The next thing we considered was what would be the consequences of extubating if he failed and needed reintubated? He had an OGT which was to suction evacuating the stomach. Unfortunately we did not have the intubation records from the outside hospital, but his significant other said that the physicians there did not report difficulty with intubation. (This is, I think, one of the most important and most frequently neglected considerations of an extubation - how difficult was the intubation?) He had a good thyromental and thyromandibular distances, normal mouth opening and normal neck mobility. So, we ought to be able to reintubate him. I reinforced to the trainees that in a case like this, if we extubate and he does not markedly improve afterwards, our test has failed. The hypothesis is: he is breathing at Ve 26 liters because of high CO2 production from agitation which is due to the endotracheal tube. If Ve doesn't decrease after extubation, this hypothesis is rejected and he should be expeditiously reintubated without equivocation and especially without denial.
So we decided to extubate the patient. Then we got the intubation equipment arranged, VL in the room, ketamine and propofol drawn up......and we extubated him.
Previously I have reported on both successful and failed "extreme extubations". Would you like to venture a guess which category this case falls into? I will entertain comments below and on twitter before I follow-up on the results of this case. Please let me know what you would have done!