Early Extubation in micro-preemies

  1. We've finally started moving towards this trend, but many of our docs and nurses are skeptical about this change. We tried it a few years ago and some of the preemies ended up much sicker in the long run - mostly NEC from what I remember. Now that we have a newer CPAP set-up that fits micro-preemies better, we're taking the plunge again.

    I've been taking care of a 600 gram 24-weeker for 2 weeks who has never needed much oxygen or vent support. He seems the perfect canidate for extubation, so that his lungs don't get any worse. Everyone around me thinks I'm crazy! They all say he'll get NEC, etc.

    What has been your experience?
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  2. 19 Comments

  3. by   iceNICUnurse
    The little ones in my unit are usually extubated in the first week or two if they dont need much oxygen or vent support.
    They are put on Cpap and it works great (not that I like Cpap but it is much better for these babies than the vent). We dont see any problems with NEC or anything like that. You have to be sure to suction them on a regular basis or they will have trouble with mucus piling up in their airway. They sometimes have to be reintubated b/c of Apnea. These ones stay on Cpap usuallyfor 6-8 weeks.
  4. by   BittyBabyGrower
    We have had 500 gramers extubated and on either high flow or CPAP..which I think we all can guess his nose looked like! Our docs extubate ASAP and if they don't make it they are reintubated. Their thought is any time off the vent is good. Do we always agree...no, some of those kids use so much energy breathing! But I guess we have to try!
  5. by   prmenrs
    I was a die hard keep-'em-tubed-an-let-'em-grow person a while back, but the new division head just kept telling me it would be ok. So I made a conscious decision to change my practice in keeping with the "evidence-based" philosophy, and I'm more than ok w/it now.

    Tube, Surf, pull it. NCPAP/SIMV (there are some new gizmos that are easier on the babies noses, now). Indocin if they act duct-y, or have one on ECHO. Trophamine and MVI the 1st day, trophic feeds as soon as mom makes a cc or 2 of colostrum. Put a PICC line in for nutrition till full feeds are tolerated. Developmental/kangaroo care. I'm serious for a change, these are good things.

    DO stock some of those olive-tipped nasal suction devices, you need to irrigate their noses once in a while, because they get "snotty". Baby prone, the suction thing in the "down" side, drip NSS in the "up" side. Don't be surprised if you get the "catch of the day".

    Other things that may be coming your way, if they haven't already: Room air in the delivery room, or at least a blender. Rationale: pO2 in utero is ~ 30, during rescus, it can get to 300 almost instantly--can this be good for your eyes? Keeping sats between ~ 85-92, never above 95. (and yes, the oximeter DOES drive you beyond crazy).

    A study in Australia (Perth, I think) led to 95% of their babies being born in the Level III hospital, i.e., transporting Mom, not baby, because the outcomes were so much better if baby was born in the tertiary hospital.

    Anybody else been to a conference lately????
  6. by   fergus51
    We do it, but I don't love it. I think it's right for some kids, but the really small ones get tired out, then retubed. If they reintubated quickly it wouldn't bug me so much, but they seem so reluctant sometimes that the kid has to have a zillion spells, lose weight and totally zonk out first. Like everything in life, I am a middle of the road kind of gal. I don't want them intubated forever, but I also don't like to pull a tube on a 500g baby who just hit 24 weeks.
    Last edit by fergus51 on May 25, '04
  7. by   BittyBabyGrower
    I hear you! We actually had an attending that would tell us to put the kid on their stomach so we couldn't see them sucking down to the bed! What an idiot!

    It is like pulling teeth to get them to reintubate...I feel so bad for the little ones!
  8. by   neominder
    as with all things...it depends on the baby. i wish the docs would all see it that way. in my unit some tend to focus too much on numbers and not enough on clinical findings:angryfire. so a good blood gas means extubate, even if the patient is working or tachypnic while on vent...we are asking for failure...sorry, venting a little. on our micro preemies the one thing that has help to keep them extubated was long canula and using conventional vent settings, this as helped with apnea.
  9. by   nurseiam
    Right now we tend to leave them intubated but there are soooooo many Et tube bugs......
    We also have a newer NCP that can use little mini masks so their nares are not looking like garden hoses have stretched them! The are nice but expensice so we have to try the prongs first........funny they never work for my pts?????
  10. by   nicu tinkerbell
    Quote from Gompers
    We've finally started moving towards this trend, but many of our docs and nurses are skeptical about this change. We tried it a few years ago and some of the preemies ended up much sicker in the long run - mostly NEC from what I remember. Now that we have a newer CPAP set-up that fits micro-preemies better, we're taking the plunge again.

    I've been taking care of a 600 gram 24-weeker for 2 weeks who has never needed much oxygen or vent support. He seems the perfect canidate for extubation, so that his lungs don't get any worse. Everyone around me thinks I'm crazy! They all say he'll get NEC, etc.

    What has been your experience?
    Oue doctors use early extubation all the time. We piloted a new form of o2 herapy about a year and a half ago called vapotherm. The o2 goes through specail tubing and a special cartridge that makesit warmed and highly humidified. it is delivered through special nasal prongs hat are the size of a regular nasal cannula. Because it is highly humidified we can give higher flow rates(on adults you can give 10-15 LPM and I've heard you can harldy feel it) It is very comfortable for the babies and we hardly use conventional CPAP any more. We have only had 1-2 cases of NEC in that time. Even on 28 weekers we tube 'em, surf 'em, and if they are stable and we can wean on vent settings, we wean to vapotherm within a week or so, sometimes even less. Good for the parents too, the can hold the sooner.
  11. by   KRVRN
    We just got a vapotherm to play with. :hatparty: My experience is that it's great for getting a borderline NC/NCPAP baby onto a NC. You can give high flow with good results. When they get down to a 1 L flow though, it seems like you get a lot of rain out. That heavy tubing is hard to get used to, and when you suction you get liquid boogers instead of plugs. I haven't played with it too much, but I did have a pt on it for a few days.

    And... we do absolutely everything prmenrs said. I will add that we automatically surf anything under 30 wks in the del room. Frequent ABG/CBG's to watch CO2 levels, we allow CO2's up to 60ish. Sat goals 85-92%

    We have a big unit with mostly preemies and long term vents/trachs are EXTREMELY rare for us.
  12. by   nicubabe
    We also extubate ASAP to CPAP. By the way I love the little masks, but you have to be careful that they're not on too tight or the nasal bridge gets dented in. Our Neo seems very reluctant to surf some of the kids and pull the tube, which drives us all crazy. He'd rather watch them struggle for a few days on CPAP rather than surf them initially. Of course these are the kids who then end up needing reintubated numerous times and have longer stays due to severe BPD.
  13. by   NoCrumping
    The units i have worked on go strictly by the gases .... if they look good, the will extubate, even if only to gain a few hours off the tube to save that much of lung tissue... when i first started, this floored me.... i used to think if they were that small, they needed to be intubated.lol that was in my early orientation days, however....
  14. by   kitty29
    We generally extubate as early as we can(ussually in the first week, after the head u/s), and have used ncpap with rates and higher pressures. We have pretty good success generally...using recemic epi and narcan at the start. Over the last year the little nares have stayed healthy we have tried some new stuff to follow the skin Real close.

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