEP ≤ 5 cm H2O, respiratory rate 10-30/min, SBP >100 mmHg and HR <130. The exclusion criteria for extubation is as follows: 1) Elderly fragile patients with multiple comorbidities; 2) Patients who had difficult intubation; 3) Patients with maxillofacial injuries with soft tissue swelling or ongoing blood oozing inside the oropharynx; 4) Patients who already had secured ICU bed and ready for shifting; 5) Palliative care or DNR patients who were already booked to be shifted to the general ward; and 6) Confused or highly agitated patients who were likely to have restraining issues after extubation [7,8].
At the point when patients are surveyed for conceivable intubation, we routinely evaluate three spaces: inability to oxygenate and ventilate inability to keep an aviation route, and expected clinical course. To assess patients for extubation, these three spaces ought to be assessed and viewed as satisfactory: Patients should have the option to oxygenate and ventilate and keep a patent aviation route, and their expected clinical course should be predictable with extubation. The superseding idea is that the pathophysiologic express that commanded intubation has been tended to and settled. Albeit numerous patients might fall into this classification, logical up-and-comers in the ED would incorporate inebriated or glut patients in whom the inebriation has settled and minor head injury patients who are improving clinically (probable with a negative head CT check and huge injury precluded). Extubation may likewise be considered for pneumonic edema patients who are altogether moved along. There are likewise few patients who are intubated and on additional request are found to have declined forceful life support or to be resuscitated. These patients are clear contender for ED extuba-tion, and as a rule, extubation ought to proceed despite the continuous illness process.
As per the ED Extubation Protocol, the decision to carry out an extubation procedure is made by the ED supervisor or MRP team. The patient is prepared for the procedure. Sedatives and other anesthetic drugs are discontinued. A nebulizer is filled with normal saline and attached to a mask. The patient is made to sit up to at least 45° and is allowed to regain full consciousness [9]. ET tube suction with bronchial suction catheter and oropharynx suction with yankauer suction is carried out. The ET tube cuff is deflated and the patient is asked to cough, pull the tube during the cough, and then remove it. The oropharynx is suctioned again. The patient is encouraged to keep coughing up any secretions. The nebulizer mask is placed on the patient at 4–6 LPM oxygen if there is no chronic obstructive pulmonary disease (COPD) [10].
Outcome measures
The primary outcome was the need for unplanned reintubation post extubation. Planned reintubation was defined as elective intubation for a surgical procedure in the operating room.
Data analysis
Data were entered and analyzed using Microsoft Excel Windows 2013.
We analyzed 50 patients who had undergone extubation in the ED, over the past 4 years. Table 1 summarizes the clinico-demographic characteristics of the study participants. The median age of the participants was 30 years, and 78% of the patients were male. Regarding injury, 72% were injured by blunt trauma due to a road traffic accident, fall, and assault; 26% had a medical cause; and 2% of the injuries were due to other reasons. 20 patients were intubated before arrival at the ED whereas 30 patients were intubated post-arrival, in the ED (Table 2). Table 3 shows the reasons for intubation: 72% due to decreased consciousness, 20% due to hypoxia, and 8% due to combative behaviour. After extubation, only 2 (4%) patients had unplanned reintubation, and 6 (12%) patients were scheduled for orthopedic and neurosurgical procedures (Table 4). Table 5 shows the disposition; out of the 50 patients only 8 (16%) were admitted to ICU while the rest (84%) were transferred to the ward [11,12].
| Characteristics | n=50 | % |
|---|---|---|
| Age, median (Years) | 30 | |
| Male % | 39 | 78% |
| Injury type | ||
| Blunt trauma % | 36 | 72% |
| Road traffic accident % | 30 | 83% |
| Assault % | 3 | 8% |
| Fall % | 3 | 8% |
| Penetrating trauma % | 1 | 2% |
| Stab wound % | 1 | 100% |
| Gunshot wound % | 0 | |
| Medical % | 13 | 26% |
Table 1: Summarizes the clinic-demographic characteristics.
| Place of intubation | # |
|---|---|
| Intubation before arrival | 20 |
| Intubation in ED | 30 |
Table 2: Intubated before arrival and post-arrival.
| Reasons for intubation | % |
|---|---|
| Conscious level | 72% |
| Hypoxia | 20% |
| Combative behavior | 8% |
| Other | 0 |
Table 3: The reasons for intubation.
| Reasons for re-intubation | # | % |
|---|---|---|
| Unplanned reintubation | 2 | 4% |
| Conscious level | 1 | 50% |
| Hypoxia | 1 | 50% |
| Planned reintubation | 6 | 12% |
| Orthopedic operation | 5 | 83.33% |
| Neurosurgical | 1 | 16.66% |
Table 4: Scheduled for orthopaedic and neurosurgical procedures.
| Disposition | # | % |
|---|---|---|
| Admission | 50 | 100% |
| Ward | 42 | 84% |
| ICU | 8 | 16% |
| Discharged | 0 | 0 |
Table 5: Disposition of transferred to the ward.
Our study involved retrospective analysis of extubation procedures performed on adult and pediatric patients who were intubated in our ED as well as those who arrived intubated to our ED from other hospitals. These included blunt trauma and other medical cases. All cases were supervised by our ED senior along with the RT [13]. Patients were selected according to the extubation policy in our department. The primary outcome was the need for unplanned reintubation post extubation.
This retrospective prognostic study indicates that ED extubation may be safe if the clinical condition necessitating airway control has resolved during the ED stay. Prospective controlled trials are needed to confirm these findings and establish whether ED extubation saves resources and limits the length of stay. At many centers, intubated patients require an intensive care unit bed, and ED extubation may allow admission to a lower acuity bed. At this stage, we do not recommend that centers inexperienced with ED extubation discharge these patients from the ED. In-hospital admission allow the patient to be observed for any post-extubation airway complications.
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Citation: Iqbal MY, Abdulkarim EA, Albassam S, Alanazi F (2022) Practice of Extubation in the Emergency Department: A Cross-Sectional Observational Study. Emergency Med. 12:231.
Received: 09-May-2022, Manuscript No. EGM-22-17391; Editor assigned: 13-May-2022, Pre QC No. EGM-22-17391 (PQ); Reviewed: 27-May-2022, QC No. EGM-22-17391; Revised: 03-Jun-2022, Manuscript No. EGM-22-17391 (R); Published: 10-Jun-2022 , DOI: 10.4172/2165-7548.22.12.231
Copyright: © 2022 Iqbal MY, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.