So I'm the director of quality improvement and peer review in the Emergency Department at Cleveland Medical Center. I also do about 300 hours of shifts at Parma, so I am used to addressing stroke in both the community and the academic setting, which is a little bit of a different beast. And we'll talk about some of the nuances there. I don't have any disclosures. If you'd like to give me a reason to have disclosures, please talk to me after the lecture. So at the end of this, I want you guys to be able to describe factors that play into the decision. Decision to manage a patient's airway specifically in acute ischemic stroke. Identify patients who may need definitive airway management. Earlier in the hospital course, we're going to discuss the difference between when people, when we say airway management, we tend to think sticking an ET tube through someone's cords right when I refer to definitive airway management, that's what I mean. But airway management, to me, is any time we're helping to intervene on a patient's respiratory status, so I consider a nasal cannula managing somebody's airways. Sometimes I consider positioning airway management. I consider by Path Airway Management, so you'll hear me refer to definitive airway management as there's a tube through chords and a balloon is up to prevent anything getting into the lungs. And I'm delivering oxygen directly through N E T tube. But airway management can be a lot of things. And then we're going to talk about the risks and benefits of the options that are available both definitively and some of the other adjuncts. We can use an airway management so in emergency medicine, and I think across the system and spectrum of specialties. When you talk about reasons to manage an airway, there are four reasons. This is something we drill into our residents. Failure to oxygenate is the first fairly easy to tell right? Put up all sex on somebody. Is it high? Is it low done, not hard. Third, eventually can be a little more nuanced and usually needs some more. Invasive testing entitled Sio two is probably the easiest way to tell that. Are they actually Blowing Co two out of their lungs? But you can't really tell necessarily based on just that alone. Sometimes a V B G or an A B G is necessary. A blood gas to help us tell whether someone's actually failing to ventilate or not. Failure to protect an airway is the third reason to in debate or to definitively manage somebody's airway. Um, and we're gonna talk about this a lot today. I think that's the biggest reason we talk about this in stroke. That is nuanced. That's the nuanced part of airway management, and you're gonna see why it's nuanced in a minute. And then projected clinical course is my favorite reason to intubate somebody. Um, this is really kind of a catch all for that person. You stand at the end of the bed and you're like, Oh, this isn't going in the right direction or the trauma patient you know is going to get worse. The angio oedema who looks okay right now. But you think may end up needing to be intubated if you think their their clinical course is going to end with an E. T tube, sometimes soon. Sometimes it's safer to take that airway sooner rather than later. Okay, so let's talk about why we care about patients who are failing to protect their airway so specifically in stroke, respiratory failure is the most frequent extra outside the brain. Right below here, complication of neuro ICU patients and stroke associated pneumonia is the most frequent and potentially preventable complication after patients have a stroke. So this study looked at stroke associated pneumonia and tried to say, um, first tried to say who does poorly and who does better, and you can see those who have good outcomes. Modified ranking scores of 0-2 tend to avoid getting pneumonia and that's not a causation. That can be correlation, right? There's a lot of reasons they're modified. Rankin might be low. The stroke scales are low. They had good pre stroke independence all of those things, but they don't get pneumonia. And then people who have poorer outcomes tend to get pneumonia more. Whether that pneumonia leads to the poor outcome isn't really studied, but they tend to be a There's a correlation there, So the incident pneumonia in stroke patients is higher than other causes of ball bar dysfunction or dysplasia, right? So they just have ball bar weakness related to other things like, for example, my senior gravis stroke associated pneumonia aspiration pneumonia happens more in stroke patients than in that population. They think this has something to do with some immuno suppression that happens in strokes. That was way too honestly, a little more complicated than I remember from medical school, so I'm not going to go into that, Um, but just know that there's a wide range of reported incidents of stroke pneumonia. Um, in the general population, it's probably lower, like all comers of strokes, but that includes very mild strokes In your NSU population, it can be as high as 50%. So it's not an insignificant number, depending on which population you're studying. So dysplasia is a known risk factor for stroke associated pneumonia. Patients who have dysplasia have a statistically significantly higher incidence of stroke related pneumonia, which is really an aspiration pneumonia it's referred to in the study of stroke related, but it's an aspiration. Pneumonia and then stroke severity, probably not surprisingly, was associated with this as well. Your higher your NIH stroke scale. The more risk of stroke associated pneumonia, which for all of those of us who take care of strokes regularly, I don't think is a surprise when we look at who's protecting their away and who is not this study looked at trying to come up with a risk score, right? I don't I know. In stroke, we like risk