An extubation pathway for safe extubation practices and preparedness for extubation failure in the ICU
CCCF ePoster library. Khosravani H. Oct 27, 2015; 117370; P79
Dr. Houman Khosravani
Dr. Houman Khosravani
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Topic: Quality Assurance/Quality Improvement Project

An extubation pathway for safe extubation practices and preparedness for extubation failure in the ICU

Houman Khosravani, F. Priestap, P. Jones, J. Fuller

Medicine, Critical Care Medicine, Western University, London, Canada | Critical Care, Western University, London, Canada | Anesthesia and Perioperative Medicine, Western University, London, Canada | Anesthesia and Perioperative Medicine, Western University, London, Canada


The need to re-intubate patients in the ICU within 24-72 Hrs of a planned extubation is reported to be on the order of 2-25% of extubations and may be more prevalent in unplanned extubations. Re-intubation in this setting can bring forth risk and possible complications and thus can impact patient safety. In contrast to difficult intubation, predicting acute extubation failure is more challenging and there is a relative paucity of data and consensus on best extubation practices. Thus, there exists an opportunity to develop an extubation checklist and assess its impact on patient morbidity and mortality.


To develop an evidence-informed extubation checklist that can be utilized by Respiratory Therapists (RTs) prior to extubating patients in the ICU.


We conducted a literature review using PubMed (Medline) and Google Scholar spanning 1995-2015 for manuscripts addressing factors that anticipate extubation failure in critically-ill patients. We reviewed the literature in a manner to separate studies that assess patient readiness or preparedness for extubation and focused on the current evidence implicating factors that anticipate failure of extubation. In addition, we solicited feedback from our local clinical practice committee and Critical Care clinicians in order to serially evaluate the developed extubation checklist in a consensus-driven manner.


Our search strategy resulted in 177 manuscripts, of which 68 satisfied our qualitative criteria with a focus on specific factors that predict extubation failure (within 24-72 hrs) in an intensive care unit. Identified variables included advanced age, prolonged ventilator days, traumatic intubation, oversized ETT, and failed cuff-leak test. Overall, the literature supports the notion that qualitative cuff-leaks are just as good as quantitative measurements and that limiting the cuff-leak test to the quantitative approach likely lowers the sensitivity of this test. The absence of a cuff-leak is a more specific finding. In addition, inability to complete actions upon command: open eyes, follow with eyes, grasp hand, stick out tongue had a high relative risk ratio. We also evaluated several other variables, from a consensus perspective, and developed a three-phase checklist addressing: 1) patient preparedness for extubation, 2) risk factors for failure post-extubation, and 3) risk factors for difficult reintubations. These factors were organized in an easy-to-follow format to be used by the bed-side RTs.


Our evidence-informed pathway identifies several evidence-informed and consensus-based variables that may be predictive of acute post-extubation failure. The main impact of this checklist is to insert a cognitive pause before extubation and to take defined steps in order to be prepared for acute extubation failure. As a future direction, we plan to evaluate the rates of extubation failure and peri-extubation adverse events in epochs pre- and post-introduction of our extubation checklist.

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