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Discussion

ETT and fighting vent??

I had a 32 weeker that was intubated and was becoming agitated and fighting the vent. After recieving report of this and morning rounds, we all agreed to aggressively try to extubate to CPAP. About 8 hours later he was still intubated and having multiple desats (to the 50s) that would take about 5 minutes to recover. The neo attending told me he was agitated because of the tube, and hypoxia and was ultimately still trying "to breath through a straw" (the ett.) What I dont understand is that I thought a 32 weeker is an obligate nose breather... does this change if they are intubated?? I know the ETT is his only airway but would he not exhibit any other signs of respiratory distress?? Thanks!!

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What were his blood gases like? Maybe he needs sedation, a chest xray and different vent settings? Being a nose breather really has nothing to do with being on the vent, especially if the tube down the throat is causing anxiety and agitation in the baby.

And he is showing signs of respiratory distress--the desats and the agitation means that he is air hungry.

Dawn

  • Author

Thanks... his blood gases were perfect and xray looked great, I didn't want to give sedation because it wasn't affecting his gases and he would calm down immediately after his spells. He probably just needed the tube out, but the RT disagreed and just wanted to sedate. The other thing was during his desats his heart rate would increase and CO2 (from the TCom) would drop from the 50s to 30s during his spells. Thanks for your input :)

I would have either given him a prn dose of fentanyl or versed if his settings were not extubatable.

If his blood gases were great, then why was he still intubated?

We're very aggressive in getting the kids extubated. Sounds like he was having spells because he was getting himself so worked up.

If the tube is occluding his trachea, then the fact that he is an obligate nose breather isn't going to make much difference. He is breathing through the ETT, whether it's the machine breathing for him or him breathing on his own. If he is not able to be extubated, I think the humane thing to do would be to offer him some sedation to help take the edge off.

We always at least lightly sedate babies who cannot be extubated but are fighting the vent. Not Fentanyl or Versed, but generally Lorazepam and maybe morphine.

Dawn

Suction?

  • Expert

If suctioning and repositioning weren't working, and he looked air-hungry, you could try increasing his PIP or increasing his I-Time on the vent. You could also try increasing the gas flow rate on the vent. If it looked like ventilator asynchrony to you, you could also increase the trigger sensitivity to try and match breaths better.

This kid probably just needed to be extubated. If he was nowhere near extubation, I'd definitely ask for some sedation.

narc & park!!! sedate & vecc leads to quick sussceful extubation!

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