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Lata Mangeshkar, a 92-year-old veteran singer, has been admitted to the Intensive Care Unit (ICU) on 8 January as she tested positive for COVID-19 and showed mild symptoms. Her family has recently released a statement informing their fans that she has been given a 'trial of extubation' and is thus, showing signs of improvement. However, she is still kept under observation in the ICU.
So, what is extubation and how it is related to Covid-19? In this article, we will discuss the same along with other details on the extubation procedure.
What Is Extubation?
Extubation is a procedure in which a medical expert removes the endotracheal tube (ETT). It is considered to be the final step in liberating a patient from the mechanical ventilator. 
In short, it is a procedure in which the respiratory support of a recovering patient is discontinued by removing the endotracheal tube to help them gain more control of the natural breathing process, instead of relying on mechanical breathing support.
Firstly, an extubation 'trial' is done and if a patient shows improved symptoms, they are extubated unless required again.
An endotracheal tube is a tube made with polyvinyl chloride and helps provide oxygen and inhaled gases to the lungs. The tube also helps protect the lungs from contamination due to blood or gastric content. 
To perform extubation, medical experts such as nurses, physicians and respiratory therapists must be experienced enough to manage before and after procedures of extubation, with a focus on readiness for weaning, spontaneous breathing trials and complications.
What Are The Terms 'Weaning' And 'Liberation'?
Weaning is an act of decreasing oxygen supply in patients who are on mechanical ventilation. It is carried out to observe patients and find out whether they can breathe properly in less oxygen supply or say, are ready to shift on their natural breathing process. 
Liberation is an act of complete discontinuation of mechanical ventilation in patients who are showing signs of improvement and can maintain their natural breathing.
To mention, liberation is done only after a successful weaning trial of the patients.
Though mechanical ventilation is a life-saving procedure, if carried out for longer it may lead to complications like ventilated-associated pneumonia. Therefore, once the condition of a patient improves on trial weaning, a decision is made to proceed with liberation.
Also, the medical expert takes into account the disease, its expected course, signs of improvement and reasons to stay longer on a mechanical ventilator.
What Is Mechanical Ventilation?
Mechanical ventilation, also known as a ventilator or breathing machine, is a machine that allows a patient, who is critically ill due to certain respiratory conditions or surgery, to breathe artificially through a tube that is inserted via mouth or nose to the lungs.
There are various stages and modes of ventilation and they are all set according to the patient's disorder, severity and need. Also, the patient is continuously monitored while they are on ventilation due to certain complications like alternation in the blood flow of severely ill patients. 
How Is Extubation Done?
Once a patient passes the weaning trial, which is a resolution of disease, adequate oxygenation, fewer fatigue rates and heart stability, they are suggested for extubation. Early identification of patients who can breathe properly can help give better outcomes.
General anaesthesia is the first step in extubation as it is carried out to make the process easier for the medical expert to remove the endotracheal tube while the patient is unconscious.
The expert will then remove the tape used to hold the tube and clear the area with a suction tool for any debris. They will also ask the patient to cough so that the remaining debris could be removed from the mouth rather than going back to the lungs.
The breathing and blood oxygen levels of the patient are then monitored and suggested for reinsertion only when the condition gets severe again.
Benefits Of Extubation
Some of the benefits of extubation include:
- To support breathing in patients who are ill with diseases like pneumonia, collapsed lung, heart failure or severe trauma.
- To relieve lungs from breathing for a short period or relax them until they recover from the condition.
- Reduction in respiratory infection and related complications.
- Improve patients comfort.
- Maintain a supply of oxygen to the lungs.
- Improvement of heart functions. 
- Clear the airways. 
Risks Of Extubation
Extubation failure is defined as the need for reintubation or putting the endotracheal pipe again within 24-72 hours after extubation. It usually occurs when a patient is unable to maintain airway patency, oxygenation, alveolar ventilation or a combination of any of these.
Some of the risks related to extubation failure include: 
- Pulmonary aspiration
- Cardiac arrest
- Brain damage
- Ventilated-associated pneumonia
- Vocal cord injury
- Irregular heartbeat
Extubation And COVID-19
COVID-19 is an infectious disease that may result in severe respiratory conditions. As the infection is contagious, proper airway management is required in patients with COVID-19 during both intubation and extubation. 
Some of the pre-extubation planning in COVID-19 patients include:
- Extubation in a negative pressure room.
- Inserting the pipe through the port in a face mask so that it can be removed in the same way with limited exposure to aerosols.
- Presence of only needed staff wearing protective gear such as a mask and gloves.
- Limiting staff interaction.
- Use of antitussive medicines to reduce the episodes of coughing and prevent respiratory droplets from coming out.
The procedure of extubation is a long process and involves many factors which must be taken care of before and after the procedure. Therefore, a medical expert must be knowledgeable enough to carry out all these processes effectively.
Image Sources: Pexels
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