Australian Critical Care xxx (xxxx) xxx

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Australian Critical Care

journal homepage: www.elsevier.com/locate/aucc

Research paper

Construction of an extubation protocol for adult tracheal intubation

patients in the intensive care unit: A Delphi study
Li Wang, MN, RN a, e, Qin Zhang, MN, RN b, e, Danyang Guo, BN, RN c, Zaichun Pu, BN, RN c,
Lele Li, BN, RN c, Ziji Fang, BN, RN c, Xiaoli Liu, MN, RN d, **, Ping Jia, BN, MM, RN a, *
a
Department of Neurosurgery Nursing, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China;
b
Department of General Ward Nursing, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China;
c
University of Electronic Science and Technology of China, PR China; d Department of ICU, Deyang People's Hospital, Deyang Sichuan, PR China

article information a b s t r a c t

Article history: Objective: The objective of this study was to develop an extubation practice protocol for adult intensive
Received 21 April 2024 care unit (ICU) patients who underwent endotracheal intubation, providing theoretical guidance for
Received in revised form clinical extubation procedures in the ICU.
20 August 2024
Methods: A research team was established consisting of medical, nursing, anaesthesia, and respiratory
Accepted 21 August 2024
therapy professionals; the multidisciplinary team systematically searched domestic and foreign litera-
ture, summarised the best evidence, and combined it with clinical practice experience to preliminarily
Keywords:
develop an extubation protocol for adult ICU patients who underwent endotracheal intubation. Seven-
Endotracheal intubation
Airway extubation
teen experts in critical care medicine, intensive care nursing, clinical anaesthesia, and respiratory therapy
Delphi method were invited to participate in a Delphi expert consultation to screen and modify the draft protocol.
Critical care nursing Results: The response rates of the two Delphi expert enquiries were 100% and 94.1%, with expert au-
thority coefficients of 0.94 and 0.93, respectively, and Kendall's concordance coefficients were 0.152 and
0.198, respectively, indicating statistically significant differences (p < 0.001). The final protocol included
three level I indicators, 14 level II indicators, and 34 level III indicators, covering extubation evaluation,
implementation, and postextubation management.
Conclusion: The extubation protocol for adult tracheal intubation patients in the ICU constructed in this
study is scientific, practical, and reliable. This study can provide theoretical guidance for extubation in
ICU patients who have undergone endotracheal intubation.
© 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction length of hospital stay, medical costs, and mortality.7 Research

showed8 that a comprehensive protocol for ventilator weaning and
Invasive mechanical ventilation (IMV) is an important means of extubation may prevent respiratory failure and reintubation and
life support. Every year, millions of critically ill adult patients reduce mortality in critically ill patients. Standardising the process
worldwide receive IMV treatment.1 Extubation refers to the of extubation and ventilator weaning can significantly reduce var-
removal of an endotracheal tube2 from the trachea, which is the last iations in medical staff judgement and the risk of respiratory failure
step in liberating a patient from the mechanical ventilation. The after extubation. Several countries abroad have already established
incidence of extubation failure in patients with IMV is 13.7%e guidelines related to the extubation of critically ill patients.9e11 The
25.7%,3e6 and extubation failure increases the duration of IMV, domestic initiation of IMV started relatively late. The expert
consensus on tracheal tube removal formulated by the Anesthesi-
ology Branch of the Chinese Medical Association12 mainly applies
* Corresponding author at: Department of Neurosurgery Nursing, Sichuan Pro- to postanesthesia patients and is not suitable for intensive care unit
vincial People's Hospital, University of Electronic Science and Technology of China, (ICU) patients with prolonged intubation time, severe conditions,
Chengdu, Sichuan, PR China. and multiple complications. Therefore, the aim of our study was to
** Corresponding author at: Department of ICU, Deyang People's Hospital, Deyang,
develop a localised extubation protocol for adult ICU patients with
PR China.
E-mail addresses: [email protected] (X. Liu), [email protected] (P. Jia). tracheal intubation that can improve evidence-based clinical
e
Li Wang and Qin Zhang contributed equally to this work. practices and increase the success rate of extubation.

