Extubation: A Case Study

“For some investigators, ‘weaning success’ is defined as sustained spontaneous, unassisted breathing with or without an artificial airway, and for others it is defined as sustained extubation” (Cook 2000). Whatever the nurse and physician see as the definition to weaning is far less important than ensuring their patient is weaned at the correct time. Allowing a patient to remain intubated and on mechanical ventilation when it is no longer needed, only puts the patient at risk for problems beyond the reason for initial intubation.

Use of daily spontaneous breathing trials to assess the patient’s ability to sustain ventilation, oxygenation, and breathing.

When trying to determine lung function of premature infants can be quite difficult, the main issue is to ensure the safety of the infant. One of the newest methods of measuring lung function is pulmonary and arterial resistance and compliance test (RC tests). RC tests are two different lung function test that when combined together can determine a thorough understanding of lung function (Okada S. et. al., 2017). One part of the RC test is the resistor-capacitor test (RP). The RP test is used to determine the blood flow through the pulmonary vasculature (Okada S. et. al., 2017). The second part to the RC test are the pulmonary arterial compliance test which determines the the blood vessels elasticity and extensibility (Okada S. et. al., 2017). When the data from the RP and CP test are merged the data can determine the pressure of the pulmonary

Terminal weaning is when mechanical ventilation is discontinued for a patient expected to die without its support (Knight & Espinosa, 2010). One of the most common methods of discontinuation is through slowly reducing the fraction of inspired oxygen (Knight & Espinosa, 2010). Terminal extubation is the removal of the endotracheal tube, and this can be done “during or after a terminal weaning process” (Knight & Espinosa, 2010, p. 527). Removal of life-supporting interventions is the cause of most deaths in critical care units (Knight & Espinosa, 2010). Knight and Espinosa (2010) discussed palliative sedation and terminal weaning in the same chapter because the two topics go together.

The patient will be able to tolerate ambulation to the bathroom and to the shower with minimal shortness of breath

Upon arriving at the scene, the advanced care paramedic would begin the primary survey. All dangers would be assessed, including environmental dangers, animals, agitated bystanders and any other alarming cues. Once all dangers have been assessed the ACPs begin investigating the patient’s responsiveness using the acronym AVPU (QLD.gov.au, 2016). An assessment of their alertness, verbal response, response to painful stimuli or unconsciousness is completed. Once assessed, the patient’s airway is then checked to be clear of any obstructions to ensure proper respiration can occur, at this point, the triple airway manoeuvre would be adjusted to only the opening of the mouth and the jaw thrust (QLD.gov.au, 2015). If the patient complains of neck and back tenderness, neurological deficit, evidence of intoxication or a distracting injury (QLD.gov.au, 2016. 2) spinal immobilisation is required to ensure no further damage to the spinal cord occurs or an aid to keep the patient as calm as possible if a distracting injury (Hodegetts et al., 2011). The patient's breathing should then be assessed now that the spine in immobilised to ensure the depth, rate and rhythm of the breaths are adequate. If needed an oropharyngeal airway may need to be inserted into the mouth to keep the tongue from blocking the airway if it is tolerated (Higginson et al,. 2013). Lastly, in the primary survey, the

An unplanned extubation (UE) in the Neonatal Intensive Care Unit (NICU) is an unforeseen occurrence observed due to various factors. One of these is due to the lack of a procedural standardization among healthcare providers. This is notably evident when staff is handling the infant during daily assessments and when care is rendered. The reason this issue was selected was because of the potential serious complications or death that a can occur to a patient due to the lack of procedural standardization, preventing UE is the issue that will be addressed.

The primary assessment of this patient is the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. According to the ABCDE approach, it is crucial to check the airway first to see if the airway is patent. Then, check the patient’s breathing. Determining the respiratory rate, inspecting movement of the chest wall, measuring pulse oximeter and using the stethoscope to auscultate the lung sounds are the possible way to check if the breathing of the patient is sufficient (Thim et al., 2012). Next, check the circulation. Skin changes, such as check the colour and sweating, relate to the circulatory problems. Also, heart auscultation, blood pressure measuring and electrocardiography monitoring should be involved in this procedure (Thim et al., 2012). When measure the blood pressure, using the AVPU score (A for ‘alert’, V for ‘reacting to vocal stimuli’, P for ‘reacting to pain’, U for ‘unconscious’) to assess the consciousness, which is for the disability part. Moreover,

ation that I will be discussing is Airway Pressure Release Ventilation (APRV). I have not had an opportunity to use this mode, so I thought I would research it for this assignment. “The degree of ventilator support with APRV is determined by the duration of the two CPAP levels and the mechanically delivered tidal volume. Depends mainly on respiratory compliance and the difference between the CPAP levels. By design, changes in ventilatory demand do not alter the level of mechanical support during APRV. When spontaneous breathing is absent, APRV is not different from conventional pressure-controlled, time-cycled mechanical ventilation”( Putensen, C. )APRV is a form of improved pressure ventilation allowing unrestricted spontaneous breath at an

You have a patient who has been on a ventilator for 3 weeks. What should be you highest assessment priority that needs to be obtained before beginning the weaning process?

Our initial evaluation includes assessment of vital signs, assessment of the cardio-pulmonary status including work of breathing, breath sounds, perfusion, and pulses for circulatory assessment (Jevon, 2012, p. 193).  Assessment of consciousness, using the paediatric Glasgow Coma Scale (GCS) (ANZCOR, 2016), Level of consciousness using Alert, Verbal, Pain, Unresponsive scale (AVPU) (Jevon, 2012, p.194). Neurological observations, EDOES and CEWT to determine deterioration (PMH, 2013).

In many neonatal intensive care units, the nasal continuous positive airway pressure is a common mode of respiratory support for preterm infants. (Yong et. al., 2005). During my exposure in the neonatal unit, I have noticed that many of the babies are on nasal CPAP. I believe that this a good choice, given the benefits of using the NCPAP for respiratory support. Improved oxygenation and gas exchange, prevention of atelectasis and apnoea, stabilisation of needed functional residual capacity, and surfactant conservation are advantages of using NCPAP according to Newnam et. al. (2013). Xie (2014) further added that NCPAP lowers upper airway resistance and most importantly, it eliminates the use of endotracheal tube and ventilator along with its

A couple months ago, my unit (Cardiovascular intensive care unit) and the other ICU unit at my hospital started implementing a set scheduled time for performing spontaneous breathing trials (SBTs) for all ventilated and intubated patients during both the day and night shift. This change allows for a structured protocol with clear instructions on how to approach SBT and is part of our strategy to decrease the amount of time that the patients stay intubated. The sooner we remove the intubation tube; it will decrease the chances of the patient developing any ventilator-associated pneumonia because we are allowing their natural lungs to exercise.

The drive of this analysis was to assess the efficiency of a three-pronged intervention to decrease the risk of aspiration in above group of patients.

There have been several studies attempting to clearly identify the risk factors for the extubational difficulty. First of all, Demling et al. prospectively investigated the use of standard criteria for extubation in 700 patients in ICU, but could not find any good predictors for extubation failure (Demling et al., 1988). Leak test is still the controversial routine choice of many practitioners used to predict the potential occurrence for airway edema evaluating whether the airway caliber is sufficient for ventilation (Chung et al., 2006; Ding et al., 2006; Kriner, Shafazand & Colice, 2005). In one study, the evaluation of the leak test in 72 spontaneously breathing ICU patients indicated that the presence of a cuff leak may associated with