UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

气管拔管管理

Author
Robert C Hyzy, MD
Section Editor
Scott Manaker, MD, PhD
Deputy Editor
Geraldine Finlay, MD
Translators
王可新, 副主任医师

引言

气管拔管是指气管内导管(endotracheal tube, ETT)的拔出，这是撤掉患者机械通气的最后一步。本文将讨论气管拔管之前需要考虑的问题、气管拔管操作本身以及气管拔管后的管理。本文也将讨论气管拔管后的结局。机械通气撤机成功的预测因素及方法将单独总结。 (参见“机械通气撤机：准备度测试”和“机械通气的撤机方法”)

气管拔管前

在机械通气撤机过程的尾声，患者可能显然不再需要机械通气来维持充足的通气和供氧。然而，在确定患者能够保护气道并且气道通畅的情况前，不应行气管拔管。

气道保护 — 气道保护是指自主呼吸期间防止误吸的能力。这需要足够的咳嗽力度和足够的意识水平，这两者均应该在气管拔管前进行评估。在气管拔管前也应该考虑分泌物的量，因为当分泌物增加时气道保护会显著更加困难。

当存在多种危险因素时，气管拔管失败的可能性最大。例如，当咳嗽时呼气峰流速(peak expiratory flow, PEF)降低(≤60L/min)、痰液量增加(>2.5mL/h)和神经功能受损(不能遵照指令)均存在时，气管拔管失败的发生率为100%，而这3个危险因素都不存在时，气管拔管失败的发生率为3%(RR 23，95%CI 3.2-167)[1]。

目前尚未确定禁止气管拔管的咳嗽力度水平、意识水平以及吸痰频率普遍接受的阈值。对于很多患者来说，如果咳嗽力度较弱、Glasgow昏迷评分(Glasgow Coma Score, GCS)评分小于8分或者需要吸痰频率大于每2-3小时1次，那么延迟拔管似乎是合理的。然而，是延迟气管拔管还是继续进行气管拔管的最终决策应视具体情况而定，因为延迟拔管有不良后果，如呼吸机相关肺炎和住院时间(length of stay, LOS)延长[2]。

                 

