INTUBATED PATIENT

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INTUBATED PATIENT

• Step by Step
• 4-16-07
• Dora M Alvarez MD

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INITIAL PROCES

• Call from ED requesting bed for and intubated
  patient
• Resident / Supervisor (if applicable) obtains
  information on patients condition on the phone,
  gets Sign out Sheets and Ventilator Order Flow
  sheets and goes to see patient in the ED
• Information needed
• Reason for intubation ()
• Clinical Diagnosis and patients condition

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Reason for Intubation

• Airway protection ?
• Alter Mental Status
• Seizures
• Drug overdose
• Angioedema
• Facial Trauma
• Severe Respiratory Distress / Impending resp
  Failure ?
• Airway disease
• Upper airway (Trauma with edema, angiodema, FB,
  Croup, Epiglotittis)
• Lower airway (Asthma. brochiolitis, CF, BPD )
• Parenchyma disease
• Pneumonia, Pulmonary edema, Pulmonary hemorrhage,
  Aspiration episode, ACS /Pneumonia)
• Broncho-parenchymal problem (Mechonial
  aspiration, Aspiration, BPD
• Trauma chest (Flair, pulmonary contusion,
  pneumothorax, hemothorax.)
• Muscular Diseases.(SMA, Botulism, Guillen Barre)

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Information needed

• Intubation process,
• ET tube Size, cuff or not cuff,
• Intubated by anesthesiologist?, ED attending?,
  resident?
• Medications given
• Complication
• Difficult intubation
• Vomited ? Aspiration
• CxR ray, position of tubes, (ET and NG) lungs
  findings
• Ventilatory settings (write settings in the
  Ventilator order flow sheet)
• ABG

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Ventilator settingExample 8 yo with status
asthmaticus (45 kg)

• Type Ventilator ..PB 840, PB (720)
• Mode
• Volume Control CMV, A/C - SIMV
• Rate (15)
• TV (320 mL (8 ml/kg) ..read the PIP is ??)
• Itime (read the Itime or IE rate show)
• Flow (30 L/min)
• PEEP (0 - 4)
• FIO2 . (100)

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PICU Admission.

• Be and Stay in the room when patient arrives
  Check
• ET tube in place, well taped
• C-R monitor, VS, O2 Sat, ETCO2
• Suction observe and describe type of secretions.
• Check Ventilator setting and order according to
  guidelines
• Usually patients are place on CMVor A/C in ED
  because they are paralyzed and/or heavily
  sedated. Changed to SIMV with PS mode according
  to patients condition, with this mode patient
  may be allow to breath spontaneously, supporting
  his/her respirations.
• Wean FiO2 according to O2 Sat. Usually patient
  came with 100 O2 and an ABG showing high PaO2 gt
  300.
• Continue brochodilator if indicated, back to
  back, MDI 6 puffs Q 30-60 min.
• Sedation order (Verbal) Midazolan / Fentanil.
  Code sheet at bedside.

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Monitoring Intubated patient

• Check
• O2 Sats
• ETC02, monitoring
• Lung auscultation
• Assessment of AB. Ventilation and oxygenation
• ABG
• Temp
• CV HR, PB, perfusion.

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PICU Admission continue

• Review /Check X Ray if not done before and
  document ET tube position
• Order
• Ventilator order as per guidelines, considering
  patients condition / lung pathology.
• Sedation (Midazolan PRN and/Or drip, Fentanyl Or
  Ketamine drip for asthma)
• If indicated order Bronchodilator. MDI 6 puffs
  Alb/ Atrovent alternated - IV solumedrol
• IV Fluids requirements, considering metabolic
  demands, fluid deficit and ongoing loses as
  indicated.

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Reevaluate the need for continuation of
Respiratory support considering the Indication
for intubation

1. If intubated because Alter mental status 2nd to
   post-ictal and /or medications gtgt patient may be
   allowed to wake up (No sedation), wean
   respiratory support quickly, assessing if
   oxygenating and ventilating with no increase work
   of breathing on minimal respiratory support,
   patient may be extubated soon. (See criterion for
   extubation )

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Reevaluate the need for continuation of
Respiratory support considering the Indication
for intubation

• 2. If patient is intubated because
• Hypoxic/Mix respiratory failure 2nd to parenchyma
  pathology I.e Pneumonia, Asthma, bronchiolitis
  patient will need sedation and mechanical
  ventilarory support till the diseases processes
  improves/resolves.
• If patient was intubated because cardiovascular
  instability Shock (Cardiac, septic )
• - Patient should remained, deeply sedated
  /paralyzed and given full respiratory support
  till hemodynamically stable
• 4. Facial trauma, protective airway gt Patient
  should remained, deeply sedated /paralyzed? and
  given full respiratory support till airway is
  consider maintainable.

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Extubation Criteria

• Resolution of condition / reasons for intubation
  examples
• If patient was intubated for alter mental status
  2nd to drug overdose or post-ictal gtgtPt is ready
  for extubation when patient is waking up and
  responsive and breathing spontaneously. (NO NEED
  TO KEEP SEDATING PATIENT TO KEEP INTUBATED)
• If patient is intubated for respiratory failure
  2nd to lower airway obstruction (asthma /
  bronchiolitis) gtgt Pt is ready for extubation when
  airway obstruction is much improved / resolving
  and patient will be able to breath without
  significant respiratory effort / work of
  breathing.