https://doi.org/10.1016/j.aucc.2024.08.007
1036-7314/© 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: Wang L et al., Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A
Delphi study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.007
2 L. Wang et al. / Australian Critical Care xxx (xxxx) xxx

2. Methods evaluation tools of the Joanna Briggs Institute evidence-based

practice. Through a preliminary search, 2186 studies were ob-
2.1. Theoretic framework tained. After duplication, preliminary screening, rescreening, and
literature quality evaluation, 19 studies were ultimately included,
This study was guided by the Knowledge to Action Framework including one clinical decision,2 12 clinical
(KTA).13 KTA emphasises careful planning and tailored imple- guidelines, 9e11,14e22
three expert consensus,12,23,24 and three evi-
mentation strategies to improve the feasibility and clinical rele- dence summaries.25e27
vance of evidence-based practices. KTA consists of two
interconnected parts: knowledge creation and action cycle.
Knowledge creation includes identifying a problem, literature re- 2.3.4. Forming the preliminary protocol
view, and summarising the best evidence. The action cycle consists Two researchers independently extracted evidence from the
of six parts: adapt knowledge to local context; assess barriers to included literature. When conflicting evidence from different
knowledge use; select, tailor, and implement interventions to sources arose, the principle of prioritising high-quality, recently
promote the use of knowledge; monitor knowledge use; evaluate published, and authoritative literature was followed. Based on
the outcomes of using the knowledge; and sustain ongoing existing clinical experience, the evidence was classified, summar-
knowledge use. ised, and organised. After discussion within the research team, a
preliminary extubation protocol for ICU patients who underwent
2.2. Set up a research group endotracheal intubation was developed, consisting of three first-
level items, 14 s-level items, and 31 third-level items.
The study team consisted of eight members: one chief physician,
one chief nurse, one deputy chief anaesthesiologist, two ICU
2.4. Delphi expert inquiry
speciality nurses, and three master's students in nursing. The chief
nurse was responsible for coordinating arrangements and selecting
2.4.1. Designing expert consultation questionnaires
experts. Other team members were assigned tasks based on their
The expert inquiry questionnaire consists of three parts: (i)
expertise, such as literature review, evidence synthesis, draughting
introduction, including the background, purpose, significance of
proposals, preparing questionnaires, collecting data, and analysing
the study, instructions for filling out the questionnaire, and feed-
information.
back deadlines; (ii) an expert rating scale: three first-level items,
14 second-level items, and 31 third-level items were included. The
2.3. Constructing the preliminary draft of the extubation protocol
experts were asked to judge the importance of each item based on
their theoretical and practical experience using a 5-point Likert
2.3.1. Literature search
scale (very unimportant ¼ 1 point, unimportant ¼ 2 points,
The following databases were searched: UpToDate, BMJ Best
average ¼ 3 points, important ¼ 4 points, very important ¼ 5
Practice, Joanna Briggs Institute, Cochrane Library, PubMed,
points). The “Modify”, “Delete”, and “Add” columns were set up,
