Effect of Applying Positive Pressure With or Without Endotracheal Suctioning During Extubation: A Laboratory Study

Abstract

BACKGROUND: During invasive mechanical ventilation, secretions accumulate in the subglottic space; consequently, there is a risk of aspiration of these secretions into the airway during cuff deflation and extubation. To minimize this risk, 2 extubation methods are used. The first consists of introducing a suction catheter into the endotracheal tube (ETT) and the trachea. After initiating suctioning, the cuff is deflated and the ETT is removed together with the suction catheter. The second technique involves applying positive pressure to the ETT using a resuscitation bag. Once the manual breath is delivered, the ETT cuff is deflated and the ETT is removed without suction. The aim of this laboratory study is to determine the existence and magnitude of differences in leak volume during cuff deflation and extubation using various combinations of positive pressure with or without endotracheal suctioning.

Safety of Positive Pressure Extubation Technique

“…Positive pressure extubation involves involves less leakage of secretions pooled in the subglottic space to the distal airway and does not require endotracheal suction during ETT removal, which leads to less airway stimulation. 9,11 Impaired oxygenation is one of the most commonly reported extubation complications, 3 and it has been associated with reduction of lung volume and oxygen stores during endotracheal suction. This is the reason why it has been the primary outcome measure in studies that compared traditional and positivepressure extubation techniques.…”

“…Positive pressure could reduce the leakage of subglottic colonized secretions into the distal airway. 9,11 However, the development of pneumonia depends on multiple factors. 26 The rate of extubation failure and reintubation found in both groups is consistent with that reported in the literature.…”

“…through the mouth to suction secretions drawn to the oropharynx by the air flow from the ventilator passing between the ETT and the larynx. 8,11 Regardless of the extubation technique used, the subjects received supplemental oxygen at the same flow level used for the spontaneous breathing trial. In case of desaturation, the flow was regulated to maintain an oxygen saturation of Ͼ90%.…”

“…9,10 Two laboratory studies showed that applying positive pressure without endotracheal suction during cuff deflation and extubation results in less leak volume. 9,11 Although some studies reported physiological outcomes with this technique, its safety has not been well studied. 6,12 Before assessing the superiority and applicability of extubation with positive pressure in daily clinical practice, we consider it essential to ensure the safety of this technique.…”

Study protocol: A randomized controlled trial assessing the avoidance of endotracheal suction in cardiac surgical patients ventilated for ≤ 12 hr

“…Although the most common practices at extubation are asking the patient to cough and suctioning the ETT at/during extubation (Dawkins, ; Gilder et al., ; Hodd, Doyle, Carter, Albarran, & Young, ; Scales & Pilswoth, ), ETS at extubation can increase the risk of atelectasis, in turn contributing to hypoxia (Loeckinger et al., ; Paulissian et al., ). There is contradictory evidence about the benefit of a positive pressure breath or recruitment manoeuvres at the time of extubation (Andreu et al., ; Hodd, Doyle, Carter, Albarran, & Young, ; Hodd et al., ; L'Hermite et al., ).…”