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Extubation Criteria

• 2. Off sedation, awake, able to follow up
  commands, (open eyes spontaneously)
• 3. Positive gag reflex, good cough effort
• 4. Able to maintain open airway.
• If intubation was because primary upper airway
  obstruction (Croup, epiglotittis, stenosis ?),
  need to check for leak around the tube or by
  documenting normal anatomy by inspection.
• 5. Able to lift Head and grip

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Extubation Criteria

• 6. Tolerating weaning down Ventilator support
  to
• CPAP or T-Piece
• Pressure support down lt 4 (at least consideration
  to be wean to nasal/mask CPAP or BIPAP which
  should be available at bedside)
• PEEP lt 4
• FiO2 lt 40 , O2 Sat gt 95 , with out desaturaion
  when succioning.
• 7. Patient is breathing on his own, without
  significant effort or increase work of breathing
  (retractions) and has been able to maintain an
  normal Pa CO2 by ABG and /Or ETCO2
• 8. Patient is hemodynamically stable
• 9. For patient who can cooperate and able to
  follow directions, ask respiratory therapy to
  check NIF (Negative Inspiratory Flow) which
  assess respiratory muscle strength.
• 10. If Patient is trying to take the tube out
  gt and fits above criteria, wean quickly to
  prevent accidental extubations.

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Things to do prior to Extubation 

• NPO (Stop NG/GT feeding for 4-6 hrs before
  planned intubation.
• Have the following ready.
• Oral airway, proper size.
• Working suctioning equipment (younker)
• Proper side ET tube, laryngoscopy for possible
  need for reintubation.
• Ambu-Bag connected to oxygen
• Aerosolized oxygen delivery system
• Nebulizer treatments (Vaponefrin and Albuterol)

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Extubation Procedure

• Suction ET tube and pharynx thoroughly
• Pre-oxygenate Lungs manually inflated with 100
  O2 to keep Sat 100 to provide a
• Reservoir oxygen buffer.
• Cuff deflated (if applicable
• Provide Humidify oxygen with aerosolize mask
  40-50
• Remove restrains and sit patient up
• Auscultate to check air-entry and if any
  adventitious signs.

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Post Extubation

• Observe for presence of stridor, if significant
  and/or persistent stridor give racemic
  epinephrine nebulizer treatment. If prolonged,
  consider the use of Decadron (0.3 -0.5 mg/kg
  ..Max 10 mg 1 dose)
• Observe for increase work of breathing and
  wheezing. Can try Nebulizer albuterol, gentle
  Chest PT, and deep pharyngeal suction to
  stimulate cough, especially in younger patients.
• Assess Oxygen requirement by decreasing FIO2
  gradually if O2 Sat are gt 98
• ABG, (or capillary, VENOUS IS NOT ACCEPTABLE), if
  patient is having signs of respiratory distress /
  increase work of breathing and is still requiring
  gt 35 FiO2.
• CxR is not routinely indicated. Post intubation
  atelectasis is common and demonstrating this in
  CxR may not change patient management.
• Incentive spirometry and CPT may be indicated in
  patients who are not having and effective cough.

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Examples
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1 mo old frequent apnea episodesin between 100
RA

• Check patient
• Nasal and/or oropharingeal secretion, suction
• RR in between 30 .min
• Mental status/ activity ..Stimulated response
  temporaly, cry vigorous and has good color
• Lungs auscultation clear, no murmurs
• HR normal 140 good perfusion
• Observation of apnea, increasing frequency Q
  15-20 min sat 88
• Chest studies CxR, EKG ABG normal, CBC, SMA,
  Blood cultures. U/A
• Intervention CPAP gtgt CPAP SIMV
• FiO2 30
• PEEP 5
• Flow.

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1 mo old frequent apnea episodesin between 100
RA

• Interventions/ Options
• Stimulator (using Bear Cub respirator)-
• OrderMechanical Ventilation-Neonatal (Patient is
  not intubated gtthe breath are going to be deliver
  into a globe which is place under the back of the
  babe)
• Mode SIMV
• Rate 25-30
• Flow (Check guide lines)
• Itime 0.5
• PEEP 0
• FiO2 RA

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1 mo old frequent apnea episodesin between 100
RA

• Interventions/ Options
• 2. Nasal CPAP
• Flow (Check guide lines)
• PEEP 4-5
• FiO2 28 30 ( as needed to keep O2 Sats gt 95
• 3. CPAP / SIMV
• Rate 25-30
• Flow (Check guide lines)
• Itime 0.5
• PEEP 4-5
• FiO2 28 30 ( as needed to keep O2 Sats gt 95

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Intubation if continue with apneas and
bradycardias

• Ventilator Bear Cub
• Mode CMV / SIMV
• Rate 25-30
• PIP 12-14 (low as pat. Has no lung pathology gtsee
  chest raise and check exhale tidal volume)
• ITime 0.5
• Flow 12
• PEEP 4
• FiO2 25-30