Embase, Web of Science, CINAHL Complete, CNKI, Wanfang data-
and the experts were asked to modify and add to the entries. (iii)
base, Sinomed, and other databases; Medlive, National Guideline
The basic information questionnaire of the experts, including the
Clearinghouse, Canadian Medical Association: Clinical Practice
general information of the experts, the familiarity with the ques-
Guideline (CMA Infobase), Scottish Intercollegiate Guidelines
tions of this letter, and the basis for judgement.
Network, New Zealand Guidelines Group, National Institute for
Health and Care Excellence, Guidelines International Network, and
other guide websites; and Websites of Professional Associations 2.4.2. Selecting the consulting experts
such as the American College of Critical Care Medicine, the Amer- The inclusion criteria used for the selection of experts were as
ican Association of Critical Care Nurses, and the Chinese Medical follows: (i) engaged in critical care medicine, intensive care
Association. The key words used were “airway extubation”, nursing, clinical anaesthesia, or respiratory therapy; (ii) having >10
“tracheal extubation”, “ntratracheal extubation”, and “endotracheal years of working experience in a tertiary hospital; (iii) nursing
extubation”, and the search deadline was from database estab- experts and respiratory therapy specialists should have a bachelor's
lishment to June 2023. degree or higher and hold at least a mid-level professional title; (iv)
medical and anaesthesia experts should have a master's degree or
2.3.2. Criteria for inclusion and exclusion of literature higher and a senior professional title; and (v)voluntary participa-
Literature inclusion criteria: (i) the study participants were pa- tion in this study.
tients with tracheal intubation, aged
18 years and (ii) the research
types include guidelines, expert consensus, systematic evaluation,
evidence summary, clinical decision-making, recommended prac- 2.4.3. Implementation of expert consultation
tices, randomised controlled trials, and quasi-experimental studies. From July to August 2023, expert consultations were conducted
The literature exclusion criteria were as follows: (i) incomplete by distributing and collecting electronic questionnaires via WeChat.
information, duplicate publications, or inability to obtain full text; After the questionnaires were distributed, reminders were sent to
(ii) non-Chinese or English-language literature; (iii) translated ensure that each round of consultations was collected within 2
versions or literature with updated versions; and (iv) low-quality weeks. Following the first round of consultations, the research team
literature. members reviewed the latest literature, held meetings, and modi-
fied, deleted, added, and adjusted items based on expert opinions
2.3.3. Literature screening and quality assessment and item selection criteria to create the second round of expert
The literature search, literature screening, and quality assess- consultation. After two rounds of consultations, expert opinions
ment were independently conducted by two researchers. The converged, and the consultations were concluded. The criteria for
updated version of the Appraisal of Guidelines for Research and item deletion were as follows: an average importance score of <4.0,
Evaluation II (2017) was used to evaluate the guidelines, whereas a full-score percentage of <50%, or the coefficient of variation (CV)
other types of literature were evaluated by the corresponding being >0.25.

