Inherently more relaxing than intubation, extubation is nevertheless potentially hazardous. It should rarely occur in the ED. Patients who are recovering their protective airway reflexes may "fight" the tube yet still need to remain intubated. Instillation of 1 to 2 mL of 4% lidocaine (sterile for injection) down the Et tube will decrease bucking. The absorption of lidocaine via the airway yields a maximum serum level that is only slightly lower than that from an equivalent intravenous dose.
Prior to extubation, consider the impact of metabolic or circulatory abnormalities. The patient should be checked for respiratory insufficiency, and nasogastric decompression is advised. On command, the patient should have an inspiratory capacity of at least 15 mL/kg. Ideally there should be no intercostal or suprasternal reactions, and the patient's grip should be firm.
After suctioning secretions, assure adequate oxygenation and explain the procedure to the patient. Positive-pressure ventilation using a mask will help to exsufflate secretions while the cuff is deflated. At the end of a deep inspiration, to prevent secretory reaccumulation, remove the tube and oxygenate by mask.
Closely observe the patient for stridor. Postextubation laryngospasm is initially treated with oxygen by positive pressure. If necessary, nebulized racemic epinephrine (0.5 mL of 2.25% epinephrine in 4-mL saline) often helps.
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USPDI, vol I. 19th ed, 1999, Micromedia and the US Pharmacopeia Connection.
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