Clinical Guidelines (Nursing)

Extubation (Elective) of the Neonate on Butterfly Ward

  • Introduction

    Aim 

    Definition of Terms 

    Assessments

    Equipment Required

    Management 

    Post Extubation Assessment

    Complications/Causes of Failed Extubation

    Special Considerations

    Companion Documents

    Links

    Evidence Table

    References

    Introduction

    Neonates in intensive care often require intubation and mechanical ventilation for a period of time. Neonates should be extubated as soon as possible in order to avoid potentially harmful complications. Extubation should only be carried out by a qualified competent health care professional.

    Aim

    This guideline aims to provide health carers with information to extubate a neonate in NICU in a safe and timely manner.


    Definition of Terms

    • Endotracheal Tube (ETT): A tube that is inserted into the trachea via the mouth or nose to maintain an airway and allow for mechanical ventilation
    • Extubation: Removal of the ETT from the trachea
    • CPAP: Continuous Positive Airway Pressure

    Assessment

    Indications that a neonate is ready for extubation:

    • Arterial blood gases or capillary acid base are within normal or acceptable limits with low ventilator parameters
    • Spontaneous respiratory effort above the set ventilator rate or when the neonate is disconnected from the ventilator e.g. for suctioning
    • All vital signs, including oxygen saturations are satisfactory with minimal supplemental oxygen requirement

    Equipment Required

    • A Neopuff must be at the bedside for delivering oxygen, CPAP, or manual breaths (with pre-set pressures) if necessary post extubation with appropriate size face mask
    • Stocked and checked resuscitation trolley in patient room 
    • Wall suction unit working and appropriate size suction catheters for suctioning the oropharynx and ETT
    • Stethoscope to check for clear and equal air entry
    • If not extubating straight to room air ensure further equipment is ready to be used i.e. midline prong/mask CPAP, single prong (nasopharyngeal) CPAP, high flow nasal cannula or low flow nasal prong oxygen
    • Ensure neonate’s “Intubation and Resus Calculator” is up to date with correct weight, drug doses and concentrations in the event that reintubation is required
    • A moist and a dry face washer for when tapes and Duoderm are removed
    • Convacare to help remove the tapes and Duoderm from face. Do not use Convacare on premature neonates – instead use a moist face washer. If Convacare is used to aid adhesive removal on neonates >37 weeks gestation, the area should be rinsed with a moist face washer, then dried, as soon as possible after use
    • Cardio respiratory and oxygen saturation monitoring should already be in situ and should remain so during and after extubation
    • For preterm infants where apnoea of prematurity may occur, a loading dose of caffeine may be ordered to be given prior to extubation

    Management

    • Verify medical order for extubation and ensure adequate medical staff are available within the NICU; notify AUM that extubation is about to occur 
    • Perform hand hygiene and don gloves before patient contact
    • Ensure two nurses are present to perform the procedure
    • Withhold feeds for four hours prior to extubation. Aspirate stomach if necessary 
    • Perform all nursing care procedures and observations before extubating so that the neonate can remain undisturbed for at least 4 hours post extubation
    • Suction ETT and oropharynx five minutes before procedure and ensure vital signs have returned to baseline prior to extubation
    • Make sure Neopuff is checked, in working order and set at the required peak inspiratory pressure and peak end expiratory pressure and oxygen concentration
    • Ensure all monitoring equipment is attached and giving an accurate trace
    • Place the bed flat and position the neonate supine and provide support to promote flexion
    • Ensure neonate’s head is in the midline and slightly extended to ensure a clear airway
    • Carefully remove tapes and Duoderm from cheeks using Convacare (if neonate is >37 weeks gestation) and the moist face washer if required. The Duoderm may be left on for a period of time to be used again if extubation fails. If positive pressure ventilation or reintubation is required, remove naso/oro-gastric tube, as this will interfere with adequate seal of the face mask
    • Withdraw ETT (If cuffed ETT is in place, deflate the cuff prior to removing ETT)
    • Gently suction any secretions from oropharynx and nasopharynx
    • Immediately apply facial oxygen via the Neopuff if necessary until heart rate, respiratory rate and oxygen saturations are within normal limits. CPAP may also be given via Neopuff if required
    • Wipe the face clean of any secretions
    • Position the neonate to enable application of the planned CPAP interface if required or consider placing prone if not contraindicated e.g. post abdominal surgery. The prone position is preferred as it allows greater total lung expansion, facilitates drainage of secretions, improves oxygenation and decreases energy expenditure 
    • Ensure thermoregulation is maintained during the procedure
    • Assess and manage pain as necessary
    • Remove gloves and perform hand hygiene

