Early Extubation in micro-preemies

[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?

[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.

[BabyNurse513]

In my unit if our little kiddos are breathing they get put on CPAP. We use bubble CPAP in our unit and it works really well for us. We don't give them surfactant either unless they need to intubated. Some kids do poop out but for the most part they do well.

[dawngloves, BSN, RN]

I think it is more an issue of how much reserve do these kiddos have? Had a 650g yestereday DOL 3 with stellar gasses, low settings. tThy extubated to CPAP. Well the kid lasted an hour. I don't think someone this small has the stregnth do do it on their own no matter how low the setting are.

Maybe a little lung tissu was saved, but what about brain cells while this kid was satting 20%? And how much trachea damage was done by re intubating?

[sparkyRN]

I so agree with Dawn. The little ones have so little reserve that they poop out, develop secondary apnea then it's back to an ETT and often higher settings initially plus the trauma of intubation and stress of desats. What exactly is gained by this?

[BabyNurse513]

Columbia University is widely recognized as a Center of Excellence for respiratory care because of their low prevalence of BPD. This is achieved by minimizing the need for mechanical ventilation. Liberal application of nasal continuous positive airway pressure (NCPAP) is central to the Columbia approach to respiratory care. However, important components of this approach also include antenatal steroid therapy, gentle resuscitation, liberal application of bubble CPAP initiated in the delivery room via Hudson nasal prongs, meticulous attention to airway management, and permissive hypercapnea. Using this approach, 90% of infants 1000-1250g, 3/4 of infants 750-999g, and more than 1/3 of infants

[prmenrs, RN]

I believe early nutrition is a good thing to help this, too. Day of delivery, they get MVI, trophamine as separate infusions (so that fluctuating glucose needs don't require repeated Hyperal orders).

I like early extubation. Some kids flunk, but a lot more succeed--and more will as we get better at it. I felt the same way, let rest and grow, but I was able to change practice as I saw that it was soooo much better for the babies in the long run. If an old fogie like me can change my mind---well, all I can say is give it a chance!

[dawngloves, BSN, RN]

Those of you that are proponates of early extubation, do you use bubble CPAP, Aladdins or what?

[fergus51]

And has anyone got any litterature about the negative consequences to the 2/3 of infants under 750g that fail at early extubation? This is the part that concerns me.