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Clinical Guidelines (Nursing)

Extubation (elective) of the neonate on butterfly ward

  • Introduction

    Aim 

    Definition of Terms 

    Assessment

    • Equipment Required
    • Pre-extubation checklist
    • During extubation (procedure)
    • Post-extubation

    Documentation 

    Complications/Causes of Failed Extubation

    Special Considerations

    Family Considerations

    Companion Documents

    Evidence Table

    Introduction

    Mechanical ventilation is commonly delivered through an endotracheal tube (ETT) within the Neonatal Intensive Care Unit (NICU). Extubation involves removal of the ETT from the trachea. Early and successful extubation can reduce complications such as ventilation acquired pneumonia (VAP). 

    Aim

    This guideline will provide information about the nursing assessment, management and complications of neonatal extubation.

    Definition of Terms

    • Endotracheal tube: a flexible, plastic tube which is used to deliver mechanical ventilation in patients. The tip of the tube lies within the trachea and may be a cuffed, or uncuffed tube
    • Extubation: Removal of an ETT from the trachea
    • CPAP:  Continuous positive airway pressure
    • CPAP test: A temporary trial of CPAP while the patient remains intubated. This can assist medical staff in determining the patient’s stability on this mode of ventilation
    • AGP: Aerosol generating procedures, which can expose health care professionals to higher concentrations of infectious respiratory particles 
    • FiO2: Fraction of inspired oxygen

    Assessment

    Patient readiness to extubate

    Nursing staff can optimise patient safety and comfort during, and post-extubation. This can include:

    • Withholding feeds as per RCH Fasting Guideline
    • Considering the timing of hygiene cares and procedures during the peri-extubation period
      • Patient’s may benefit from these procedures hours beforeor after extubation to reduce patient fatigue
    • For more on comfort measures and management, see Neonatal Pain Assessment

    Medical staff will assess the readiness of the neonate for extubation. This will include deeming the patient as low-risk for re-intubation. Common signs the patient is ready for extubation:

    • Patient has tolerated weaning of sedation, ventilator settings, and requires minimal oxygen supplementation
    • Stable blood gas reports, in conjunction with the patient requiring minimal support from the ventilator to achieve target tidal volumes
    • The patient is consistently breathing above the set breathing rate on ventilator (commonly > 30 breaths per minute)
    • All vital signs are within acceptable parameters
    • Patient has passed a CPAP test 

    Note: Careful consideration must be made for patients who have had previous failed attempts at extubation, and the reasons for the failure. Peri-extubation drugs may be used to optimise extubation (see Steroid use in NICU)

    Equipment Required

    • Standard personal protective equipment (PPE) includes gloves, googles, plastic apron and Level 2 surgical mask
      • PPE for respiratory infections and/or COVID-19-specific patients click here
      • Department-specific policies are subject to change. Discuss with ward management
    • Neopuff with appropriate size facemask
    • IV access which has been flushed successfully within 4 hours of planned extubation
    • Functional suction unit with appropriate size suction catheters
    • Resuscitation (red) Emergency trolley outside of patient room
    • Stethoscope
    • Respiratory support equipment if required, ie: CPAP, high flow, or low flow nasal prongs
    • An up-to-date “Intubation and Resuscitation Calculator” sheet
    • A face washer, partly moist
    • Niltac
    • Continuous cardiac and oxygen monitoring (ensuring appropriate alarm limits are set)

    Pre-extubation Checklist

    • Ensure procedure has been discussed with parents via medical or nursing staff
      • This includes encouraging parent(s) to exit the room during the procedure for optimal patient safety
    • Verify and acknowledge a new “ventilation” order on EMR
      • New ventilation order will include type and amount of respiratory support post-extubation, eg: CPAP of 8cmH20
      • Comments on order MUST read “Ready for extubation”
    • At least two Registered Nurses MUST be present for extubation
    • Confirm with AUM and Medical staff if extubation is appropriate, and adequate staff are within the NICU
    • Ensure neopuff is set at within appropriate parameters for patient, and tubing can reach the patient’s face
    • Consider aspirating remaining stomach contents prior to extubation
    • Suction ETT and oropharynx approximately 5 mins before extubation
    • Ensure patient’s vital signs are within acceptable parameters
    • Position the bed flat and position the patient supine
    • Ensure the patient’s head is midline with slight extension

    During extubation (procedure)

    • Perform hand hygiene and don gloves
    • Consider removing orogastric tube if facial CPAP and/or oxygen is required
    • Remove ETT tapes while another nursing is supporting the ET tube
    • Deflate the cuff, if required
    • Withdraw the ETT
    • Suction any secretions from oropharynx or nasopharynx, if required
    • Apply facial oxygen or CPAP to ensure patient’s vital signs are within normal parameters
    • Doff gloves and perform hand hygiene

    Post Extubation 

    Continuously assess clinical stability of the patient post-extubation. This includes, but not limited to:

    • Activity and tone
      • Airway patency
      • Breathing 
      • Circulation
      • Disability, such as temperature
    • Notify medical staff as soon as possible of any medical concerns
      • Position the patient as clinically appropriate
    • Prone position can stabilise the chest wall, optimise oxygenation and promote sleep
    • Avoid disturbing or over-stimulating patient for a minimum of 4 hours post-extubation
      • Consider a medical review if patient is requiring longer, or shorter time frames
    • Assess and manage temperature and pain as necessary
      • Consider parental touch, feeds, cuddles and containment as appropriate 

    Documentation 

    Document vital signs pre, during and post-extubation

    • Highlight “significant event” in observation flowsheet at time of extubation
    • Discuss in progress notes how the patient tolerated procedure, and if there were any complications 
    • Remove ETT from LDA flow sheet
    • Select “YES” in “ventilation off” on the ventilation observations, or commence new ventilation support observations if required 

    Complications/Causes of Failed Extubation

    • Apnoea
    • Bradycardia
    • Hypoxia
    • Atelectasis
    • Respiratory acidosis
    • Upper airway obstruction
    • Laryngeal oedema
    • Subglottic stenosis
    • Respiratory distress
    • Haemodynamic instability
    • Neurological compromise

    Special Considerations

    Management of upper airway obstruction post-extubation may require nebulised adrenaline and/or steroids (See Steroid use in NICU). Medical staff are required to order this via EMR prior to administration. 

    Nebulised Adrenaline

    Adrenaline 1:1000 (1mg/ml) ampoules are the first line management within the NICU. The dose for neonates is 0.5ml/kg, further diluted normal saline (NaCl) to a total of 6mls, and delivered via nebuliser with 8-10L/min flow.

    Consider a maximum dose of 5mg for patients 1 month or older

    Family Considerations 

    Education for family members regarding extubation is an important aspect of the neonate’s holistic care plan. 
    Education may include:

    • Purpose and plan for extubation
    • Risks and side effects of extubation
    • Optimising patient safety pre, during and post-procedure


    Family-centered care is one of our key priorities during medical and nursing procedures. Communication surrounding the extubation procedure is vital, and should be completed as early as possible. Communication can be updated in EMR ‘Progress Notes’. 

    Companion Documents

    Evidence Table

    Please remember to  read the disclaimer

     

    The revision of this nursing guideline was authored by Shanai Cramer, Clinical Nurse Specialist, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated September 2020.