sores in the emergency department. We love risk scores, right? We love being able to try to predict the future. And who's going to get pneumonia, for example, in this case and who isn't. So you know, there's nothing that lacks. Like, um, that isn't intuitive about this score. They finally just put some numbers on risk. Factors like age hi NIH stroke scale and having a pre stroke, Independence or not being independent takes a pretty significant dive up at about a 10. So that's what the this group, which is a very small study, not well validated and definitely not something we use regularly in the emergency department, mostly because I don't think this is much worse. Much better than clinical gestalt, right? These are the people you look at, and you also agree that they are older and have a very high stroke scale that they are probably more likely to get an aspiration. Pneumonia. So what can we do to prevent, um, this is where the swallow evil comes in, right we harp it in the emergency department. Sometimes I think we don't really know why. And this is why, right? If patients fail that, we need to keep them MPO until they can get a more formal evaluation of their swallowing ability. Because aspiration pneumonia harms them. In addition to what's already going on in their brain, keeping patients mobile early is recommended to help prevent this. And then there's some argument about antibiotics sooner rather than later. That's been unproven, and it's generally not recommended that you give antibiotics to prevent this. Once the aspiration pneumonia exists, the argument between pneumonitis just irritation from what they've swallowed an actual Bacterial infection is a nuanced one. But generally antibiotics get given once it's proven right, but not prophylactically. So let's go back to this failure to protect an airway. Um, we're gonna go. We're gonna play a little game, I'm gonna show you some pictures and you're gonna tell me who's protecting the airway and who's not. Okay, so is this person protecting the airway? Probably not, but honestly, I've seen people Who look like this who are breathing just fine, and it's all their tongue. AM I still going to take this airway 100%. But are they protecting it? I don't know. This may fall more under that projected clinical course. Right. Is this person protecting the airway? I don't know, Right? He could be sleeping. He could be a case college kid who had a little bit too much fun, Right? Or he could be gurgling and not protecting his airway. His oxygen could be 60. There's no way to know by looking at him from the door. Is this person protecting the airway? No idea, Right. What about this person? This is actually a CT of one of my patients who, like, told me his life story. He was definitely protecting his airway. I was shocked to see t looked like this. So what I'm getting at is this isn't an easy assessment, right? It's not something an imaging study can tell you. It's not something that walking through the door can tell you. There's so many pieces of information you need, and we're gonna walk through what some of those in pieces of information might be that might help you make this decision. So we're gonna kind of do red light, yellow, light green light in this. So making the decision, I always look at vitals first, right? Vitals are vital for a reason. It's the first thing I asked my residents when they come, talk to me. What do they look like? And what are the vitals? So if your vitals are abnormal in a patient, significantly, you need to intervene. On their way again. Doesn't necessarily mean you need to put a tube through chords. Or you need to do something if they have hypoxia. If they have an a respiratory acidosis or if their respiratory rate is very high or very low, you need to do something. Whether that's a nasal cannula for the first one, whether it's a bi pap for the second one, whether it's some you know, some Narcan for certain patient populations or just supplementing oxygen to get a respiratory rate lower to lower. If someone who's a little air hungry, you need to do something that's a red light. That's a stop. Do something about it now. Some of them are nuanced. Ones are. What's the time course here? How quickly is this person changing? Are they changing very fast in front of you or has it been a little bit of a slow decline. And what's the trajectory? Right? Caesar patients are some of my favorite patients to talk about airway management in because the one person who is having one seizure just had one will come in looking like they need to be intubated. Right? Residents are always running around looking for the glide scope, looking for et tubes or get all excited. And if they're not still seizing, give them 10 minutes. This person is going to be talking to you, right? The trajectory of that person is only up, so they may need some supplemental oxygen. They may need a nasal cannula or a nasal trumpet to help them breathe through waking up. But their trajectory, time course and rate of change is what's important in making that airway decision For a stroke patient. If you know the 30 minutes ago they looked really well and now they're so generous or they're starting to get sleepy. That's someone you need to keep an eye on. When you think about their airway management very specifically for the emergency department and especially working out in the community, where is this human going to exist? you know, in a in A when you think about watching their airway, are they gonna exist in the back of an ambulance? When I was in residency, I did transport medicine. Back of ambulances, Back of helicopters. Worst place to intubate a patient. It's Loud. No one can hear breath sounds. Everybody's moving your drivers all over the place. So not a great place to do an airway. So you may consider taking an airway a