Extubation in the Pediatric Intensive Care Unit

Vapotherm’s Hi-VNI® Technology is a tool for treating respiratory distress in hospital settings. The views and ideas presented in this video are solely those of the speaker, and the content is not intended to serve as medical advice. Vapotherm does not practice medicine or provide medical services. Practitioners should refer to the full indications for use and operating instructions of any products referenced herein before prescribing them. Willie Bailey is a paid consultant of Vapotherm.

One of the most crucial aspects of clinicians’ work in the PICU is identifying patient extubation readiness while maintaining patient safety. Because no single parameter can accurately predict which patients are ready to assume successful spontaneous breathing¹1. LahamJL, Brehemy PJ, Rush A (2013) Do Clinical parameters predict first planned extubation outcomes in the pediatric intensive care unit? Intern Care Med 30:89-96Read Full Text, there are several factors to consider when making a decision to extubate a patient. The below is a protocol I have followed in my decades of practice:

 

1. There should be weaning and no continuous sedative or neuromuscular blockade on board.
2. Is the patient a candidate for Spontaneous Breathing Trials (SBT)? SBTs should be considered as soon as the patient begins to show signs of spontaneous breathing.
3. Does the patient have adequate mentation? This is controversial, and some suggest at least a GCS > 8, some should be able to follow commands, while others may not.
4. Can the patient lift his head off the pillow, raise arms in the air or clap his hands?
5. Does the patient have a gag and cough reflex?
6. Consider a Cuff Leak Test. 40 % of patients that have been intubated long term experience Laryngeal edema. There’s no clear set of indicators for the pediatric population, and for some patients a NIF (Negative Inspiratory Force) > – 20 cmH2O pressure should be achieved prior to extubation.
7. The patient should have adequate oxygenation and gas exchange. FIO2 should be less than 40%, PaO2 > 60 mmHg, PEEP should equal 5-6 cmH2O.
8. The patient should have a stable Chest radiograph or improving, stable cardiac rhythm, and no tachycardia.
9. There should be adequate fluid status (not overloaded).
10. Patient should be afebrile with sepsis controlled²2. YangKL, Tobin MJ, (1991) “A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation”. N Engl J Med 324(21)1445-50Read Full Text.

Some would suggest that the patient be placed on a T-piece for 60 minutes, but I would suggest placing your patient on a non-self-inflating bag with a continuous fresh gas flow and at least 5 cm PEEP for 15 minutes to assess readiness.

There are a few other factors which could be considered: Is the patient considered to be a difficult Intubation (i.e. critical airway)? Are there other procedures to be scheduled? What time of day it is? Are your staffing skillsets adequate in the unit to re-intubate if necessary?

When the majority of these parameters are answered I have experienced an 80% success rate of extubations.