Introduction

Neonates in the Intensive Care Unit often require mechanical ventilation when critically unwell. This is delivered through an endotracheal tube (ETT) and known as invasive ventilation. Even though mechanical ventilation is a life saving measure, it can cause complications, such as ventilator-induced lung injuries, ventilator-associated pneumonia, airway injuries and neurodevelopmental impairment. Studies also show that prolonged ventilation strongly correlates with increased mortality and morbidity in neonates, which is why planning and discussions about extubation readiness are an important part of the care of the neonate.

As a neonate recovers, the aim of treatment is to remove the ETT and facilitate either non-invasive forms of ventilation (ie CPAP or High Flow Nasal Prongs) or self-ventilation. Elective extubation involves the planned removal of the ETT, under direction of the medical team, by nursing staff.

Aim

This guideline outlines the principles and process of elective extubation of neonates on the Neonatal Intensive Care Unit (NICU, Butterfly Ward) at the Royal Children’s Hospital.  By standardising the preparation, the procedure and the post extubation care, clinicians will be able to reduce the risk and identify any possible complications that may arise following the procedure.

Definition of Terms

• Aerosol generating procedures (AGP): includes intubation, nasal prong oxygen, tracheostomy management and, suctioning, which may expose health care professionals to increased risk of transmission of infection, due to causing additional respiratory particles.
• Continuous positive airway pressure (CPAP): is a means of providing respiratory support to neonates with either upper airway obstruction or respiratory failure.
• CPAP Test: Done on an intubated and ventilated baby that is preparing for extubation. A Medical Officer/ Neonatal Nurse Practitioner switches the ventilator mode to the CPAP mode to assess if the patient is stable without delivered breathes. After 1-5 minutes is then changed back to the previous ventilation mode. 
• Endotracheal tube (ETT): 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 ETT from trachea
• FiO₂: Fraction of inspired oxygen – the concentration of oxygen being delivered to patient, ranges from 21% (room air) to 100% of oxygen.
• HFNP: High Flow Nasal Prongs is another method of respiratory support that may be better tolerated than nasal CPAP in some situations for some neonates.
• mPATS: modified Pain Assessment Tool; an updated and modified multidimensional observational scale used to assess or measure neonatal pain

Phase 1

Assessment 

Readiness for extubation can be assessed to identify risk factors of the likelihood for the need of reintubation. The final decision to extubate a patient is a medical decision, made by the NICU Consultant or NICU Fellow and following consultation with the bedside nurse and AUM.  

It is important to consider the following factors, during a full clinical assessment, to inform the decision to prepare a patient for extubation.

Neurological and Pain Assessment

The patient should be awake and alert, as appropriate for their condition. They may be irritable due to the discomfort of the ETT, but should not be in significant pain, as indicated by their mPAT score (see RCH Nursing Guideline: Neonatal Pain Assessment).  Pain and sedation medications should be in the process of weaning, which is usually started at minimum 24hrs pre-extubation. The dose that is appropriate to extubate on can differ between patients, especially patients who have been on pain relief or sedative medications long term and should be part of the Ward Round discussion (see RCH Nursing Guideline: Neonatal Pain Management in NICU).

Ensure any preterm patients <32 weeks gestation have been adequately loaded or maintained on Caffeine dosing, to prevent the risk of apnoea following extubation. Please refer to RCH Departmental Resource: Screening and supplementation for preterm infants- a quick reference guide.

Airway

Assess the percentage of leak around ETT (monitored via the ventilator). An increasing leak can indicate that any swelling from intubation has reduced and that the airway is therefore more open. It doesn’t guarantee there isn’t or won’t be swelling post-extubation but is a useful consideration when preparing a patient for extubation.