Please cite this article as: Wang L et al., Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A
Delphi study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.007
 L. Wang et al. / Australian Critical Care xxx (xxxx) xxx 3

2.5. Statistical methods collected, with an effective response rate of 94.12%. Four experts
proposed modification suggestions. In this study, the expert
IBM SPSS Statistics for Windows Version 25.0 (IBM Corp: consultation Cs values were 0.96 and 0.95, both the Ca values were
Armonk, NY) was used for statistical analysis of the data. Count data 0.91, and the Cr values were 0.94 and 0.93, indicating that the au-
were described by the frequency and composition ratio, and nor- thority of the experts was high.
mally distributed measurement data were described by the
mean ± standard deviation. The enthusiasm of the experts was 3.3. Coordination degree of expert opinion
reflected by the questionnaire recovery rate and suggestion rate.
The authority degree of experts was quantified by the authority In the first round of expert consultation, the item's importance
coefficient (Cr), which is the average of the judgement basis coef- rating was 3.94e5.00, the standard deviation was 0e1.24, and the
ficient (Ca) and the coefficient of familiarity (Cs); Cr > 0.7 is the CV was 0e0.31. In the second round of expert consultations, the
ideal authority degree. The coordination degree of expert opinions item's importance rating was 4.06e5.00, the standard deviation
was expressed by the CV and the Kendall W coefficient, and the was 0e1.19, and the CV was 0e0.27. The Kendall harmony co-
concentration degree of expert opinions was determined by efficients of the two rounds of correspondence were 0.152 and
calculating the mean of item importance assignment and the full- 0.198, respectively (both p < 0.001), indicating that the degree of
score ratio. coordination of the experts was high. After two rounds of consul-
tations, the experts' opinions tended to be consistent.
2.6. Ethical considerations
3.4. Results of the first round of Delphi expert consultation
Before the study, ethical approval was acquired from Sichuan
Provincial People's Hospital. Experts who met the inclusion and After Delphi Round I, the entry was revised as follows:
exclusion criteria provided informed consent and were invited to
participate in this study. (i) Deleted two second-level items, added two second-level
items, and modified five second-level items. Items with a
CV value >0.25 under “time selection” were deleted. The
3. Results
experts suggested that “general conditions” were too general
and that they should be refined to include “ability for
3.1. General information of the experts
autonomous breathing”, “patency of the airway glottis”, and
“improvement of the primary disease causing acute respi-
A total of 17 experts were consulted; they came from five cities:
ratory failure”. After group discussion, two new second-level
Beijing, Chongqing, Shanghai, Chengdu, and Luzhou. The general
items were added: “spontaneous breathing trial” and “de-
information of the experts who participated in the study is shown
gree of airway patency”. The experts thought that “extuba-
in Table 1.
tion risk” was unclear, so after discussion, it was changed to
“reintubation risk”. The experts also suggested that, based on
3.2. Enthusiasm and authority of experts the risk assessment of extubation failure in patients, appro-
priate respiratory support should be chosen after extubation
In the first round, 17 questionnaires were distributed, and 17 instead of solely oxygen support. Following expert advice,
questionnaires were recovered, with an effective recovery rate of “personnel preparation” was changed to “operator prepara-
100%. Twelve experts provided suggestions for modification. In the tion”, “patient position” was changed to “patient prepara-
second round, 17 questionnaires were distributed, and 16 were tion”, and “airway clearance” and “oxygen reserve” were
merged into “airway preparation".
Table 1 (ii) Deleted four third-level items, added two third-level items,
General information of the experts in the Delphi study (n ¼ 17). and modified 14 third-level items. The CV value of item 1.5.6
was greater than 0.25, and this item was deleted. Item 1.1.3
characteristics Mean (SD) or n (%)
“Metabolic stability, electrolyte, and acid‒base balance” was
Age (y) 43.06 (4.75) considered by experts to be “not a necessary condition for
Sex
Male 5 (29.41)
extubation assessment” and was removed. In addition, some
Female 12 (70.59) items that experts believed were repetitive were removed.
Level of education The experts suggested “to add the ability of autonomous
Bachelor's degree 7 (41.18) breathing in the general condition assessment”, which was
Master's degree 7 (41.18)
adopted after group discussion. The experts also recom-
Doctor's degree 3 (17.65)
Specialty mended “adding aerosolized humidification to airway man-
Critical care medicine 5 (29.41) agement”. After reviewing the literature, the research group
Critical care Nursing 6 (35.29) added two items: “Aerosolized bronchodilators and expec-
Clinical anaesthesia 4 (23.53) torants can be used after extubation to humidify the airway,
Respiratory therapy 2 (11.76)
Professional title
dilute sputum, and promote sputum drainage” and “In the
Intermediate title 2 (11.76) case of upper airway obstruction or wheezing, aerosolized
Subsenior professional title 12 (50.59) corticosteroids can reduce airway oedema”. The experts
Senior professional title 3 (17.65) suggested that the evaluation of cough ability and airway
Department
secretions in item 1.4.1 should be divided into two separate
ICU 11 (23.53)
NICU 2 (11.76) items. Similarly, item 1.4.2 should be divided into two
Anaesthesiology 4 (23.53) separate items for airway patency and cuff leak test because
Years of working experiences (y) 19.24 (5.60) they are two different points, and both are crucial. For item
ICU: intensive care unit; NICU: neurosurgery intensive care unit; SD: standard de- 2.2.1, the experts suggested that the anaesthesiologists or ICU
viation; y: years. physicians should be qualified for endotracheal intubation.

