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Discussion

intubation threshold

What do you see on your unit regarding when to intubate? It seems that there is a huge push to never intubate. I understand the risks involved, but when you are dealing with tiny micropreemies, it kinda seems almost inevitable. We are extubating kids earlier and earlier... a lot do really well... and a lot don't. Where I worked previously, we rarely saw a NCPAP of 7. If we did it was a last resort and was very short term. At my new job, we routinely use 7 and now even 8 and 9!! We just intubated this kiddo (3wk old 24weeker) who was on a CPAP of 8 for 10 days. He is so shut down and exhausted, he is still having bad events on the ventilator. So, I would like to know what are all of you doing in your units? Do you leave kids intubated forever? Not long enough? Ever? How high do you go on NCPAP? Do you notice any long term benefits or have bad outcomes? I feel like we are doing a greater dis-service to these kids by allowing them to struggle, forcing their lungs open with massive amounts of pressure, and causing more ROP and brain damage from high O2 swings and apnea/brady/desat events.

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    Wow! We do not do CPAP beyond 7. I would be interested to see what the literature supports. We try to limit vent days, but sometimes it is inevitable. We intubate for A/B episodes, evidence of severe WOB, and even xrays. We try to wean off quickly but safely. It is a delicate balance, as well you know!

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    Wait. Your 24 weeker was never intubated??

    HOnestly, it depends on who the attending is. Some look at gasses, some look at the settings and what kind of volumes the kid is getting, ect, ect. A 24 weeker on CPAP sounds extreme. I'm surprised that PEEP didn't give him a pneumo.

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    Wow! We do not do CPAP beyond 7. I would be interested to see what the literature supports. We try to limit vent days, but sometimes it is inevitable. We intubate for A/B episodes, evidence of severe WOB, and even xrays. We try to wean off quickly but safely. It is a delicate balance, as well you know!

    Same here and sometimes for gasses.

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    I've worked from time to time in a place that will use up to a CPAP of 12 (!) with FiO2's >70% if it means keeping a kid from being tubed. The thinking (not that I agree) is that the trauma to the airways from intubation/ventilation is more of a concern than the risks of letting the kid struggle on CPAP. I haven't worked there enough to get a feel for how all of that plays out in the long run.

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    omg. i'd die if i saw a 24 weeker on cpap...i've never seen us use cpap greater than 6...and it's rare for us to use 6...we generally use 4-5...we may try to extubate around 28 weeks to cpap...depends on the patient...depends on their gases...but they will go right back to the ventilator if their gases dont improve...if their retractions worsen...tachypneia increases...thankfully i work at a hospital where most docs trust the nurses and will at most give the infant a little more time, but will usually trust the nurse and do what needs to be done. i know that they do not want the infants to be intubated for a long time and to be at risk for VAP, etc...but crapping out is a whole lot worse...

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