What are the indications for reintubation in a post-operative patient who developed atelectasis after extubation following endotracheal intubation (ETI)?

From the Guidelines

Reintubation in a post-operative patient with atelectasis should be considered when there are signs of respiratory failure that cannot be managed with less invasive measures, such as severe hypoxemia, hypercapnia with respiratory acidosis, increased work of breathing, inability to protect the airway, hemodynamic instability, or deteriorating mental status, as indicated by the most recent guidelines 1.

Indications for Reintubation

The following indications for reintubation are recommended:

• Severe hypoxemia (oxygen saturation <88-90% despite supplemental oxygen)
• Hypercapnia with respiratory acidosis (PaCO2 >50 mmHg with pH <7.30)
• Increased work of breathing with respiratory rate >30-35 breaths/minute
• Inability to protect the airway
• Hemodynamic instability
• Deteriorating mental status

Less Invasive Interventions

Before reintubation, less invasive interventions should be attempted, including:

• Aggressive pulmonary toilet with chest physiotherapy
• Early mobilization
• Bronchodilators if bronchospasm is present
• Non-invasive positive pressure ventilation (NIPPV) such as CPAP (5-10 cmH2O) or BiPAP (inspiratory pressure 10-16 cmH2O, expiratory pressure 5-8 cmH2O), as recommended by the European Society for Anaesthesiology and Intensive Care and European Society of Intensive Care Medicine (ESA/ESICM) guidelines 1

Decision to Reintubate

The decision to reintubate should be based on clinical judgment considering the patient's overall condition, the severity and progression of respiratory compromise, and the potential for recovery with less invasive management, as suggested by the most recent study 1. Delaying necessary reintubation can lead to emergency situations with higher complication rates, while premature reintubation exposes patients to unnecessary risks associated with mechanical ventilation.

From the Research

Indications for Reintubation in Postoperative Patients with Atelectasis

• Reintubation may be necessary in patients who develop postoperative atelectasis, especially if they require high levels of PEEP or have severe hypoxemia 2.
• The decision to reintubate should be based on the severity of the atelectasis and the patient's overall clinical condition, including their ability to maintain adequate oxygenation and ventilation 3, 4.
• Patients with large atelectasis or those who are unable to clear secretions with chest physiotherapy may require bronchoscopy to remove mucous plugs 4, 5.
• Reintubation may also be considered in patients with relapsing atelectasis or those with swallow disorders 4.

Factors Influencing the Decision to Reintubate

• The severity of the atelectasis, including its size and location, can influence the decision to reintubate 6, 5.
• The patient's underlying lung disease and overall health status can also impact the decision to reintubate 2, 3.
• The effectiveness of noninvasive respiratory support, such as CPAP or high-flow nasal cannula, in managing the patient's respiratory failure can also influence the decision to reintubate 2.

Alternative Management Strategies

• Chest physiotherapy, including chest wall percussion and vibrations, patient positioning, and breathing exercises, can be effective in managing postoperative atelectasis 3, 4.
• Bronchoscopy can be used to remove mucous plugs and improve lung expansion 3, 4, 5.
• Noninvasive ventilation, such as CPAP or bi-level positive airway pressure (BiPAP), can be used to support patients with postoperative atelectasis and respiratory failure 2.