Please cite this article as: Wang L et al., Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A
Delphi study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.007
4 L. Wang et al. / Australian Critical Care xxx (xxxx) xxx

After group discussion, it was revised to “For patients at a wording of item 3.2.2 was changed to “for those who cannot
high risk of extubation failure or postextubation stridor, at expectorate effectively, fiberoptic bronchoscopy should be
least one skilled physician in endotracheal intubation should used for sputum suction under visual conditions; if there is
be present”. For item 2.2.3, the experts recommended adding no fiberoptic bronchoscope, it is recommended to use No.
“informing the patient's family about the potential risk of 8e10 sputum suction, which can better avoid airway injury”.
reintubation”. According to item 3.2.2, the experts suggested
that “for those who cannot expectorate effectively, fiberoptic
bronchoscopy should be used directly; the reverse suctioning 3.5. Results of the second round of Delphi expert consultation
of sputum suction tube can easily lead to lower airway
pollution and even the aggravation of epiglottis and glottis After Delphi Round II, no items were deleted or added, and three
oedema” and the “children's sputum suction tube” should be third-level items were modified. The experts suggested adding
changed to “the No. 8e10 sputum suction tube”. After the “appropriate partial pressure of carbon dioxide” to item 1.1.3. The
panel discussion, the expert's opinions were adopted. The experts believed that “the cost of using goggles and face screens for

Table 2
Items and their weights in the extubation protocol.

Subjects Importance value (Mean ± SD) Full-score ratio (%) CV

1. Extubation assessment 5.00 100 0.00

1.1 General situation 4.69 ± 0.48 70.59 0.10
1.1.1 Improvement or removal of the causes of IMV 4.81 ± 0.40 82.35 0.08
1.1.2 The ability to breathe regularly and autonomously to ensure adequate gas 4.94 ± 0.25 94.12 0.05
exchange.
1.1.3 Adequate oxygen supply (PaO2/FiO2
150e200 mmHg or SaO2
90% 4.94 ± 0.25 94.12 0.05
when FiO2  40%e50%, PEEP  5e8 cmH2O), pH > 7.25, appropriate partial
pressure of carbon dioxide.
1.1.4 Hemodynamically stable, no active myocardial ischaemia, no or low-dose 4.81 ± 0.40 82.35 0.08
vasopressors (such as dopamine or dobutamine < 5 mcg/kg/min or
norepinephrine < 0.1 mcg/kg/min), mean arterial pressure > 60 mmHg, and/
or 90 mmHg < systolic pressure < 180 mmHg, or within the patient's baseline
level.
1.1.5 Patients are conscious or easy to wake up and are able to follow the 4.81 ± 0.40 82.35 0.08
instructions (open eyes, look after, shake hands, look up, etc.); for
neurologically severe patients, the GCS score is
8 points.
1.2 SBT: pass the SBT of 30 min ~ e2 h. 4.81 ± 0.40 82.35 0.08
1.3 Airway patency 5.00 100 0
1.3.1 Assess the airway patency, patients with one or more risk factors for 4.94 ± 0.25 94.12 0.05
wheezing after extubation should undergo a cuff leak test.
1.3.2 For patients with a cuff leak volume < 110 mL or <24% tidal volume, short- 4.56 ± 0.63 70.59 0.14
term corticosteroid therapy should be administered 4 h before extubation or
earlier.
1.4 Airway protection capability 4.94 ± 0.25 94.12 0.05
1.4.1 Adequate cough capacity (cough peak expiratory flow rate > 60 L/min or 4.81 ± 0.40 82.35 0.08
the white card test is positive or having spontaneous coughing.)
1.4.2 The airway secretions are not abundant (suctioning frequency < 1 time/2 4.75 ± 0.45 76.47 0.09
e3 h or sputum volume < 2.5 mL/h)
1.5 Risk of reintubation 4.75 ± 0.45 76.47 0.09
1.5.1 Assess whether it is a high-risk patient for failed extubation. 4.81 ± 0.40 82.35 0.08
1.5.2 Assess whether it is a difficult airway 4.81 ± 0.40 82.35 0.08
2. Conduct extubation 4.81 ± 0.40 88.24 0.08
2.1 Preparation of instruments 4.88 ± 0.34 88.23 0.07
2.1.1 Materials for extubation: suction tube, suction device, 5-mL syringe, 4.69 ± 0.48 70.59 0.10
oxygen therapy device, gloves, prepare face screen/goggles, isolation suit/
protective clothing as needed
2.1.2 Emergent medicine, material, and reintubation equipment must be readily 4.94 ± 0.25 94.12 0.05
available and in good condition.
2.1.3 Patients at a high risk of extubation failure may require preparation of 4.69 ± 0.48 70.59 0.10
noninvasive ventilators or high-flow oxygen therapy devices, according to
the situation depending on the situation.
2.2 Operator preparation 4.69 ± 0.60 82.35 0.12
2.2.1 At least two qualified and experienced medical staff members are required 4.94 ± 0.25 94.12 0.05
for extubation. For patients with difficult airways or at high risk of extubation
failure, an additional skilled physician proficient in endotracheal intubation
should also be present.
2.2.2 Standard preventive measures are taken for all patients, including gloves, 4.44 ± 0.89 64.71 0.2
masks, wearing protective goggles or face shields as necessary, as well as
wearing isolation or protective clothing.
2.2.3 Explaining operational procedures to the patient, obtaining consent and 4.5 ± 0.63 58.82 0.14
cooperation, and informing the family about the potential risks of
reintubation.
2.3 Patient preparation: raise the head of the bed by 45 or take a half-seated 4.75 ± 0.45 94.12 0.09
position, patients with doubts about stomach emptiness should use a left-
side supine position and be prepared to exercise according to instructions.

