Ped Extubation

Question 1

How often should a ped be assessed post extubation?

Answer 1

At a min, every one hour post extubation for three hours as needed

Question 2

Pediatric Post extubation care? (5)

Answer 2

1. CBG 1 hour after extubation
2. CxR
3. NIV
4. Aerosolized epi (start at 5ml but if less than 5kg 2.5ml)
5. Heliox

Question 3

Pediatric Extubation equipment?

Answer 3

1. ETT + Oral Sxn Equipment
2. O2 delivery equipment
3. Manual resuscitator and mask
4. Intubation equipment
5. Stethoscope
6. Securement device removal equipment (Scissors, adhesive remover, gauze, sterile water)
7. SVN as required
8. PPE

Question 4

Pediatric Extubation procedure?

Answer 4

1. Verify MRHP order
2. Gather equipment
3. Inform bedside nurse/MRHP its happening
4. Don PPE
5. Raise HOB if possible
6. Suction ETT, Nasopharynx, and oropharynx, if cuffed ETT in place ensure secretions above cuff are removed
7. Pre oxygenate on 100% for 1-2 mins
8. Disconnect from vent to manual resuscitator, place vent on standby
9. Provide appropriate PEEP and insp pressure to support patient breathing
10. Deflate cuff using syringe
11. Remove ETT
12. Apply appropriate O2 delivery source
13. Suction orally as required

Question 5

Troubleshooting post extubation if inspiratory stridor is present?

Answer 5

1. Inform MRHP
2. obtain order for nebulized epi
3. Prepare to nebulize epi (5ml)

Question 6

PED Extubation Readiness testing (ERT) inclusion criteria

Answer 6

1. Patient is able to trigger spontaneous breaths (determined by short term decrease in RR)
2. Patient can trigger a good effective cough
3. O2 goals met (OI less than 6) or PEEP less than 8 with FIO2 less than 0.5

Question 7

PED extubation readiness testing (ERT) exclusion criteria?

Answer 7

1. Epi greater than 0.1 mcg/kg/min or escalated in last 6 hours
2. Active management of intracranial hypertension
3. Pt vent dependent with or without trach
4. Existing order from sunrise clinical manager

Question 8

PED extubation readiness (ERT) prossess?

Answer 8

1. Like SBT, ensure nurse is present for entire procedure
2. Stay for the first 5 mins, and monitor for 15 min intervals following
3. Intubated < 48hrs ERT for 30 mins, intubated > 48hrs ERT for 60-120 mins
4. Leave FiO2 at current settings, but may escalate up to 0.5 to maintain SpO2 goals as needed
5. Adjust PEEP to 5, decrease by 1 every 5 mins until achieved. Ensure SpO2 targets met with FiO2 less than 0.5
6. Adjust Pressure support to 6 for greater than 4 ETT and PS 8 for less than 3.5 ETT

Question 9

PED extubation readiness testing (ERT) pass criteria?

Answer 9

Passed if patient can breath comfortably with reasonable O2 requirements and acceptable RR for age

Question 10

PED extubation readiness testing (ERT) fail criteria?

Answer 10

1. SpO2 falls below goal despite FiO2 less than or equal to 0.5
2. Exhaled Vt consistently less than 5ml/kg
3. Consistent increase in RR by 20% above initial RR
4. Persistent EtCO2 increase greater than or equal to 15

Question 11

What should be done post ERT?

Answer 11

Increase PS to rest and comfort patient to the following:

1. PS greater than or equal to 8 for ETT greater than 4
2. PS greater than or equal to 1- for ETT less than or equal to 3.5
3. In rounds, discuss pts ability to manage secretions, assessment of adequate cuff leak, and NPO status

Question 12

PED extubation readiness testing (ERT) settings for:

1. Pts with ETT 4 or higher
2. Pts with ETT 3.5 or lower?

Answer 12

1. PSV 6/+5
2. PSV 8/+5

Question 13

How long should tube feeding be d/c before extubation?

Answer 13

4 hours

Question 14

For Pediatrics, how would perform a cuff leak test?

Answer 14

1. Disconnect Pt from vent at the HMEF
2. Deflate the cuff and occlude HMEF, ensure air movement around the deflated cuff on inspiration and expiriation
3. Consult MRHP if biphasic leak not detected prior to performing extubation
4. Inflate cuff and reattach pt to vent

Question 15

How does a leak test differ for peds on a active circuit?

Answer 15

You need to remove pt from the circuit and attach the HMEF to the ETT. At the end, you need to remove HMEF since they’re on active humidity circuit

Question 16

How would you perform a leak test if a ped patient is on a AC-VC mode?

Answer 16

1. Reduce RR to 15, FiO2 to 1, PEEP to 0, and Vt 10ml/kg
2. wait for vent cycles to be within 20mls difference
3. Deflate ETT and wait for Pt to adjust to cuff deflated before peroming measurements
4. Record exhaled Vt over 6 cycles
5. cuff leak is calculated as diff between inspired Vt and average of 3 lowest exhaled Vt
6. Pts with cuff leak greater than 15% of delivered Vt difference have a lower prob of post extubation stridor

Question 17

How would you perform a leak test if a ped patient is on a PSV?

Answer 17

1. Change PSV 10, FIO2 1.0, PEEP 0
2. Wait for cycles to allow inspired and expired Vt to be within 20ml of each other
3. Deflate cuff and wait for pt to settle before measurements
4. Record inspired/exhaled Vt over 6 cycles
5. Pts with cuff leak volume greater than 15% of the average of 3 lower inspired Vt or greater than 140 mls

(cuff leak volume = Inspired Vt - average of 3 lost exhaled volumes)