little sooner than you would if it were going to stay in your emergency department. That's always part of our thoughts. How visible is this person? What's your nursing ratios? That's huge right now in the emergency department, right? Is this someone I can stand next to? And if they aren't tolerating, their secretions aren't tolerating, thereby path. I can make a decision, or is it someone that I can't keep an eye on? And I might make a different airway decision based on that and monitoring honestly right now in the E. D. Monitors are a commodity, and so how closely can I monitor whether this person is changing more rapidly than I thought also goes into this and then, you know, times where I might forego more definitive airway management. Always family wishes, right? We always try to have that conversation to explain why we might want a more definitively manage an airway. But if families don't want to, never going to force an ET tube down somebody who doesn't want it right and then things like and this is the discussion that doctor style and I had about a patient was he needed to get to throw it back to me. And as you guys all learned this morning and are going to continue learning throughout the day, time is brain. I don't think there's a situation in which doing an airway should to prevent you from giving t p A. But it definitely can stall getting to a definitive management like thrown back to me. I think this is going to become more and more of a conversation as we learn who gets thrown back to me more and more so, you know, deciding maybe we wait to manage this person's airway after they're thrown back to me is a discussion that we're continuing to have at the bedside, and I think it's going to push the boundaries of who were comfortable going to a throwback to me Sweet without something through their cords. Is it going to be a conversation we're going to continue to have? But that might be a reason I might stop not definitively manage support through that, not let them go hypoxic or hypercar pick, but support them through with less invasive measures. So, um, the emergency neural life support, um, list says that this these are reasons to consider intubating Someone has a huge issue with using GCS and stroke. It's not developed for stroke was developed as a research tool in traumatic brain injury. My least favorite thing is when my residents tell me a GCS of a stroke patient doesn't mean anything to me Right again. My case. Kids who drank a little bit too much have GCS of five. I'm not gonna intubate them right away, right. You should just let them sit on a pulse ox and wake up to regret being in the emergency department on their own. The G. C. S is a difficult one, they say a GCS less than nine in trauma. We say less than eight intubate, and that's a pretty hard and fast rule. But again, GCS was developed for that patient population. Not for this one. Signs of increased ICP sleepiness, vital sign abnormalities that would point you in that direction. Persistent vomiting. I'm more on board with maybe needing to take that person's airway. Persistent seizures that are becoming are refractory to normal treatment. I consider, you know, these imaging ones I have some difficulty with as well. I don't think I'd be sticking to these rules. I presented it because it's on a lot of the papers, but in practicality, I'm not going to let imaging decide an airway decision for me as we just when you saw what I walked through, what the C T looks like or what the MRI looks like has nothing to do with what I'm thinking right. We've all seen horrible MRIs and people who are protecting their airways, and we've seen minimal MRIs and people who aren't so. I don't think there's a direct correlation. This is just something to consider midline shift, you know, in a bad head bleeder swelling. I think you You Your exam is consistent with that, but we have people who have subdural with the bun shift, all the time that don't need their airways managed him urgently. So it's all. It's a lot of clinical Gasol. So the 2018 guidelines on management of of acute ischemic stroke overall do tell you that airway support is important in patients who have decreased consciousness and ball bar dysfunction, which we've kind of already said, but just good to know that the guidelines agree with us. They're not more specific than that, though. So let's talk about ways we can do this specifics about how we actually manage airways. So I think this is a spectrum, right? The things we do easily at the bedside are often aimed at oxygenation, right nasal cannula as venti masks, positioning of the patient, um, nasal trumpets. We love those in the emergency department to help deliver oxygen more directly past someone's big obstructive tonsils or whatever they have. I'm a big fan of, um, actually, a soap box of mine is a non rebreather to me, and non rebreather is is a bridge to something more definitive. My residents could get up here and tell you about myself box about this. To me, it's either you're waking up from your seizure or your overdose Or you're about to get intubated. If you need 15 liters of oxygen, you probably need more help than just a non rebreather. At least long term. It's a good it's good some. It's something that we use to temporize, but it should not be a definitive plan, right? My first thing, when a resident comes out of the room and says they're on a non rebreather, I said, What's your plan to get them off of that? The management guidelines say that if the patient is less than 94%, then we should be supplementing oxygen. But if they aren't leave them alone. There's no benefit to oxygen if they're already setting above 94%. Okay, so that's what the guidelines say. When we talk about supporting ventilation, it gets more invasive. We've all had a little more experience with things like