Extubating Neonates

Question 1

What are the primary things you should assess when considering extubation?

Answer 1

• Spontaneous respiratory rates (appropriate age/weight)
• Apnea or periodic breathing?
• Look for downward trends
• cough & gag reflex
• minimal sedation needs

Question 2

What mode should you put a babe on for a Spontaneous Breathing Assessment?

Answer 2

PRVC

Question 3

How is a Spontaneous Breathing trial performed on a babe?

Answer 3

PRVC and roll back the RR until @ 20.

• Once @20, if babe hits 40-60bpm they pass SBT and are ready for extubation.

Question 4

What should you look for when assessing unsupported breaths?

Answer 4

Babes can’t trigger vents effectively so they induce WOB. look for:

• RR
• head bobbing, indrawing, paradoxical breathing.

Question 5

How are kids and some bigger neonates assessed on a SBT?

Answer 5

Bigger kids can be put on pressure support like adults on 7/5 (initial).

• Kids can use Automatic Tubing Compensation (ACT) to reduce WOB via ETT

Question 6

What conditions are needed to use pressure support (PS) to be used on a SBT?

• why isn’t it used?

Answer 6

Pressure support isn’t used when Pts don’t have enough muscle strength to trigger a breath.

• 7 as PS, need to provide enough PS to overcome extra resistance provided by ETT

Question 7

What is Automatic Tube Compensation (ACT)

Answer 7

Built in program where you input tube size and it figures
out resistance from endotracheal tube and give that much
pressure support

• pressure support you set with ATC is 0
• 0/5 + ATC

Question 8

Why is high ICP dangerous and what is a high ICP?

Answer 8

Brain death, a high ICP < 15

Question 9

What are contraindications for weaning kids and babes?

Answer 9

• Brain death/high ICP
• Paralytics running
• unstable airways
• team decisions
• ECMO
• babes w/genetic conditions
• muscular atrophy pts or c-spine injuries

Question 10

If a babe was intubated bc of epiglottis, would you extubate if swelling hasn’t resolved but the baby was stable?

Answer 10

Hell no

Question 11

What issues should be addressed before extubation?

Answer 11

Reversal of underlying cause of resp. failure

• Fluid overload, have we reached goals? are they +/-?
• Meds that might affect their extubation (paralytics)
• Time frame of tube feeds shut them off 4 hours before
  extubation
• small bore and large bore
• large bore is adults and older peds have ability to evacuate
  whatever is in the belly
• Imminent procedure, they will delay extubation

Question 12

What are the 3 stages of extubation?

Answer 12

1. Initial/acute stage (escalation)
2. Vent. Management (Plateau)
3. Discontinuance (Deescalation)

Question 13

What factors would make you stop a SBT in a babe/kid?

Answer 13

Increased WOB/unstable stats would end SBT and let patient rest and overcome

• Tachypnea, bradypnea, apnea (age appropriate)
• Excessive accessory muscle use
• significant unresolved agitation/anxiety
• significant unresolved tachy/bradycardia
• hemodynamic changes
• unacceptable decrease in SpO2

Question 14

What information can you use to assess extubation status of a Pt?

Answer 14

ABGS and PF ratio, pay attention to time though.

• PF ratio < 150 don’t extubate
• Maintain ABG near the 1hr or 45min to see how they maintain gasses.
• pH >= 7.25

Question 15

Bedside Equipment for Peds/neonates during extubation

Answer 15

Suction equipment, Bagger

• reintubation equipment nearby (doesn’t have to be in room)
• possible racemic epi for swelling

Question 16

What post extubation equipment should be ready?

Answer 16

CPAP and O2 therapy.

• No delays
• biphasic (try prior to extubation)

Question 17

How long can hyperoxygenation be done?

Answer 17

1-2 minutes. Ask team first though.

• ensure they are oxygenated well.

Question 18

What should be done first in the extubation procedure?

Answer 18

1. Verify orders
2. Clean procedure (PPE)
3. Consider presuction and meds
4. Place Pt in high fowlers
5. Place towel/pad on Pts chest to absorb secretions

Question 19

What do you need to consider for pre-suction for a extuabtion procedure?

Answer 19

Deep or oral suctioning?

• deep suction of lungs if required, leave time for recovery
• oral suctioning to lessen risk of aspriation

Question 20

What do you need to consider for meds for a extubation procedure?

Answer 20

Caffeine and bronchodilators given ahead of time to be active

Question 21

What position should a pt ideally be in for extubation?

Answer 21

High Fowler

Question 22

What should you set FiO2 @when extubating kids?

Answer 22

10% above their set FiO2 (need to fact check)

Question 23

What is apart of the post extubation assessment?

Answer 23

Monitofr Pt regularly for their:

• RR
• SpO2
• WOB

Question 24

Assessing for extubation section needs review

Answer 24

Refer to kristines side notes