Please cite this article as: Wang L et al., Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A
Delphi study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.007
 L. Wang et al. / Australian Critical Care xxx (xxxx) xxx 5

Table 2 (continued )

Subjects Importance value (Mean ± SD) Full-score ratio (%) CV

2.4 Airway preparation 5.00 100 0

2.4.1 Sputum suction: fully aspirate the patient's mouth, nose, pharynx, 4.81 ± 0.75 94.12 0.15
subglottic, and lower respiratory secretions. The outer diameter of the
suction tube should not exceed 50% of the inner diameter of the tracheal tube
The suction negative pressure should be controlled between 80
and 150 mmHg. If the sputum is viscous, the negative pressure can be
appropriately increased.
2.4.2 Oxygen supply: provide high-concentration oxygen before extubation to 4.56 ± 0.63 64.71 0.14
ensure an adequate oxygen reserve; if possible, continue to supplement
oxygen during the extubation process.
2.5 Remove tracheal intubation: use positive-pressure method to remove 4.75 ± 0.45 76.47 0.09
tracheal intubation.
3. Postextubation management 4.88 ± 0.34 88.24 0.07
3.1 Respiratory Support 4.75 ± 0.45 76.47 0.09
3.1.1 For most patients with a low risk of reintubation, conventional oxygen 4.56 ± 0.63 64.71 0.14
therapy is recommended.
3.1.2 NIV or HFNC is not commonly used to prevent reintubation after 4.69 ± 0.48 70.59 0.10
extubation, but in patients with a high risk of respiratory complications
postextubation, NIV or HFNC is recommended for sequential treatment.
3.1.3 For patients with a high risk of extubation failure (hypercapnia, chronic 4.81 ± 0.40 82.35 0.08
heart and respiratory diseases, elderly patients), prophylactic use of NIV after
extubation can reduce the risk of acute respiratory failure.
3.1.4 Patients who are intolerant to NIV, have hypoxaemic respiratory failure, or 4.44 ± 0.81 76.47 0.15
require high oxygen levels can be treated with HFNC.
3.2 Airway management 4.81 ± 0.40 82.35 0.08
3.2.1 Encourage the patient to breathe deeply and cough effectively, and can 4.56 ± 0.73 70.59 0.16
stimulate the superior sternal fossa to cough up the sputum in the deep part
of the airway.
3.2.2 For patients unable to effectively cough up phlegm, fiberoptic 4.69 ± 0.48 70.59 0.10
bronchoscopy is recommended to aspirate sputum under visible conditions;
When there is no fiberoptic bronchoscope, using number 8e10 sputum
suction tubes for effective suction, which can better avoid airway damage.
3.2.3 After extubation, bronchodilators and expectorants can be nebulised to 4.69 ± 0.48 70.59 0.1
humidify the airway, thin mucus, and promote mucus clearance.
3.2.3 If a patient experiences upper airway obstruction or wheezing, systemic 4.13 ± 0.96 52.94 0.23
application of glucocorticoid and atomised adrenocortical hormone can
reduce respiratory tract oedema.
3.2.4 Good pain management can optimise postoperative respiratory function, 4.62 ± 0.50 62.71 0.23
pain management should be individualised, and sedatives should be used
cautiously.
3.3 Clinical observation 4.88 ± 0.34 88.24 0.07
3.3.1 Key monitoring after extubation: vital signs, consciousness, muscle 5.0 100 0
strength, haemodynamics, sputum production capacity, airway patency,
auscultation results, respiratory function, SpO2, etc.
3.3.2 If conditions permit, monitoring end-tidal CO2 can help detect airway 5.0 100 0
obstruction early.
3.4 Recording and handover 4.63 ± 0.62 70.59 0.13
3.4.1 Record the time of extubation: if the patient has a difficult airway, the 4.81 ± 0.40 82.35 0.08
presence and cause of the difficult airway should also be recorded
3.4.2 Do good handover, which can guide and improve future care. 4.81 ± 0.40 82.35 0.08