like Arvo or high flow nasal cannula. Since Covid started, however, that might. That might support ventilation a tiny bit if the patient keeps their mouth closed. Maybe, but our main support of ventilation short of an ET tube in the emergency department, is noninvasive. Positive pressure, ventilation, right? That's the main ways we support a patient's ventilation. Positioning can also really help with patients ventilation as well. If they are in a trauma patient, you can set them up, get their chests to, like, slumped back down a little bit if they're obese. Um, that all helps a lot with ventilation and then protecting the airway. Unfortunately, we don't have a ton of options other than any T tube through someone's cord. So I really think of this as a spectrum. And the more help they need, the more invasive we get. And the more of these boxes they need checked, the more invasive invasive we get. So why don't we just intubate everybody right? My residence would love to. They'd be standing here with an 82, ready to intubate me if I would let them. Um, But it's not a benign procedure, right? The time is a whole separate conversation, I think probably one of the more important ones when it comes to stroke patients. Time to definitive management. But the procedure itself is not without its risks, right? 90% of critically intimations are technically successful, and that number seems high. But that is not high enough for me, right, Because unsuccessful airways mean, you know, surgical Airways, especially in t p A. Patients that get super complicated super fast, right? That means bagging a patient through an unsuccessful technical intubation until you can get more help. And at a community hospital and nobody coming up like nobody showing up, right, that's me. So 90% isn't as high as it might seem, but more importantly, 25% develop hypoxia or hypotension, which, in a stroke patient is extremely important, right? That's even more important than other critically ill patients. And over in about 2% of them actually suffer a cardiac arrest. So the procedure itself is not benign again. We talked about DeLay to definitive treatment, and I really tried hard to find a study that said what the delay of an intubation was on average, how long it takes. I can tell you on a good day, My team firing on all cylinders. Intubating a patient will take me 20 minutes Because I'm gonna do it right. I'm going to confirm a tube I'm gonna put sedation on. I'm gonna have to get a ventilator attached to it, right? It just I'm not gonna do it faster than 20 minutes, and that's on a good day. And then there are risks with actually being intubated, right? There's ventilator associated pneumonia. There's delay to OT and PT participation if they're sedated on a ventilator. And then there's ventilator in slung injury, which I'm gonna let um are Artie talk about here soon. Uh, I'm gonna leave that alone. But the risks of actually being intubated once the procedure is done or aren't without complication. So if we have to intubate somebody, what are we going to do? We're gonna pre oxygenate them. This is where I love non re breathers. Throw non rebreather on or a positive pressure ventilation at 100%. And we're gonna let them sit there for a couple minutes at 100% oxygen so we can avoid hypoxia when we integrate them. We're going to avoid hypertension. Depending on their vital signs. I may choose ketamine or accommodate ketamine. Actually giving us a little blood pressure boost to dominate being blood pressure neutral at the bedside. I'm going to have fluids or push those pressers so that if they become hypotensive, I can fix that rapidly. I'm ready for that because positive pressure ventilation in itself will cause some hypertension, Not to mention all the cattle cola means that you suppress when you take away someone's will to be alive, right? Their bodies saying, Save me, save me, you knock them out and their body doesn't care anymore. And now their blood pressure drops. Those are all known complications of trying to intubate somebody using rapid sequence intubation. And then, um, this was from the emergency neural life support. They specifically addressed endovascular therapy and there last one and said, Consider intubation before the therapy in these patients have significant ball bar dysfunction is very difficult to evaluate. I think one thing I'm going to say I meant to mention this at the beginning. If you get nothing from this lecture, please get that. The way to test this is not to stick something in the back of a patient's throat. That's my biggest fear, right, because someone may still have a gag reflex, but doesn't mean they're protecting their airway, right? And if you cause them to vomit and they're not actually protecting their airway, that just caused you just caused an aspiration pneumonia. So there are many ways to test bulb or dysfunction sticking something in the back of a attended patient's throat. Please don't do that. If you get nothing else in the lecture, that's what I want you to take away. So if you if they're not handling secretions, if there gurgling if they seem unable to cough, those might be reasons to consider definitive airway management. If they're hypoxic or hypercar Bic and it's not fixable by one of our less invasive adjuncts, then it's something to consider their persistently vomiting right, and they don't seem to be able to say, like I need a vomit bag. I'm gonna, you know, vomiting into a handbag very different than just throwing up and not seeming to be able to handle that and then agitation itself might be a reason to consider. That's really more about sedation than it is about their way. That's projected clinical course, right? This person is not going to lay on the table because they are too agitated. What do we need to do about it? So if you're