How do you approach determining appropriateness for extubation in a patient with acute respiratory failure in the setting of known chronic neuromuscular disease?

1 Answer

Mednet MemberInvited Expert

Pulmonology · University of Utah School of Medicine

Answered on

This can be a very challenging situation in the ICU. I first discuss the options with the patient (if possible) and caregivers before considering extubation. I consider baseline/pre-illness data if available such as prior FVC or NIF/MIP, need for NIV, etc. Also, it is important to consider why they needed intubation such as pneumonia vs worsening weakness, etc. Obtain vent weaning parameters but...

There is no evidence that RSBI-dependent weaning improves clinical outcomes, such as duration of weaning, duration of mechanical ventilation, length of stay, or reintubation rate.
Neuromuscular patients were not included in these RSBI studies!

Some studies on extubation protocols in this situation are:

Bach protocol
Peak cough flow greater than 160 L/m predicted success with trach decannulation in patients with NM disease and reduced vital capacity (Bach & Saporito, PMID 8989078)
157 neuromuscular patients who failed SBTs before and after extubation, 87% success rate on first attempt. Only two patients required tracheostomy. (Bach et al., PMID 20040608)
Vianello et al., PMID 21273033
7 out of 10 patients were extubated successfully using a similar protocol as Bach except for ether manually assisted coughing or mechanical assisted coughing depending on patient’s ability to cooperate.

With my patients, if they elect for extubation I have a plan for if they want to be reintubated and whether they would want a trach. I do aggressive cough assist and metaneb/volera to clear secretions as they will fatigue quickly if they are fighting to clear them. Extubate to NIV and adjust settings to support respiratory effort and CO2 clearance. Continue to do aggressive secretion clearance and wean off NIV as tolerated. Also will use mouth piece ventilation or nasal mask during the daytime to support them as needed.