Peri-extubation steroids may be used to optimise extubation, as they significantly reduce the need for reintubation of patients who have ETT induced upper airway injuries. Steroids should be discussed for at-risk patients and at minimum one dose given at least 4 hours pre-extubation. (see RCH Departmental Resource: Steroid Use in NICU)

Patients with a complex airway will be at a higher risk of a requirement for reintubation.  Also, if reintubation is required, it is important to plan to ensure appropriate personnel are available to support a complex intubation procedure. It is therefore a consideration to extubate such patient in a theatre environment with anaesthetic support.  This decision will be made by the neonatal consultant in conjunction with anaesthetics and theatres.

Respiratory and Ventilation Assessment

A full respiratory assessment should be completed by the bedside nurse and medical staff, including:

• Work of breathing
  
• Auscultation and assessment of chest sounds
• Amount, consistency and colour of ETT secretions
• Review of recent blood gases to assess for any concerns or significant changes
• Toleration of recent ventilation weaning
• Minimal support required to achieve target tidal volumes (shown on ventilator)
• Review Fi02 requirement.  This should be low (ideally Fio2 ≤ 0.4) or at an appropriate level that suggests they can be supported by non-invasive ventilation
• Assessment of patient’s spontaneous breathing effort by initiating breaths and breathing above the set ventilation rate (shown on the ventilator) while awake and asleep.
  

A CPAP test should be completed prior to extubation, as part of the respiratory assessment. It is completed by the NICU Consultant or Fellow/Neonatal Nurse Practitioner and lasts 1-5mins, with the doctor assessing the patient's vital signs and WOB. If a patient fails their CPAP Test this is a clear indication, they aren’t ready for immediate extubating.

Preparation

Plan

Preparing a neonate to extubate is an important step in supporting extubation success. It gives the neonate the best chance at extubating safely, being supported adequately post extubation and being comfortable during and after the procedure.  It is important to discuss the plan, in advance of patient’s extubation. Planning discussions should involve medical and nursing teams, including AUM, preferably occurring during ward round. This will provide the opportunity for any safety concerns to be raised and addressed appropriately and to consider equipment needed, clinicians required, safety concerns and access to reintubation equipment. 

Respiratory Support

The requirement of non-invasive respiratory support should be determined, either as a planned or next step approach. Monitoring parameters should be determined in preparation for initiating medical reviews or support following the procedure. The consultant will determine this and have a clear alternative plan of when the next step may need to be initiated, or further review of the patient is required. Careful consideration must be made for patients who have had previous failed attempts at extubation, and the reasons for the failure.

Timing

It is important to consider an appropriate timing for the extubation and will ensure the patient is ready and will be in the best position to tolerate the procedure, in anticipation of success. The timing should also take into consideration the flow of the rest of the unit and the medical and nursing staff are available to support the procedure and, if re-intubation or further support may need to be initiated. 

Medications

A plan should be in place for weaning of any sedative medications if required in case of effect on respiratory drive.  The respiratory drive of patients who are tolerant to opioid or sedative medications may be less impacted and should be considered when planning for weaning such medications.   It is also important to ensure that the patient has adequate analgesia to support their pain as apnoea may present in a neonatal patient who is experiencing pain. Pain, sedation and withdrawal scores should continue to be monitored as required.

Feeds and Cares

Feeds should be held for 1 hr prior to extubation, to reduce the risk of aspiration in the case that reintubation is required.   It may be possible for continuous NJT feeds to continue if indicated by the medical team.  A period of minimal handling following the extubation may reduce the risk of the patient tiring following the procedure (refer to post-extubation section).

Checklist 

This pre-extubation checklist has been developed as a method of ensuring that everything has been considered, prepared and planned as a pathway to a safe extubation procedure.

See RCH Departmental Resource: Butterfly Neonatal Extubation Checklist.

Phase 2

Management 

Procedure

Minimum two nurses must be present for extubation

Confirm ANUM and Medical Team have been informed and it’s appropriate to proceed

Hand Hygiene should be performed throughout, and PPE applied as per RCH Infection control policy

See RCH Departmental Resource: Butterfly Neonatal Extubation Procedure.

