need vent tips - mainly for flipping / suctioning

Imafloat, BSN, RN · Oct 23, 2009

Until you are completely comfortable, call respiratory over to help you reposition baby. It is their job and you don't want to deal with an accidental extubation.

I usually disconnect the vent from the ETT if the baby is on low settings or fairly stable, reposition, then reconnect the vent. We don't usually suction until the baby is repositioned, because moving them will loosen up secretions. I am comfortable moving these babies by myself.

If it is an unstable kid, or someone on nitric or an oscillator, I call my friends from respiratory for help.

asdjkl · Oct 23, 2009

it is one of those things where the 'policy' says that we are supposed to do it with two people, but everyone really does it by themselves and if you are asking someone for help "just" to reposition a baby you look like an idiot so essentially, while i have help moving the baby around now, i'm expected to learn how to do it by myself, at least for the easier stable babies. i will make sure my preceptor is always around for now.

i have had different preceptors this week than usual, and some of them seem to expect me to know how to do it all by myself after only a couple of tries. one of them left me by myself, i thought i would be okay because i had done it all right in the morning ---- and whoosh, there goes the water down the ETT, she didn't tell me about the disconnecting or the water in the tubing, until after i had a 'flooded' kid.

Galore · Oct 23, 2009

it is one of those things where the 'policy' says that we are supposed to do it with two people, but everyone really does it by themselves and if you are asking someone for help "just" to reposition a baby you look like an idiot

As a new nurse, you aren't held to the same standards as much more experienced nurses though (or at least shouldn't be!). Better to feel stupid for asking for help, then trying to do it yourself and having an accidental extubation. I remember being in your shoes when I first started out not too long ago, and deliberating asking for help. I know that it's something that all the other nurses can manage on their own, but if you don't feel comfortable doing something, you should trust your gut instinct and ask for help. You will develop a feel for which coworkers are more helpful and understanding than others.

I usually don't bother suctioning first if I'm going to reposition. If there's visible water in the tubing, then you can tilt it down away from the baby and into the receptacle, or briefly disconnect and dump (ask respiratory if you don't feel comfortable doing this).

I'm also not sure what you mean by flipping. I usually move their body first, then their heads so I use one hand to guide their head and one hand to stabilize the ETT. So if baby is prone, I would rotate their body first so they're on their back. Then move their head to the other side.

Confidence will come with experience :)

dawngloves, BSN, RN · Oct 23, 2009

I would never turn a pts head or flip them without disconnection them from the vent. It makes it that much easier to extubate them. I always get help from someone if I am flipping a baby.

RN4Little1s · Oct 25, 2009

Disconnecting the infant from the vent can make it easier to flip their head sometimes, however this leads to an increase in ventilator associated pneumonia (VAP). I try not to disconnect unless there is a large amount of water in the tubing. Our RTs are good about checking the vent tubing frequently because the standing condensation also increases risk for VAP. We also make sure HOB is up. We are big on this, can you tell?

RNs reposition vented infants on their own. When going side to side, I rotate the body some, then follow with one hand turning head and the other supporting ETT. I rotate the tubing connected to the ventilator quickly so it's not causing the ETT to twist or pull. I do this unless it is a HFOV - This takes at least 2 people.. sometimes 3 if we are changing the linens. We flip HOB so head can rotate the other way Q12H.

As far as your plan for an assessment, just realize that each baby is different and things won't go a standard laid out way each time. A squirmy kiddo may throw their head over the other way while you are assessing and you may need to go with it and support the ETT for him turning his head. If your baby "gets a drink" and the water goes down the tube - go ahead and suction him out as quickly as possible. No one wants an unplanned extubation - but if this is something you are really stressing about, go through exactly what you would do if it happened with your preceptor. Ask for help as much as you need! I wish I had asked more questions when I was orienting - because once you aer on you're own is when you get strange looks for asking simple questions!

dawngloves, BSN, RN · Oct 25, 2009

When going side to side, I rotate the body some, then follow with one hand turning head and the other supporting ETT. I rotate the tubing connected to the ventilator quickly so it's not causing the ETT to twist or pull.

Are you doing this in an isolette? Where does your tubing go in?

Bookworm14 · Oct 27, 2009

it is one of those things where the 'policy' says that we are supposed to do it with two people, but everyone really does it by themselves and if you are asking someone for help "just" to reposition a baby you look like an idiot so essentially, while i have help moving the baby around now, i'm expected to learn how to do it by myself, at least for the easier stable babies. i will make sure my preceptor is always around for now.

I am lucky to work with people who are more than happy to help. I worked with vented adults for almost 12 years and switched to NICU recently. THE most nerve-wracking thing for me so far has been repositioning babies on vents. It still makes me nervous that the tubes aren't cuffed and just have a neobar holding them in. Plus the babies I have taken care of so far aren't sedated much at all and can get very squirmy during the turn. I am used to adults who are paralyzed and/or sedated on propofol and don't move much during the turn. I have had other RN's help me so I could see how they coordinate the turn. I have also asked Respiratory to help me and they were more than happy to help.

The thing that I found made it easier to turn them, was to disconnect the suction tubing. I have had the tubing get "stuck" part way through a turn on the ends of the isolette. Of course this means you need to hook it back up quickly if they need suctioned right away after the turn.

I am getting more comfortable with turning them by myself but I will NEVER hesitate to ask for help if that's what is needed to keep the baby safe and intubated.

RM-RN · Nov 12, 2009

For the most part, you'll get better with practice. If anyone is expecting you to reposition without any guidance or help, they're looking for some extubations. That's just not reasonable. Be confident in advocating for your baby. That includes asking for help when you're unsure of how to proceed.

After some practice, a "stable" vent is a one-person event for me. New/unstable vents are me plus RT. HFJV or HFOV are me, another RN and RT....especially if I'm doing something else like linen changes.

I also suction before and after the repositioning to get whatever might be tossing around in there. Sometimes it's much easier to disconnect and reconnect as much as you safely can, rather that trying to untangle it all, so you can avoid making big knots of your tubes and wires. Just be careful to protect the exposed ends from coming in contact with any other surface. The stuff you can safely disconnect for a second are leads (from the cable, not the baby), suction tubing (from the distal end), and POx (cable, not baby).

So...I get everything ready and call for some assistance. I'll ask RT to secure the tube, and I'll do everything else. I reposition the body of the baby first, and rearrange all of their wires/tubes after that. I try to go in a positioning order that makes sense, and makes the whole ordeal less traumatic for everyone. Vented kids are usually in Omnibeds, so their tubing comes into the bed right down the middle. It makes it easier to move from side-to-side.

We don't disconnect vent tubing unless it's absolutely necessary. Breaking into the circuit leads to an increase in VAP and tracheal infections. Not to mention, that you loose whatever pressures you've been trying to gain.

Frankly, I couldn't care less if people think I'm an idiot for asking for too much help. IMO...there's no such thing. The worst case scenario? I've asked them for 5 minutes of their time so they can stand around and do nothing. I'm okay with that. :)

EmilyPeruana · Feb 15, 2010

wanna know the easiest trick to doing it - GET A FRIEND. i'm the one who always takes the hardest babies or gets assigned the most complicated chronic ones because i dont mind them and have experience with them. but i still get another nurse or RT to help me when it comes to changing a trach (even though i can probably manage alone) or flipping a baby or repositioning...

always ask someone for a hand...even the most experienced will ask for help! plus, you dont want that tube coming out or being pushed down that right lung and not expanding that left one at all! :)

good luck! i'm sure you're doing a fabulous job! :)