Vent to CPAP...scenario and questions for ya'll!

[NICU_Nurse, BSN, RN]

Hey, all. I have yet another question. We have a baby who is about eight hundred grams- a twin who is about the size of my hand from wrist to fingertip. She is about 30 days old, and was born at 28 weeks. She was on a vent at first, and within two days, she self-extubated and they decided to try her on CPAP, unsuccessfully...she had to be re-tubed. She yanked it out again, and once again, was tried on CPAP. Wasn't happenin'. Back to the vent. She is now on a traditional vent at the lowest settings- 21%, rate of 12, etc. We usually take successful babies on these settings and move them to CPAP, but as I mentioned, she hasn't done well and the doctors have tried at LEAST two times in the last month (adjusted, I think she's now at about 32 weeks, give or take one or two). She is satting 100 on these settings, and the doctors are very enthusiastic (teaching hospital) about extubating her. I'm wondering what you experienced people think about this? It seems to me that she is just not ready, and she is SO SMALL. Maybe I am getting a block, and not seeing the whole picture, and I know better than to underestimate some of these babies, but...well, do you see what I'm wondering here? Having a hard time phrasing it. I guess I'm wondering if she should just be left alone until she gets a bit larger (weight is not steadily increasing yet- still very fluctuant). What do you think? What do you do in situations like these? Is it putting too much stress on her to keep insisting that she be put on CPAP, only to have to be re-intubated?

[dawngloves, BSN, RN]

Well usually when a baby yanks out a tube they're saying. "I'm ready for CPAP!" But yes they fail sometimes. Is she breathing above settings ? Clamping down on the tube? How are her gases I wouldn't use weight as a gauge. I've seen 700 gram 24 weekers go right to CPAP and fly.

Talk to the docs about your apprehension. You are part of the decision making process too!

[kids]

I'd want to see her get a long trial on pressure support before weaning her down to CPap.

3 weeks ago I admitted to home care yet another premie (830 gram/26 week abruption) who was "doing fine on a 'little' O2 bled into her trach mist"...2 weeks ago she went to the Pulmo for follow up...CO2 was 96. She came home from the PICU on a vent last week...pressure support 12, PEEP 6. Goal is to start weaning her onto CPap with the long term goal of CPap 12 hrs/ night.

[KRVRN, BSN, RN]

In that scenario we would extubate and try CPAP again. We actually wean down to a rate of 10 or even 8, more rarely. Is she already on aminophylline or caffeine?

We too, have extubated 24-25 weekers to CPAP within that first week or two. Pretty amazing when you think about what we can do these days. We have a few older nurses that remember the pre-surfactant days. Never would have happened back then. And it wasn't so very long ago either.

[nell]

Originally posted by KRVRN

...We have a few older nurses that remember the pre-surfactant days...

God, I feel like such a dinosaur! I vividly remember our trials of surfactant: how the Neos were saying they didn't think it would really work, then one told me to decrease the vent rate drastically (like by 10) and my brain mis-heard and I only decreased by a few breaths. Kids used to be on vents for months then, now it's maybe a week for most....

[prmenrs, RN]

One word: steroids

[prmenrs, RN]

Actually---more than one.

"If I were in charge--" a VERY short course of steroids, i.e. 2-3 days, tapering; also, consider nasal SIMV--that's CPAP w/a rate. That would give the kid more support than just CPAP.

Also, make sure the nutrition is adequate--what's the growth curve like? You may have to go to NJ feeds if too much air goes in the stomach.

[Jolie, BSN]

Also being a dinosaur, I vividly remember the pre-surfactant days when having a micro-preemie come off a vent in a week or two was almost unheard-of. I worked in one unit where these babies who failed CPAP, but didn't really need ventilation were placed on nasal cannulas at about 1/4 lpm flow. The prongs were long enough on these tiny kids to have the same effect as CPAP, but allowed for much greater freedom of movement, ease of handling, and comfort for the babies and caregivers, and it also allowed the parents to hold their tiny ones. It worked surprisingly well and was a simple solution. I think in this day and age of super high-tech, we sometimes write off the older and simpler way of doing things. If you suggest this in your unit, you'll probaby get blank stares.

[NiteNICUNurse, BSN, RN]

Depends what the reaons were for her needing to be reintubated...if it was because of A's & B's starting on caffeine or rebolusing her might help. If it was mechanical, steriods or an ENT consult is probably needed. In our unti if an infant fails extubation mutiple times and did not fail because of sepsis etc. then the ENT's usally take them to the OR for a bronc at the same time of extuabtion