going to intubate somebody, we're going to try to avoid hypoxia hypoxia afterwards, so we're gonna put them on an F. I 02. That will give us a set of 94% or higher, but we're not going to go above that. We're going to, uh, aim for normal ventilation. So not hypochondria or hypercar bia. And then we're going to try to prevent ventilator induced lung injury by using our 6-8 mils per kilo of ideal body weight. So, you know, I think I think, Dr Style. I was hoping I would come and say we could use by pap on everybody in stroke when she asked me to do this lecture because that was the discussion we've had multiple times. Um, and from a timing perspective, I totally agree. That is what we need to get to. His intubation definitely prevents us from getting too definitive therapy. As endovascular therapy becomes more and more prevalent. It's not. I went to the bottom of the Internet. I could not find a good study on it. Um, I think it probably has a temporary role in a monitored setting in certain patients, you know, endovascular therapy. There's a bunch or endovascular intervention. There's a bunch of people around who might be able to help protect the patient's airway. if they can't take the bi pap off if they throw up or if their secretions get too bad and they might be able to help. But as we get farther into a patient's care, they will have less and less people around them, so it may have a temporary role. But by definition it is contraindicated in patients who cannot protect their airway. But my argument to that is, I just spent 30 minutes telling you it's very difficult to define that person. So this is where how many people are around. Are their airway experts around? Is there an R T around who can help you make that decision and help mitigate the risks of having a mask that is blowing positive pressure into someone's face on them if they can't take it off themselves if they start to throw up or if their secretions get poor? So I think there's still more to come on this. It's not well studied, and I don't have a good answer for who this is indicated in in the emergency department. So just to go over our conclusions very briefly, it's a complicated decisions. Vital signs are vital. Know them intervene on them when they're abnormal. Your clinical scenario and evaluation of the ability to protect airway is going to help you decide about airway management. There may be decision rules. They're not great. We probably still have some work to do on those. You're going to actually choose to manage airways and stroke patients to prevent aspiration pneumonia and fix vital signs. And then, you know, noninvasive may play a role, but it hasn't been well studied. All right, here's my references. Thank you very much. Mm hmm. Okay, right. That was excellent. That was actually exactly what I was looking for. So we're gonna have you give that lecture over and over again. Um, so the second part of this is, uh, the respiratory monitoring protocol. Uh, so I'd like to welcome And Anthony Creen Oh, who's the coordinator of respiratory education at CMC? Anthony. All right. Thank you, Dr Rockso. All right, so, um, we're gonna go ahead and pretend here for a second. Um, that all of Dr Gross, those patients that we, um I saw from a respiratory standpoint ended up intubated. Okay, so we have to make the decision on where to go from there. but basically what we're going to talk about this morning is making the decision on where to go post intubation with our patients. Um, once we've made the decision to intubate them, um and then how we manage them from then on out, Eventually, we do want to get to the point of getting them off the ventilator. So we're going to talk very briefly on that as well. So, um, kicking it off here, your patient's intubated. Now, what do we do? Historically, the decision was made to intubate, uh, physicians nursing. We're all in the room. We're all doing our thing. And then post intubation mostly everyone disappears, right? And the ET tube is left in the hands and the ventilators left in the hands of the respiratory therapist. So, um, as a team, um, there's some things that we need to be doing immediately for monitoring. Um, right after intubation. One of those things is we need to be looking at our vital science. Um, it's very, very, um, Easy to kind of get focused on the patient's condition, be focused in on the et tube, get focused in on the fact that well, this could just consumed about 2025 minutes of our time. We've got to move on. We'll leave it in the hands of the respiratory therapist. However, um, intubation is they all practice skill. So we're all involved in this. We've got to be looking at our blood pressure to make sure that we didn't, um maybe drop that blood pressure during providing sedation. We should be looking at our pulse ox, making sure that that is back to an acceptable range. Um, we want to also order a chest x ray. This is paramount. Um, as clinicians, we will listen to breath sounds. We'll look at chest rise, but ultimately, we need a good place marker of where this, uh, intubation e t tube is placed in the first place. Um, as you can see my picture up there, This this patient received a right main stem intubation. So this was clearly in the wrong spot. But that's why we get that that confirmation immediately. And then comes the arterial blood gas. And when we when we induce someone for intubation, we remove all of their ability to manually ventilate or ventilate themselves. Okay, so we assume control of their ventilation um, by putting them on a machine and sedating them. So about an hour after intubation, we go ahead and we get a blood gas and kind of get a place marker of where we're at, and then we can use that place marker for, um monitoring or adjusting the ventilator from then on out. Um, once those initial interventions are