Documentation 

• Verify and acknowledge a new “ventilation” order on EMR
• Remove ETT from LDA flow sheet
• Select “YES” in “ventilation off” on the ventilation observations
• Any respiratory support, such as CPAP or Hi flow should be documented. 
• Vital signs, such as heart rate, oxygen saturations, respiratory rate and blood pressure should be documented in the EMR flowsheets prior to, during and post-extubation.
• A “significant event” should be highlighted in observation flowsheet at time of extubation
• The patient’s tolerance of the procedure, as well as any complications or further supports required should be documented in the patient’s progress notes.

Complications

Extubation failure is when the patient requires reintubation soon after the procedure, usually defined as with 24-48hrs.

Causes of extubation failure are wide ranging and include: 

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

Post-extubation Stridor

A patient may develop a stridor post extubation. This is caused by upper airway obstruction, often due to laryngeal or subglottic oedema, which is treated with nebulised adrenaline to reduce the swelling. Stridor can be caused by other issues, but first line treatment is nebulised adrenaline. If stridor persists despite several rounds of adrenaline, then other causes, such as brainstem dysfunction, vocal cord paralysis, vocal cord granuloma, or subglottic stenosis, will have to be investigated (see

Phase 3

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

Also consider the following:

• 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

Special Considerations

• Should an aerosol generating procedure be undertaken on a patient under droplet precautions then increase to airborne precautions by donning N95/P2 mask for at least the duration of the procedure.
• Management of upper airway obstruction post-extubation may require nebulised adrenaline and/or steroids (See RCH Departmental Resource: Steroid use in NICU). Medical staff are required to order this via EMR prior to administration.

Accidental extubation

It is important to prevent the likelihood of an unplanned extubation event with hourly inspections of the ETT taping and continuous monitoring and the requirement of an extra staff member to support the ETT and ventilation tubing during handling of ventilated neonates.

Early recognition of ETT dislodgment is important to ensure that adequate personnel are called to assist, and respiratory support can be provided.  

This may be displayed by:

• Sudden deterioration of a ventilated neonate, including desaturation and decrease in heart rate
• Loss of air entry sounds/ chest wall movement or end tidal co2 detection
• An increase in the leak detected by the ventilator
• Audible cry

In the event or suspicion of unplanned extubation, staff should seek immediate support by pressing the emergency buzzer and utilising the neopuff.

Extubation from High Frequency Ventilation

High frequency ventilation modes are used as a method of respiratory support for neonates in NICU as a lung protective strategy as well as a rescue strategy.

Although clinicians will often choose to switch patients to a conventional ventilation during the weaning process and prepare a patient for extubation, it is possible to extubate patients directly from high frequency ventilation.  An example of appropriate HFOV settings prior to extubation from HFOV may be MAP ≤ 8 cm H20 and Fio2 ≤ 0.4.  However, there are some patient’s, such as patients with severe BPD or lung hypoplasia where higher extubation settings may be acceptable.  This will be determined by the neonatal consultant. 

Family Considerations

It is important that the patient’s family has a good understanding of the plan and the procedure and what to expect following extubation. Explain the possible need to provide minimal handling following the procedure, to increase the likelihood of a successful extubation.  Ensure family are aware of the timing of the procedure and why more staff may be present during the procedure.  Explain the plan for fasting and when feeds may recommence and when we would consider further assessment or investigations or other respiratory supports.  If alternative respiratory support is required medical update may be required to ensure that family is adequately updated. 

Companion Documents

RCH Clinical Practice Guidelines

• Fasting
  
• Resuscitation

RCH Nursing Guidelines

• Assisting with the elective intubation of the neonate on the Butterfly Ward
• CPAP- Care in the Newborn Intensive Care Unit (Butterfly Ward)
  
• Neonatal Pain Assessment

RCH Departmental Resources

• Butterfly Intubation Checklist
• Butterfly Neonatal Basic Life Support Algorithm
• Emergency Intubation
• Nebulisers on Butterfly
• Emergency Intubation Plan D: Rescue Cricothyroidotomy/ Tracheostomy
• Screening and supplementation for preterm infants- a quick reference guide
• Steroid use in NICU