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-07 . | This topic last updated: 2017-04-07.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 2004; 30:1334.
  2. Coplin WM, Pierson DJ, Cooley KD, et al. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med 2000; 161:1530.
  3. Khamiees M, Raju P, DeGirolamo A, et al. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001; 120:1262.
  4. Beuret P, Roux C, Auclair A, et al. Interest of an objective evaluation of cough during weaning from mechanical ventilation. Intensive Care Med 2009; 35:1090.
  5. Thille AW, Boissier F, Ben Ghezala H, et al. Risk factors for and prediction by caregivers of extubation failure in ICU patients: a prospective study. Crit Care Med 2015; 43:613.
  6. Epstein SK. Putting it all together to predict extubation outcome. Intensive Care Med 2004; 30:1255.
  7. Smina M, Salam A, Khamiees M, et al. Cough peak flows and extubation outcomes. Chest 2003; 124:262.
  8. Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med 2001; 163:658.
  9. Ouellette DR, Patel S, Girard TD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest 2017; 151:166.
  10. Schmidt GA, Girard TD, Kress JP, et al. Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med 2017; 195:115.
  11. Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 2012; 308:1985.
  12. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010; 375:475.
  13. Maury E, Guglielminotti J, Alzieu M, et al. How to identify patients with no risk for postextubation stridor? J Crit Care 2004; 19:23.
  14. Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care 2005; 50:1632.
  15. Sukhupanyarak S. Risk factors evaluation and the cuff leak test as predictors for postextubation stridor. J Med Assoc Thai 2008; 91:648.
  16. Cheng KC, Hou CC, Huang HC, et al. Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients. Crit Care Med 2006; 34:1345.
  17. François B, Bellissant E, Gissot V, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet 2007; 369:1083.
  18. Santos PM, Afrassiabi A, Weymuller EA Jr. Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg 1994; 111:453.
  19. Friedman M, Baim H, Shelton V, et al. Laryngeal injuries secondary to nasogastric tubes. Ann Otol Rhinol Laryngol 1981; 90:469.
  20. Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor. Chest 1996; 110:1035.
  21. Jaber S, Chanques G, Matecki S, et al. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med 2003; 29:69.
  22. De Bast Y, De Backer D, Moraine JJ, et al. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med 2002; 28:1267.
  23. Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care 2007; 11:R72.
  24. Ochoa ME, Marín Mdel C, Frutos-Vivar F, et al. Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med 2009; 35:1171.
  25. Zhou T, Zhang HP, Chen WW, et al. Cuff-leak test for predicting postextubation airway complications: a systematic review. J Evid Based Med 2011; 4:242.
  26. Girard TD, Alhazzani W, Kress JP, et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit Care Med 2017; 195:120.
  27. Fisher MM, Raper RF. The 'cuff-leak' test for extubation. Anaesthesia 1992; 47:10.
  28. Engoren M. Evaluation of the cuff-leak test in a cardiac surgery population. Chest 1999; 116:1029.
  29. Ding LW, Wang HC, Wu HD, et al. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur Respir J 2006; 27:384.
  30. Sutherasan Y, Theerawit P, Hongphanut T, et al. Predicting laryngeal edema in intubated patients by portable intensive care unit ultrasound. J Crit Care 2013; 28:675.
  31. Mort TC. Continuous airway access for the difficult extubation: the efficacy of the airway exchange catheter. Anesth Analg 2007; 105:1357.
  32. Darmon JY, Rauss A, Dreyfuss D, et al. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study. Anesthesiology 1992; 77:245.
  33. Ho LI, Harn HJ, Lien TC, et al. Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone. Intensive Care Med 1996; 22:933.
  34. Khemani RG, Randolph A, Markovitz B. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev 2009; :CD001000.
  35. Fan T, Wang G, Mao B, et al. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials. BMJ 2008; 337:a1841.
  36. Cheng KC, Chen CM, Tan CK, et al. Methylprednisolone reduces the rates of postextubation stridor and reintubation associated with attenuated cytokine responses in critically ill patients. Minerva Anestesiol 2011; 77:503.
  37. Wang CL, Tsai YH, Huang CC, et al. The role of the cuff leak test in predicting the effects of corticosteroid treatment on postextubation stridor. Chang Gung Med J 2007; 30:53.
  38. McCaffrey J, Farrell C, Whiting P, et al. Corticosteroids to prevent extubation failure: a systematic review and meta-analysis. Intensive Care Med 2009; 35:977.
  39. Kuriyama A, Umakoshi N, Sun R. Prophylactic Corticosteroids for Prevention of Postextubation Stridor and Reintubation in Adults: A Systematic Review and Meta-analysis. Chest 2017; 151:1002.
  40. Jaber S, Jung B, Chanques G, et al. Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials. Crit Care 2009; 13:R49.
  41. Tischenkel BR, Gong MN, Shiloh AL, et al. Daytime Versus Nighttime Extubations: A Comparison of Reintubation, Length of Stay, and Mortality. J Intensive Care Med 2016; 31:118.
