ICUs Intubation and Weaning Protocol

September 2024

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Icu team
This s intubation protocol is prepared to be used in ACSH ICUs . The protocol
includes Benefit of good intubation and Extubation , how to prepare and the role of all
the nurses.
The document is prepared by
1. Goiteom Redae - Critical Care Nurse Director
2. Rahel Embaye - SICU Head Nurse
3. Girmay Legass - Emergency and Critical Care Quality Officer

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Contents
Introduction............................................................................................................................................................4
General Objective..................................................................................................................................................4
Specific Objective..............................................................................................................................................4
Indications for Intubation....................................................................................................................................4
Equipment preparation.......................................................................................................................................4
Intubation procedure..........................................................................................................................................6
Nurses Role during intubation.......................................................................................................................6
Post Intubation...................................................................................................................................................6
Weaning.................................................................................................................................................................6
Sequence of weaning.........................................................................................................................................6
Extubation..............................................................................................................................................................7
Practical procedure of extubation......................................................................................................................7
Post extubation management.............................................................................................................................7
Reference...............................................................................................................................................................8

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 Introduction
Intubation and extubation of ventilated patients are not risk-free procedures on the intensive care unit
and can be associated with morbidity and mortality. Intubation in the ICU is frequently required in
emergency situations for patients with an unstable cardiovascular system who may be hypoxic .
Under these circumstances it is a high-risk procedure with life-threatening complications such as
hypotension and respiratory failure. Technical problems can also give rise to complications.
Generally three unsuccessful intubations or two unsuccessful attempts at laryngoscope are needed to
justify the description difficult airway. These can make up 10–20% of intubations in the ICU and are
associated with an increase in morbidity.
General Objective
It provides oxygen and inhaled gases to the lungs and protects them from contamination, such as
gastric contents or blood.
Specific Objective
 To ensure that vital oxygen is delivered to your body while you are unconscious
 Opening up the air way to give oxygen, anesthetist, or medicine & Removable of blockage s.
 Helping a patient breath if they have collapsed lungs, heart failure, trauma
 Helping to prevent a person from breathing in liquids
Indications for Intubation
 Cardiac or respiratory arrest
 Tachypnea or bradypnea with respiratory fatigue or impending arrest
 Acute respiratory acidosis
 Refractory hypoxemia Refractory hypoxemia (when the P a O 2 could not be maintained
above 60 mm Hg with inspired O 2 fraction (F I O 2 )>1.0)
 Inability to protect the airway associated with depressed levels of consciousness
 Shock associated with excessive respiratory work
 Inability to clear secretions with impaired gas exchange or excessive respiratory work
 Newly diagnosed neuromuscular disease with a vital capacity <10 capacity <10 - 15
mL/kg
 Short term adjunct in management of acutely increased intracranial pressure (ICP) 2
Equipment preparation
 Suction set up. Verify it is functioning
 Ambu bag and mask –ready to be \hooked up to oxygen cylinder
 Oral air way
 Laryngoscope: set of blades. Verify that light is working.
 Etts: confirm size selection with MD anesthetist. Typical size 7,7.5,for female 7.5-8 foe
males. Have a second backup tube ,usually size smaller.
 Stylet
 Syringe 10ml

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  Towel or pillow to raise head if needed
 Tape and gauze to secure tube after intubation
 NG tube if one will be placed(easy to do while patients is still sedated from intubation
Ventilator preparation
 Set up Ventilator in advance of intubation if possible
Patient preparation
 Inform patient about what to expect and provide comfort
 Iv ensure good functioning iv(best practice two ivs)
 EKG and puls oximetry Monitoring should be verified to be functioning
 Set Automatic BP cuff to Measure Bp every 5 Minute
 If NGT is in place, empty the stomach using suction
 Preoxygenation: even if the oxygen saturation appears good , patients with
spontaneous Breathing should Receive face mask oxygen at high rate for 5
minut wight up to momentof intubation.
Medication Preparation
 Discuss medication choice (s) and dose wit Md/anesthetist
a. Intubating medications: agents ,doses and what order they will
be Given
b. Medication for sedation after intubation
 Prepare syringes with medication. Label syringes 4 using \plaster. Verify dose with another
nurse.
 If Bp is low before intubation, it will probably drop even lower. If SBP is <110 mmprior to
intubation have the following prepared to give after intubation for hypotension:
a. 1 letter NS or Ringer lactete
b. Adrenaline, 1mg/1ml+9ml ns
Induction Agents
On set Duration Comments
Ketamin1.5-2mg/kg 40-60 s 10-20 min Best choice for hypotensive patients good choice for
possible difficult airway to use with out
neuromascular blockade
Propofol 1.5mg/kg 14-45 s 5-10 min Often drops blood pressure
Thiopental 3-4mg/kg <30 s 5-10 min Often drops blood pressure, sometimes severly
Neuromuscular Blockade agents ( do note use for difficult airways)
Onset Duration comments
Succinylcholine 1.5mg/kg 45 s 6-10 min May cause hyperkalemia in certain patients:
Vecuronium 0.1-mg/kg 120- 45-60 min Seldom used due to slow onset and long
180s duration of action