taken place or have taken place, um, we then kind of go into maintenance mode from a respiratory care standpoint. Um, and this is where our nursing colleagues, our physician colleagues, uh, they'll see the rt sneak into the room every few hours, Um, punch them, punch some buttons on the ventilator, take a listen to breath sounds. And they're like, What? What in the world are they doing in there besides causing trouble? Um, but as you see on screen here, uh, that that ventilator track is is all encompassing. So we're doing a physical assessment of the patient we're taking. Listen to breath sounds that should be done with with every ventilator check as you will. Um, we're looking at the depth of the ET tube. We're making sure it's still secure. We're gonna listen for secretions we're gonna suction the patient if necessary. And then comes the part of data gathering and and I underline and analysis. Um, we can as RTs we can have a $5 cable plug into the back of the ventilator and transport all the data from the ventilator into EMR. But you need somebody who is familiar with that data to analyze the data and decide. Okay, is this ventilator and the rest of what we're doing for this patient the most appropriate for their condition. So we're looking at that data and there's a list there of Of what? All these mean. Unfortunately, for time's sake, I don't have time to go into detail for all of them. But we're looking at a lot of pressures, pressures of the air going into the patient's lungs both when it goes in when it evens out. Um, we're looking at the amount of air that goes in from a volume standpoint. We're also looking at the volume of air that comes back out. Um, we're gonna we're gonna look and see if there's any leak in the circuit, um, or in the airway. Um, maybe through the ET tube cuff, we're going to look at minute ventilation. We're gonna look at respiratory rate, and that's a combination of what we're giving the patient versus what they're doing. Um, on top of that and then we're going to look at something called airway resistance and lung compliance. Um, all of these things, Like I said, we can have these numbers auto populate into the into the EMR if we wanted to. But somebody really needs to take a look at that data. Trend it on a very regular basis every few hours and, um, take action if any of those numbers are off. So that may be notifying the team that may be changing ventilator settings. What have you. So, uh, and as mentioned, we're doing that just about every four hours, Um and then after any kind of significant events. So let's say we do a bedside trick or we transport the patient to CAT scan or what Have you were going to be doing one of these ventilator checks after that? So again, World War Tour here, we're gonna fast forward and we're gonna say All right, how do we know we've done these ventilator checks? We've monitored them for a day or two, sometimes a week or longer. How do we know when they're ready to come off of the ventilator? So there's a few things that we can readily assess at the bedside 1st, 1st and foremost, are they awake and alert? You know, in our neuro critical patients, this may be, um, something that it may never happen. They may never be alert and awake as much as we would like them to be, Um, so we have to kind of take that into consideration with our assessment. Are they following commands? Are they an sedation, or do they require any sedation? And then, as Dr Brosseau pointed out in in the very beginning of the discourse here, can they protect their own airway? Basically, we're looking at are all the things that caused them to be intubated in the first place resolved? If they're not, we really shouldn't be thinking about taking up that E t tube, and then we want the patient to have the drive to breathe, so we're gonna be making sure that they're breathing over the ventilator. There's certainly some contraindications to removing the ventilator, and this is part of our weaning protocol. Um, they're listed there. Um, any active, life threatening bleeding. We wouldn't want to be removing the et tube. Myocardial infarction. Um, if they're agitated, um, if they have some diminished inventory efforts meaning they're not going to be doing a very good job ventilating if the tube wasn't there And then, um, FIO two greater than or equal to 60%. That may be kind of difficult to manage off the ventilator. We can do it. But are we Are we maybe just creating more problems for ourselves? To where? If we gave them a day of, you know, uh, fluid removal that would be resolved GCS of five or lower if they're posturing. Um, if they're hemo dynamically unstable, we are unstable. We wouldn't want to take that breathing tube out. Um, if they're requiring a peep greater than eight, if they have a pulse ox less than or equal to 88% and then if they're requiring the oppressors. So, um, as you can see, this encompasses not just respiratory care concerns. But this is also this is a multi discipline, um, disciplinary assessment. So we rely on nursing. We rely on physicians to kind of provide us with that data so we can all make an educated decision together. So once we decide that we are ready to take that breathing tube out or are thinking about taking the breathing tube out, we're going to go through, uh, what's called a spontaneous breathing trial or we'll put them on a wean. A lot of times we refer to it as that, um, during that spontaneous breathing trial, we're gonna switch the ventilator mode over to what's called CPAP mode. We're going to give them just a little bit of peop a little bit of pressure support, Um, and essentially let them do most of the breathing on their own. Um, during that period of time, we're gonna monitor them as well. So we're going to look at their title Volume's their respiratory rate. Um, they're human