CO2, carbon dioxide; ETT, entotrachial tube; FiO2, fraction of inspired oxygen; GCS, Glasgow Coma Scale; HFNC, high-flow nasal cannula; IMV, invasive mechanical ventilation;
mcg, microgramsl; NIV, noninvasive ventilation; PaO2, partial pressure of arterial oxygen; PEEP, positive end-expiratory pressure; SBT, spontaneous breathing test; SpO2, pulse
oxygen saturation.

all patients during extubation may be relatively high”, so face the methods of spontaneous breathing test; what strategy to use
screens/goggles and isolation clothing/protective clothing were for patients who fail one or more aspect of the extubation readiness
changed to be prepared on demand. The experts suggested assessment; whether or not to cease nasogastric feeding prior to a
changing item 3.1.4 to “a high-flow nasal cannula can be used for trial of extubation; the timing of tracheotomy to facilitate weaning
patients who are intolerant of noninvasive ventilation, have hyp- from invasive respiratory support, etc.
oxic respiratory failure, or have a high oxygen demand".
After two rounds of expert consultations, an extubation protocol 4. Discussion
for adult tracheal intubation patients in the ICU was developed,
consisting of three primary items, 14 secondary items, and 31 ter- 4.1. The importance and necessity of developing extubation
tiary items, as shown in Table 2. This extubation protocol is a dy- protocols for adult ICU patients
namic and continuous process, which mainly includes specific
implementation details of extubation assessment, extubation Extubation is a transition from the controlled to the uncon-
implementation, and postextubation management. It does not trolled stage, and it's a high-risk stage for ICU patients on me-
involve the following aspects: the management of pain, agitation, chanical ventilation. Postextubation complications such as
and delirium in patients with IMV and the management of fluid; breathing difficulties, laryngeal edema, and airway spasms pose
the optimal methods of weaning from invasive respiratory support; serious threats to patients' life.25 A survey showed that many

Please cite this article as: Wang L et al., Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A
Delphi study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.007
6 L. Wang et al. / Australian Critical Care xxx (xxxx) xxx

