Try ACET + MPA combination for Extubation Failure after good Spontaneous Breathing Trial

 

Try ACET + MPA combination for Extubation Failure after good Spontaneous Breathing Trial



A 52M was admitted with h/o fall from height with D12 compression fracture and right side hemothorax. Plate fixation was done and hemothorax was drained. On day 5 he successfully passed spontaneous breathing trial on low FiO2 (25-30%). NIV was applied but it failed. He was re intubated and was started on Tab Acetazolamide 500 mg TDS and Tab Medroxyprogesterone 20 mg TDS. On the subsequent day the process was repeated and was extubated successfully. 

 

What are the factors which predispose to reintubation after successful SBT and what are the best strategies to support this situation?  

 

*Risk factors:*

Old age

Left ventricular dysfunction

Anemia

Positive fluids balance and transfusions given

Renal dysfunction

Fentanyl use (Cumulative dose)

Prolonged mechanical ventilation

Neurological impairment

Airway edema (Cuff leak test < 110 ml)

Low diastolic pressure

High APACHE II score

Limb muscle weakness (Upper limb more important then lower)

Poor or absent Gag reflex (In traumatic brain injury however it was shown that poor gag reflex patients could be successfully extubated)

Excessive airway secretions

====

 

*Management*

Prophylactic NIV

NIV on the onset of extubation failure

Acetazolamide (250-500 BD or TDS)

Medroxyprogesterone (20-40 BD or TDS)

ACET + MPA combined treatment is more effective

Inj Doxapram 20 mg can be repeated with interval upto 100 mg

Respiratory stimulant action of ACET + MPA combination can be given prior to extubation in high risk cases. Even in cases which require NIV to avert extubation can be managed on this regimen.

Use Ant sialagogues in case of excess airway secretions (Inj. Glycopyrollate 0.2 mg IV stat)

Tracheostomy

====

 

Please share your experience and strategy of managing any less commonly happening extubation failure – besides NIV.

 

*Dr. Prashant Kumar*

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