Friday, January 11, 2019

Cough in extubation

Q: Despite passing weaning parameters, poor cough strength is a reliable indicator of failed extubation. What is an easy bedside method to test adequate cough strength in a patient who otherwise seems ready for extubation? 

Answer: After detaching endotracheal tube (ETT) from the ventilator circuit, an index card is held about 2 cm from the end of the ETT. A patient who is unable to moisten the card with few efforts of cough is more likely to fail extubation. 1

Extubation failure is well documented in patients who cannot cough on demand despite good weaning parameters. More appropriate method to test the cough strength is to insert a spirometer into the ventilator circuit. Strength of cough can be measured with peak expiratory flow (PEF) during the cough. PEF ≤60 L/min are five times more likely to fail extubation.



References/further reading:

1. 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. 

2. 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. 

3. 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. 

4. Epstein SK. Putting it all together to predict extubation outcome. Intensive Care Med 2004; 30:1255. 

5. Smina M, Salam A, Khamiees M, et al. Cough peak flows and extubation outcomes. Chest 2003; 124:262. 

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