Step by Step 4-16-07 Dora M Alvarez MD INTUBATED PATIENT Step by Step 4-16-07 Dora M Alvarez MD

INITIAL PROCES Call from ED requesting bed for and intubated patient Resident / Supervisor (if applicable) obtains information on patients condition on the phone, gets Sign out Sheets and Ventilator Order Flow sheets and goes to see patient in the ED Information needed: Reason for intubation (*) Clinical Diagnosis and patient’s condition

* Reason for Intubation Airway protection ? Alter Mental Status Seizures Drug overdose Angioedema Facial Trauma Severe Respiratory Distress / Impending resp Failure ? Airway disease Upper airway (Trauma with edema, angiodema, FB, Croup, Epiglotittis) Lower airway (Asthma. brochiolitis, CF, BPD ) Parenchyma disease Pneumonia, Pulmonary edema, Pulmonary hemorrhage, Aspiration episode, ACS /Pneumonia) Broncho-parenchymal problem; (Mechonial aspiration, Aspiration, BPD Trauma chest (Flair, pulmonary contusion, pneumothorax, hemothorax.) Muscular Diseases.(SMA, Botulism, Guillen Barre)

Information needed Intubation process, ET tube Size, cuff or not cuff, Intubated by: anesthesiologist?, ED attending?, resident? Medications given Complication Difficult intubation Vomited ? Aspiration CxR ray, position of tubes, (ET and NG); lungs findings Ventilatory settings (write settings in the “Ventilator order flow sheet) ABG

Ventilator setting Example: 8 yo with status asthmaticus (45 kg) Type Ventilator: …..PB 840, PB (720) Mode: Volume Control: CMV, A/C - SIMV Rate: (15) TV: (320 mL (8 ml/kg) …..read the PIP is ??) I:time… (read the I:time or I:E rate show) Flow:… (30 L/min) PEEP: …(0 - 4) FIO2: …. (100%)

PICU Admission. Be and Stay in the room when patient arrives & Check … ET tube in place, well taped C-R monitor, VS, O2 Sat, ETCO2 Suction: observe and describe type of secretions. Check Ventilator setting and order according to guidelines: Usually patient’s are place on CMVor A/C in ED because they are paralyzed and/or heavily sedated. Changed to SIMV with PS mode according to patient’s condition, with this mode patient may be allow to breath spontaneously, supporting his/her respirations. Wean FiO2 according to O2 Sat. Usually patient came with 100% O2 and an ABG showing high PaO2 > 300. Continue brochodilator if indicated, back to back, MDI 6 puffs Q 30-60 min. Sedation order (Verbal) Midazolan / Fentanil. Code sheet at bedside.

Monitoring Intubated patient Check: O2 Sats ETC02, monitoring Lung auscultation Assessment of A&B. Ventilation and oxygenation ABG Temp CV: HR, PB, perfusion.

PICU Admission continue Review /Check X Ray if not done before and document ET tube position Order: Ventilator order as per guidelines, considering patient’s condition / lung pathology. Sedation (Midazolan PRN and/Or drip, Fentanyl Or Ketamine drip for asthma) If indicated order Bronchodilator. MDI 6 puffs Alb/ Atrovent alternated - IV solumedrol IV Fluids requirements, considering metabolic demands, fluid deficit and ongoing loses as indicated.

Reevaluate the need for continuation of Respiratory support considering the Indication for intubation If intubated because Alter mental status 2nd to post-ictal and /or medications >> patient may be allowed to wake up (No sedation), wean respiratory support quickly, assessing if oxygenating and ventilating with no increase work of breathing on minimal respiratory support, patient may be extubated soon. (See criterion for extubation **)

2. If patient is intubated because: Reevaluate the need for continuation of Respiratory support considering the Indication for intubation 2. If patient is intubated because: Hypoxic/Mix respiratory failure 2nd to parenchyma pathology: I.e: Pneumonia, Asthma, bronchiolitis; patient will need sedation and mechanical ventilarory support till the diseases processes improves/resolves. If patient was intubated because cardiovascular instability: Shock (Cardiac, septic ) - Patient should remained, deeply sedated /paralyzed and given full respiratory support till hemodynamically stable 4. Facial trauma, protective airway > Patient should remained, deeply sedated /paralyzed? and given full respiratory support till airway is consider maintainable.