dynamics. Um, you know, a good indication that somebody is failing. Weaning trial is if we see their heart rate go up and their blood pressure go up means they're not tolerating it very well. Generally, of course, we could see their blood pressure go the other direction when they really start to fail. Um, so it's something to keep in mind, uh, their mental status. Are they still remaining as calm as they were when we were providing the mechanical ventilation, or are they very anxious or panicked? Um, and then their overall patient appearance from just how they look, are they? Are they working hard to breathe? Do they look like they're using accessory muscles? Are they die? A heretic? Um, in my career, I've seen quite a few patients that you've put them on awaiting trial and you've said, How you doing? You know, and they're awake so they're responsive and they'll shake their head and not, and they're saying Good, because they really want that to about. But you see them using accessory muscles and they're profoundly diaphragmatic. And you're thinking, Yeah, I don't know that that's such a good idea not to call you a liar. But, you know, it's you don't quite look like you're ready to go, So we'll let them go on this winning trial for about 30 minutes, and that can last actually up to two hours. That's within our protocol to do. Um, once we've decided that they've passed their winning trial, um, we're actually going to get something called weaning parameters. Um, this is a mixture of values that kind of tell us, How good is this patient going to do in the absence of the tube and the ventilator? So we'll get some measurements here. Usually you can, you know, turn all of the support of the ventilator off, go to zero of peop and zero pressure support. But there's been some studies that show that, really the numbers aren't that much different on five and 5. Um, but those values include a spontaneous title volume. We're going to look at how much volume they can breathe in with a normal breath. Um, without the support of the ventilator, We're gonna make sure their respiratory rates less than 35 We're going to make sure their minute ventilation, which is their title volume, Multiplied by their respiratory rate. We're going to make sure that's less than 10 L. We're going to ask them to do what's called the vital capacity. So we're gonna ask them to take a gigantic deep breath in and blow it out so we can measure it. We're gonna get a calculation of the rapid, shallow breathing index. Um, what that is is is a calculation of their respiratory rate divided by their title volume in milliliters. And that gives us a number on the screen there, it says. We want that number to be less than 105. The lower the number, the better. So if they're approaching that 105 mark, that tells us that there's a pretty good indication that they may not do so well. Um, one value I accidentally left out of the slide here was our negative inflammatory force. And NIF um, we want to be able to see how strong, uh, someone's inventory muscles are to know if they can generate a cough, so we'll have them suck in on the breathing tube as hard as they can and measure those breathing muscles. And then one of the other, um, weaning parameters that in our ICU, we consider to be one of our weaning parameters, especially in our narrow issue. But it's not necessarily in our textbooks is the cuff leak test, and this is paramount for patients in the neuro, uh, the neuro world, because a lot of them end up intubated longer than your surgical patients do in a cardiothoracic I see or what have you. So what we're doing when we're looking at that is we're deflating the cuff around the ET tube. Um, we're, uh, at some point, including the et tube and seeing that they can breathe around it. And basically that's helping to eliminate the possibility that there's airway swelling or that if we took that ET tube out, that the airway would close down around it. So that's part of our we need parameters. So, uh, if all goes well, we excavate the patient. Okay, Um, now, in preparation for this for this discourse, um, you know, I was trying to think over material, and I was thinking, you know, wait a minute. We have this protocol in the respiratory care department at our hospital, and we use it on basically everybody universally, However, in the neural world, a lot of times, those weaning parameters aren't perfect. In fact, a lot of times they they're not. None of them are perfect. Yet we still excavate people. So a lot of that, a lot of that has to do with metals. However, um, there was a study done in 2009 that was published in neuro critical care journal that found that actually winning parameters in the neuro world are not a very good predictor of excavation failure. Um, and they compared patients at this one hospital and found that there really needs to be some other alternative weaning parameters created, um, for folks in the neural world. So, um, it's important to not get fixated, um, on making sure every number is perfect. Essentially. So a quick list of some of the alternative weaning parameters we can use maximum expository pressure. How good can they cough? We want to make sure that they're fluid volume status is good. We want to make sure they're not fluid overloaded prior to X debating them. We want to consider making sure they don't have a lot of secretions because if they do, that's going to become a management issue, post excavation and then provider discretion. We all as a team need to discuss and say, Hey, do we think this is a good idea whether the winning planners look a certain way or not? So, in conclusion, as mentioned, um, we do have a protocol for obtaining weaning parameters. However, um, with our neuro patients. We may have to vary from that and come up with a good clinical decision based on