patients who successfully passed a spontaneous breathing test are 5. Limitations

not extubated in a timely manner;28 factors perceived to contribute
to extubation delays most commonly included spontaneous This study only developed the protocol, and it has not yet been
breathing test timing, low provider confidence levels in making applied. Future research we will apply the protocol to clinical
extubation decisions, and patient-specific factors.29 Therefore, practice to verify its effectiveness and practicality and to gradually
developing a comprehensive and sensitive extubation readiness improve the protocol.
bundles are key to balancing the competing risks of prolonged IMV
and extubation failure.30 The 2022 American College of Anesthe- 6. Conclusion
siologists Difficult Airway Management Practice Guidelines14 also
suggested having a pre-established strategy for extubation and This study presents the construction of an extubation protocol
airway management to improve the success rates. On the other for adult ICU patients who underwent tracheal intubation that
hand, many medical staff participated in the decision-making and consists of three primary items, 14 secondary items, and 31 tertiary
implementation of extubation. In North America, respiratory ther- items. The methods adopted in this study were scientific and
apists dominated weaning screening assessment and actual extu- reasonable, and the process was rigorous and reliable. The protocol
bation, whereas in the UK, Australia, and New Zealand, these is scientific and comprehensive and can provide theoretical guid-
operations were mainly led by nurses. Across these regions, the ance for the practice of extubation in adult patients who have un-
decision to extubate was mainly made by attending intensivists.28 A dergone tracheal intubation in the ICU.
survey conducted in 20 Asian countries or regions in 2021 showed
that attending intensivists, consultant intensivists, senior trainees,
Funding
junior trainees, respiratory therapists, and nurses were involved in
extubation decision-making and actual extubation to varying de-
Key Research and Development Project of Sichuan Provincial
grees.31 There is a shortage of respiratory therapists in our country,
Science and Technology Department (Investigation of the Devel-
and 43.9% of respiratory therapists are transferred from nurses after
opment and Implementation of a Tracheal Tube Extubation Pro-
6 months of on-the-job training.32 The decision to extubate is
gram in the Intensive Care Unit within a Multidisciplinary
mainly made by the intensivists, and the extubation operation is
Team Model; Project Number: 2023YFS007).
mainly performed by nurses. It was suggested to develop a clear
and specific extubation protocol to decrease the practice variation
seen in the current extubation decision-making and promote the CRediT authorship contribution statement
common understanding of medical staff on extubation.29 At pre-
sent, there is a lack of evidence-based practice guidelines for adult Li Wang: formal analysis, data curation, writingdoriginal draft
endotracheal intubation and extubation in ICUs in China. The preparation; Qin Zhang: formal analysis, data curation, wri-
extubation protocol constructed in this study includes the whole tingdoriginal draft preparation; Danyang Guo: formal analysis,
process of extubation evaluation, extubation implementation, and data curation, writingdreviewing and editing; Zaichun Pu: data
post extubation management, which can provide theoretical curation, writingdreviewing and editing; Lele Li: data curation,
guidance for ICU medical staff in the process of extubation, reduce writingdreviewing and editing; Ziji Fang: data curation, wri-
judgement differences and extubation delay, and improve the tingdreviewing and editing; Xiaoli Liu: conceptualisation, meth-
success rate of extubation. odology, software; Ping Jia: conceptualisation, methodology,
supervision, writingdreviewing and editing.

4.2. The extubation protocol is scientific and reliable Conflict of interest

In this study, an extubation protocol guided by the KTA was No conflict of interest has been declared by the authors.
developed for adult ICU patients who underwent tracheal intuba-
tion. The protocol was developed through a multidisciplinary team Copyright
approach involving literature review, group discussions, and expert
consultation using the Delphi method. The experts consulted in this If the article is accepted, the authors assign copyright to
study were rigorously selected based on the inclusion criteria. They Australian Critical Care.
come from five different cities, providing regional diversity. The
consulted experts, including critical care doctors, critical care Data availability
nurses, anaesthesiologists, and respiratory therapists, all have over
10 years of clinical experience and unique insights into the extu- Raw data are available upon reasonable request by directly
bation of tracheal intubation. The response rates for the first and request to the corresponding author.
second rounds of expert enquiries were 100% and 94.1%, respec-
tively. The feedback rates from the two rounds of experts were
Acknowledgements
70.59% and 25%, indicating high enthusiasm and participation. The
Cr values of the two rounds of expert inquiry in this study were 0.94
We thank all the experts for their contributions.
and 0.93, both >0.7, indicating a high level of authority of experts
and reliable consultation results. The Kendall's concordance co-
efficients from the two rounds of expert consultations were 0.152 References
and 0.198, both of which were statistically significant (both
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Please cite this article as: Wang L et al., Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A
Delphi study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.007
 L. Wang et al. / Australian Critical Care xxx (xxxx) xxx 7

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Please cite this article as: Wang L et al., Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A
Delphi study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.007