  42. Gershengorn HB, Scales DC, Kramer A, Wunsch H. Association Between Overnight Extubations and Outcomes in the Intensive Care Unit. JAMA Intern Med 2016; 176:1651.
  43. Tiruvoipati R, Lewis D, Haji K, Botha J. High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients. J Crit Care 2010; 25:463.
  44. Maggiore SM, Idone FA, Vaschetto R, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med 2014; 190:282.
  45. Hernández G, Vaquero C, González P, et al. Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial. JAMA 2016; 315:1354.
  46. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 2005; 33:2465.
  47. Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med 2006; 173:164.
  48. El-Solh AA, Aquilina A, Pineda L, et al. Noninvasive ventilation for prevention of post-extubation respiratory failure in obese patients. Eur Respir J 2006; 28:588.
  49. Ferrer M, Sellarés J, Valencia M, et al. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet 2009; 374:1082.
  50. Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev 2013; :CD004127.
  51. Khilnani GC, Galle AD, Hadda V, Sharma SK. Non-invasive ventilation after extubation in patients with chronic obstructive airways disease: a randomised controlled trial. Anaesth Intensive Care 2011; 39:217.
  52. Girault C, Bubenheim M, Abroug F, et al. Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial. Am J Respir Crit Care Med 2011; 184:672.
  53. Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350:2452.
  54. Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA 2002; 287:3238.
  55. Hernández G, Vaquero C, Colinas L, et al. Effect of Postextubation High-Flow Nasal Cannula vs Noninvasive Ventilation on Reintubation and Postextubation Respiratory Failure in High-Risk Patients: A Randomized Clinical Trial. JAMA 2016; 316:1565.
  56. Stéphan F, Barrucand B, Petit P, et al. High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial. JAMA 2015; 313:2331.
  57. Jaber S, Lescot T, Futier E, et al. Effect of Noninvasive Ventilation on Tracheal Reintubation Among Patients With Hypoxemic Respiratory Failure Following Abdominal Surgery: A Randomized Clinical Trial. JAMA 2016; 315:1345.
  58. Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015; 372:2185.
  59. Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998; 158:489.
  60. Razek T, Gracias V, Sullivan D, et al. Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation. J Trauma 2000; 48:466.
  61. Krinsley JS, Barone JE. The drive to survive: unplanned extubation in the ICU. Chest 2005; 128:560.
  62. Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med 2000; 161:1912.
  63. de Larminat V, Montravers P, Dureuil B, Desmonts JM. Alteration in swallowing reflex after extubation in intensive care unit patients. Crit Care Med 1995; 23:486.
  64. Coppolo DP, May JJ. Self-extubations. A 12-month experience. Chest 1990; 98:165.
  65. Vassal T, Anh NG, Gabillet JM, et al. Prospective evaluation of self-extubations in a medical intensive care unit. Intensive Care Med 1993; 19:340.
  66. Listello D, Sessler CN. Unplanned extubation. Clinical predictors for reintubation. Chest 1994; 105:1496.
  67. Tindol GA Jr, DiBenedetto RJ, Kosciuk L. Unplanned extubations. Chest 1994; 105:1804.
  68. Betbesé AJ, Pérez M, Bak E, et al. A prospective study of unplanned endotracheal extubation in intensive care unit patients. Crit Care Med 1998; 26:1180.
  69. Boulain T. Unplanned extubations in the adult intensive care unit: a prospective multicenter study. Association des Réanimateurs du Centre-Ouest. Am J Respir Crit Care Med 1998; 157:1131.
  70. Chevron V, Ménard JF, Richard JC, et al. Unplanned extubation: risk factors of development and predictive criteria for reintubation. Crit Care Med 1998; 26:1049.
  71. de Lassence A, Alberti C, Azoulay E, et al. Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit: a prospective multicenter study. Anesthesiology 2002; 97:148.
  72. Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002; 287:345.
  73. Curry K, Cobb S, Kutash M, Diggs C. Characteristics associated with unplanned extubations in a surgical intensive care unit. Am J Crit Care 2008; 17:45.
  74. Chang LY, Wang KW, Chao YF. Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study. Am J Crit Care 2008; 17:408.
  75. Moons P, Sels K, De Becker W, et al. Development of a risk assessment tool for deliberate self-extubation in intensive care patients. Intensive Care Med 2004; 30:1348.
  76. Frutos-Vivar F, Ferguson ND, Esteban A, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 2006; 130:1664.
  77. Thille AW, Harrois A, Schortgen F, et al. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med 2011; 39:2612.
  78. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997; 112:186.
  79. Torres A, Gatell JM, Aznar E, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 1995; 152:137.
  80. Rady MY, Ryan T. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med 1999; 27:340.
  81. Reyes A, Vega G, Blancas R, et al. Early vs conventional extubation after cardiac surgery with cardiopulmonary bypass. Chest 1997; 112:193.