alternative winning parameters and references at the end. Here. Thank you. Yeah, sure. He will take some questions we should spend held up in the emergency room because it's just not safe for them to come to euro angio further thrown back to me because their airway is not protected. And the main point that hit me that you made was having people around the patient to take that mask off that they can't because there draped under under, um, plastic on the table. And we have, especially in the middle of the night. One nurse, one fellow, one attending one tech. And we're trying to do everything in the room. So to get to them quickly, that mask would really be not a good situation in the in the angio suite. Yeah, I think that's the concern we have as well. Um, I think enough of us have spent time, at least, you know, as a resident, we spend some time in that area. We hear stories from you know what's available as far as far as monitoring. So I think That's one of the concerns. And I think that probably leads people to, you know, definitively manage airways a little bit more because then at least that they take that question off the table. The question is the risk benefit of the time it takes to take that question off the table. Um, and you know, I think as we go forward developing some more definitive protocols around, you know, do we put the by pep on, and then where it would take 20 minutes to, you know, intubate a patient. We take five minutes and watch them. And make sure, you know, I think a vomiting patient is your worst scenario there. You know, any time we mess with the brain, people get nauseous, right? So I think it's not. That's not a small amount of this population, so we definitely have to do both. Make sure the people in your world are comfortable with troubleshooting that and having enough people in there to do it. If we were going to do this more often. I think if we're going to be more risky about who we send to you without a definitive airway, um, I think ultimately most people are probably fine. Um, with that bi pap on. But those people who vomit into it are probably your highest risk people. The people who aren't handling their secretions. They may be fine for 30 minutes. Honestly, um, maybe micro aspirating for 30 minutes when you are considering the risk of delaying getting their brain Reaper fused is a nuanced but important conversation. But the vomiting ones are who we have to worry about. Mhm for sure. What about going to MRI? Yeah, we do. We talk about this, Um, not infrequently. I think it's a constant conversation between your team and my team about who is safe to go to Emory and who's not. Because memory is fairly unmonitored. Unless we can spare any d nurse, which is, you know, becoming harder and harder to do. Um, you know, I think bi pap machine can go to m R. I. No, actually, they can't. Now, the MRI ventilator that we do have is capable of publishing over into non invasive ventilation. Okay, I know I've sent patient's on bypass, but they have to be with monitors. So monitors and someone to help troubleshoot. And as we know, staffing is usually the real limiting step there. Yeah, all challenges. Yeah. You know, I think laying flat is so insignificant to most of us and to the neurologically challenged patient, both stroke and also, you know, jamboree and my senior gravis. And, you know, blank flat is not an insignificant thing. And unfortunately for a lot of these procedures, I assume they have to lay flat in the in. Just we haven't been there in a while, but I remember from what I remember and Mari demands, you know, unless we're doing a portable one demands laying flat. So it's a doing. A trial of laying flat is something we talk a lot about. You know, let's lay them flat for five minutes in the E d. Put him, Keep him on a monitor stand next to him, make sure it's going to go okay and then let him go. There is one question in the chat. What about using an extra galactic airway like eye gel? Yeah, that's fascinating. That's a whole another conversation. Um, I like that as a temporary option. I don't think in my practical experience that that minimizes the amount of time in the idea if that's the rate limiting step, right, in theory, that should block some aspiration. If we're using the right ones, that should allow for sedation and say, you know, we do. They put extra galactic airways and in the oh, are all the time and sedate patients completely. Um, in my experience, that still takes, You know, I don't think the rate limiting step Time wise is actually getting a tube through the cords. That takes 30 seconds, right? You still probably for most patients need to paralyze them. If you're going to use an eye gel, they need propofol on. They're gonna need, you know, the same ventilator and vital sign management. Um, so to me, that doesn't minimize time very much. It's definitely a thought where the procedure of intervention or the procedure of an MRI is what is going to cause this person's airway to fail, not the disease process. Um, there are a lot of institutions around the country who are keeping extra galactic devices that are put in by the field in their patients for days, and they're showing that it's pretty safe to do. Um, those are in the South. They're doing that with post cardiac arrest patients. They just keep the Nigel in for a couple of days and until they decide where they're going from a narrow perspective, I don't think it's been studied in stroke, and most stroke patients are awake enough that they're not going to tolerate that in their face without a significant sedation and paralysis. So, you know, anecdotally, I don't think it would decrease the amount of time, but it's definitely something to look at. All right, well, thank you very much. So more to come. We'll probably have an update in the future conferences.