**Extubation Criteria Resolution of condition / reasons for intubation: examples If patient was intubated for alter mental status 2nd to drug overdose or post-ictal >>Pt is ready for extubation when patient is waking up and responsive and breathing spontaneously. (NO NEED TO KEEP SEDATING PATIENT TO KEEP INTUBATED) If patient is intubated for respiratory failure 2nd to lower airway obstruction (asthma / bronchiolitis) >> Pt is ready for extubation when airway obstruction is much improved / resolving and patient will be able to breath without significant respiratory effort / work of breathing.

**Extubation Criteria 2. Off sedation, awake, able to follow up commands, (open eyes spontaneously) 3. Positive gag reflex, good cough effort 4. Able to maintain open airway. If intubation was because primary upper airway obstruction (Croup, epiglotittis, stenosis ?), need to check for leak around the tube or by documenting normal anatomy by inspection. 5. Able to lift Head and grip

**Extubation Criteria 6. Tolerating weaning down Ventilator support to CPAP or T-Piece Pressure support down < 4 (at least consideration to be wean to nasal/mask CPAP or BIPAP which should be available at bedside) PEEP < 4 FiO2 < 40 %, O2 Sat > 95 %, with out desaturaion when succioning. 7. Patient is breathing on his own, without significant effort or increase work of breathing (retractions) and has been able to maintain an normal Pa CO2 by ABG and /Or ETCO2 8. Patient is hemodynamically stable 9. For patient who can cooperate and able to follow directions, ask respiratory therapy to check NIF (Negative Inspiratory Flow) which assess respiratory muscle strength. 10. “If Patient is trying to take the tube out” > and fits above criteria, wean quickly to prevent accidental extubations.

Things to do prior to Extubation: NPO (Stop NG/GT feeding for 4-6 hrs before planned intubation. Have the following ready. Oral airway, proper size. Working suctioning equipment (younker) Proper side ET tube, laryngoscopy for possible need for reintubation. Ambu-Bag connected to oxygen Aerosolized oxygen delivery system Nebulizer treatments (Vaponefrin and Albuterol)

Extubation Procedure Suction ET tube and pharynx thoroughly Pre-oxygenate Lungs manually inflated with 100% O2 to keep Sat 100% to provide a Reservoir oxygen buffer. Cuff deflated (if applicable Provide Humidify oxygen with aerosolize mask 40-50% Remove restrains and sit patient up Auscultate to check air-entry and if any adventitious signs.

Post – Extubation Observe for presence of stridor, if significant and/or persistent stridor give racemic epinephrine nebulizer treatment. If prolonged, consider the use of Decadron (0.3 -0.5 mg/kg ..Max 10 mg 1 dose) Observe for increase work of breathing and wheezing. Can try Nebulizer albuterol, “gentle Chest PT, and deep pharyngeal suction to stimulate cough, especially in younger patients. Assess Oxygen requirement by decreasing FIO2 gradually if O2 Sat are > 98% ABG, (or capillary, VENOUS IS NOT ACCEPTABLE), if patient is having signs of respiratory distress / increase work of breathing and is still requiring > 35 % FiO2. CxR is not routinely indicated. Post intubation atelectasis is common and demonstrating this in CxR may not change patient management. Incentive spirometry and CPT may be indicated in patients who are not having and effective cough.

Examples

1 mo old frequent apnea episodes in between 100 % RA Check patient Nasal and/or oropharingeal secretion, suction RR in between 30 .min Mental status/ activity ..Stimulated response temporaly, cry vigorous and has good color Lungs auscultation clear, no murmurs HR normal 140 good perfusion Observation of apnea, increasing frequency Q 15-20 min sat 88 % Chest studies: CxR, EKG ABG normal, CBC, SMA, Blood cultures. U/A Intervention: CPAP >> CPAP SIMV FiO2 30 % PEEP 5 Flow.

1 mo old frequent apnea episodes in between 100 % RA Interventions/ Options: Stimulator (using Bear Cub respirator)- Order:Mechanical Ventilation-Neonatal (Patient is not intubated >the breath are going to be deliver into a globe which is place under the back of the babe) Mode: SIMV Rate: 25-30 Flow (Check guide lines) I:time 0.5 PEEP 0 FiO2: RA

1 mo old frequent apnea episodes in between 100 % RA Interventions/ Options: 2. Nasal CPAP Flow (Check guide lines) PEEP 4-5 FiO2: 28 –30 % ( as needed to keep O2 Sats > 95 % 3. CPAP / SIMV Rate: 25-30 I:time 0.5

Intubation if continue with apneas and bradycardias Ventilator: Bear Cub Mode: CMV / SIMV Rate: 25-30 PIP 12-14 (low as pat. Has no lung pathology >see chest raise and check exhale tidal volume) I:Time 0.5 Flow 12 PEEP 4 FiO2: 25-30 %