    Post Extubation Assessment

    • Closely observe for any signs of increasing respiratory distress e.g. tachypnoea, increased work of breathing, colour changes, desaturations requiring an increase in oxygen or CPAP or stridor which may indicate upper airway obstruction
    • A blood gas may be requested by medical staff after extubation
    • A chest x-ray may be performed if thought necessary by the medical staff
    • Feeds may be restarted four hours after extubation or as ordered by medical staff
    • Document in EMR:
      • the time of extubation on the flow sheet and whether the extubation was to room air, oxygen or CPAP +/- oxygen
      • on flow sheet under “Significant Events” row
      • how extubation procedure was tolerated in the progress notes
      • remove ETT from LDA Flow Sheet
      • “Ventilation Off” on the flow sheet if appropriate
    • Document all observations immediately to facilitate early recognition of any changes

    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 (which usually manifests as stridor and increased work of breathing) may require adrenaline nebulisers or steroids.

    Nebulised adrenaline: 0.05mL/kg of 1% adrenaline* diluted to 6 mL via nebuliser with 10 L/min flow
    (or 0.5 mL/kg 1:1000 adrenaline diluted to 6ml) – see table below as a guide

    (*If 1% adrenaline solution is not available use 1:1000 vials)

    Guide for nebulised adrenaline dosing:

    Adrenaline concentration

     mg/mL

     %

     mL of preparation required

     Nebuliser solution

     10 mg/mL

     1%

     0.05 mL/kg diluted to 6 mL

     1:1000

     1 mg/mL

     0.1%

     0.5 mL/kg diluted to 6 mL 

     1:10,000

     0.1 mg/mL

     0.01%

     NA

     

    Companion Documents

    Links

    Evidence Table

    References

    • Australian Resuscitation Council. 2016. Neonatal Guidelines 13.1. Introduction to resuscitation of the newborn infant. Available at www.resus.org.au
    • Baucalari E and Polin RA. 2012. The Newborn Lung. Neonatology Questions and Controversies. 2nd Ed. Philadelphia: Elsevier Saunders.
    • Butterfly Ward, RCH data team statistics. 2012
    • Clinical Skills. Endotracheal Tube Extubation (Neonatal) http//mns.elsevierperformancemanager.com.Nursing Skills; accessed 17/03/2016
    • Davis PG and Henderson-Smart DJ. Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants. (Review). The Cochrane Collaboration. The Cochrane Library 2009, Issue 2
    • Extubation of a patient in PICU. PICU  Royal Children’s Hospital Melbourne. Clinical Practice Guideline. August 2010.
    • Extubation of a neonate. NICU Mercy Hospital for Women Melbourne. Clinical Practice Guideline. May 2010.
    • Extubation of infant in Neonatal Services The Royal Women’s Hospital Melbourne. December 2008.
    • Gardner SL., Carter BS., Enzman-Hines M. and Hernandez JA. 2011. Merenstein and Gardner’s Handbook of Neonatal Intensive Care. 7th Ed. St Louis: Mosby Elsevier
    • Henderson-Smart DJ and Davis PG. Prophylactic methylxanthines for endotracheal extubation in preterm infants. (Review). The Cochrane Collaboration. The Cochrane Library  2013. Issue 3.
    • Martin RJ , Fanaroff AA and Walsh MC. 2011.  Fanaroff and Martins Neonatal Perinatal Medicine. Diseases of the Fetus and Infant. Vol 2. 9th Ed Chapter 44.  St Louis: Elsevier. 
    • Shann, F. 2014. Drug Doses. 16th Edition. Royal Children’s Hospital Melbourne.


    Please remember to  read the disclaimer

     

    The development of this nursing guideline was coordinated by Sharlene Pattie, Clinical Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2017.