Intubation procedure
Time-out

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  If time allows, team leader and Nurse should pause to discuss plan ; sequence of medications,
expected procedure, roles
Anesthesiologist roll during intubation
 Once you are asleep, the anesthesiologist or CRNA may insert a flexible, plastic breathing
tube into your mouth and down your windpipe.
 tube ensures that you get enough oxygen.
 It also protects your lungs from oral secretions or fluids such as stomach fluids.
Nurses Role during intubation( best to have two Nurse)
 Administer meds as directed, Meds should be Bloused quickly and line flushed to ensure rapid
delivery
 Monitor patients; heart rhythm , oximetry, breathing status
 Assist MD /anesthetist during procedure as needed
 Help secure ETT after intubation

Post Intubation
 Connect to ventilator – verify initial ventilator settings with md
 Frequent blood pressure for first 15-30 min
 Administer any post – intubation sedation, fluids
 Record how deep the ETT is inserted. adjust ETT cuff pressure according to protocol
 Adjust ventilator settings.
Weaning
Weaning a patient from a ventilator occurs when the condition of the patient improves, and a
decision is made to remove them from the ventilator through a trial of spontaneous breathing
through the endotracheal tube and eventually extubation (removal of the tube).
Protocol for Respirator Weaning
Patients on CMV/AC mode: change to SIMV/PS mode
Patients on SIMV/PS mode: change to CPAP/PSV mode
Patients on CPAP/PSV mode: change to CPAP
Patients on CPAP mode for 24 hours: change to O2 tube 3l O2 for 5 minutes - Extubate

Sequence of weaning
• FiO2 ≤ 0.5
• I:E ratio to 1:2 if it is inversed
• Pi (PCV) that TV achieved is 6ml/kg bw.
• TV (VCV) to 6ml/kg bw.
• Reduce/stop analgosedation
• Reduce RR in steps of 1(-2)
• Reduce PS in steps of 1 to PS 4(-3)
• Reduce PEEP to 3-5
• Put patient on O2 tube 3l for 5 min and extubate
• Or reduce PS to 0 and let the patient breath CPAP 3-5 for 24 hours, then O2 tube and
extubation
Note: Do not wean the trigger by decreasing the trigger sensitivity

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 Extubation
 FiO2 ≤ 0.4
 Stable circulation
 Improvement of pulmonary findings
 No sign of infection
 Normal fluid balance
 Normal bowel function
 RR ≤ 30/min
 O2 saturation 93-95%
 CO2 in normal range
 Good cough reflex
 Cooperative patient

Practical procedure of extubation

 Explain the procedure to the patient
 Prepare O2 cylinder and connect nasal canula
 Sit the patient up
 Suck NGT and leave NGT open during extubation
 Suck the oropharynx carefully
 Deflate the cuff of the ETT
 Insert a suction tube into the ETT and remove ETT under continuous suction.
 Remove the oral airway.
 Fix the nasal O2 canula and give 3l O2.
Post extubation management
 Patient remains in sitting position
 NPO for 2 hours post extubation
 Frequent chest physiotherapy
 Coughing and breathing exercises
 Frequent auscultation of the chest (atelectasis)
 Chest X-ray control after 24 hours.

Reference
1. American association for respiratory care 2022
2. WHO

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3. National institute of health 2024 https/www rchorg>rchpg>end tracheal-tube
4. Miller-Keane OT, O’Toole M. Miller-Keane encyclopedia and dictionary of medicine,
nursing and allied health.
5. MD, F. (2019). Simplifying Mechanical Ventilation – Part I: Types of Breaths - REBEL
EM - Emergency Medicine Blog.