- Email: [email protected]
Collaborative extubation; best practice?
Journal of Neonatal Nursing (2008) 14, 166e169
www.elsevier.com/jneo
Collaborative extubation; best practice? Karina Vandertak* Medway Maritime Hospital, Gillingham, Kent ME7 5NY, United Kingdom Available online 31 July 2008
KEYWORDS Extubation; Premature; Interprofessional collaboration; Guidelines; Handling; Audit; Caffeine
Abstract Extubation of very low birth weight (VLBW) neonates is a crucial stage in their and their families’ lives. Despite this, there are very little nursing studies published regarding the care of the baby around the time of extubation. The author hypothesised that successful extubation is a collaborative effort between nursing and medical staff, the actions of the nurse being highly influential. In order to test this hypothesis the author carried out an audit over 2 months of planned extubations of VLBW neonates. Following a literature review a number of medical and nursing parameters were identified to be included in the audit. Although only 11 babies were reviewed the findings have resulted in the change in both the medical and nursing guideline. Results showed that the successful extubations were given a higher dose of caffeine. Findings around the nursing issue of handling were most notable as every baby which failed extubation had ‘all cares’ at the time of the procedure. All of the successful babies had ‘all cares’ 1e2 h pre-extubation. ª 2008 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Introduction It is well known that mandatory ventilation is harmful to neonatal lungs (Sweet et al., 2007; Greenspan and Shaffer, 2006). There has been recent interest in early CPAP with studies by Booth et al. (2006) and the COIN study (Morley et al., 2007). This has prompted the author to look at the extubation success of very low birth weight pre-term neonates on her unit.
* The Oliver Fisher Neonatal Unit, Medway Maritime Hospital, Windmill Road, Gillingham, Kent ME7 5NY, United Kingdom. Tel.: þ44 01634 825125; fax: þ44 01634 825126. E-mail address: [email protected]
The unit has a paragraph on extubation within the nursing guidelines at the end of the intubation guideline. Unlike the other guidelines this paragraph is not referenced. The author reviewed the literature to find evidence for this guideline. Nursing journals were more concerned about fixing endotracheal tubes to prevent accidental extubation. The nursing textbooks also had very little references, for example, Merenstein and Gardner (2002) simply says CPAP can be useful. Boxwell (2006) mentions differing practices of endotracheal suctioning around the time of extubation, without references for this. It seems that extubation is seen by nurses as a medical activity, although on the author’s unit it is the nurses who extubate. The unit did not have a medical
1355-1841/$ - see front matter ª 2008 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2008.05.001
Collaborative extubation
167
Table 1 Details of baby Ventilation prior to extubation Pre-extubation gas Caffeine Lines Grade of nurse Cares Position of baby post-extubation Post-extubation gas Sequalae
Gestation birth weight age at extubation Mode settings FiO2 R.R. pH pCO2 SBC BE Loading to ext. interval maintenance UVC UAC PA PIV LL Band 5 Jr./Snr. band 6 Jr./Snr. band 7 Before extubation post-extubation Supine prone Side lying pH pCO2 SBC BE
guideline for extubation, but did have a guideline for weaning ventilation. This guideline states its aim as ‘to maintain normal blood gases’ rather than aiming to extubate! The medical journals look at extubation from the viewpoint of ventilator weaning (Sinha and Donn, 2000), the use of CPAP (Owen et al., 2007) and caffeine (Steer et al., 2004). All of which have been shown to influence extubation success. These areas are also addressed in the medical textbooks (Goldsmith and Karotkin, 2003), (Greenough and Milner, 2003). The lack of comment about the handling of the babies, positioning and suction in the medical literature suggests that the doctors see this as either irrelevant or the domain of the nurses.
The objective of the review The author has always considered the successful extubation of a VLBW neonate as collaboration between medical and nursing staff, requiring experience, skill and good judgement. With the aim of stimulating discussion within the unit, the author undertook a short review of current extubation practice prior to presenting a respiratory study day, in-house, to doctors and intensive care nurses on the unit.
A
Planned extubations
success failure
Chart A
Planned extubations.
Method Parameters for the audit were identified from the nursing and medical literature, the unit guidelines and observations from practice. A data collection template was designed (Table 1). The parameters were gestation, age and birth weight of the baby, the ventilator settings, including oxygen fraction at time of extubation, blood gas prior to and after extubation, interval of caffeine loading and time of extubation, caffeine maintenance dose, grade of nurse, time of cares prior to and post-extubation, position after extubation, time nil by mouth and access lines. Sequelae were also collected. Data was collected over a 6 week period from all planned extubations under 32 weeks gestation, retrospectively using the notes and charts. The results were then collated in the ‘failed’ or ‘successful’ groups. For ease of comparison the MAP ventilator settings were used, as some babies were on high frequency oscillation and some on conventional ventilation. The results for each group were then combined to give a mean or percentage.
Results Eleven neonates under 31 weeks were electively extubated during the review period. Five were unsuccessful; requiring re-intubation within 48 h. Six were successful, remaining off the ventilator for the rest of their stay (Chart A). The mean gestation, the ventilator MAP, the lines, blood gases and period nil by mouth were similar in each group. The caffeine load to extubation interval mean was 2 days in each group. The caffeine maintenance was 11 mg/kg in the failed group and 15.8 mg/kg in the successful group. Post-extubation positioning was similar in both groups; 4/6 (66%) prone in the successes, 3/5 (60%) in the failures.
168 Table 2
K. Vandertak Audit results
Mean results*
Success
Fail
Mean airway pressure* Gestation* Oxygen requirement* Caffeine maintenance dose* Post-extubation position-prone Post-extubation position- sup/side Time interval; extubation to next cares* Time interval; preextubation cares until extubation* Grade of nurse extubating e band 7 Grade of nurse e senior band 6 Grade of nurse e junior band 6 Grade of nurse e band 5 Nil by mouth interval
7 26.6 weeks 26.5% 15.8 mg
6.6 25.6 weeks 28% 11 mg
4/6
3/5
2/6
2/5
5.5 h
7.4 h
2.1 h
0h
0
0
1
2
3
2
2 4h
1 4h
The * indicates the results represented by a mean and the results with no * are actual values.
The experience of the nurse slightly favoured the more junior nurses for success. The interval from extubation to the first ‘all cares’ was a mean of 7.4 h in the failure group and a mean of 5.5 h in the successful group. ‘All cares’ prior to extubation interval in the failure group was 0 h. All the failures had ‘all cares’ and were extubated within the same hour. The successes had a mean interval of 2.1 h between ‘all cares’ and being extubated. None of the successes had cares at the time of extubation. A summary of the results can be seen in the Table 2.
Discussion The aim of this review was to generate discussion around ways to improve outcomes when extubating VLBW neonates as part of an interprofessional respiratory study day. The results very strongly suggested a link between handling at extubation and extubation success. The author had not expected to have such strong evidence from a very small audit. The question of what to do with this information had to be addressed. Having a small sample raised issues of validity, with the ethical question of whether a larger
sample should be audited before changing practice or should practice be changed before a larger audit. The results of the audit were sent to the unit consultants and presented to 43 intensive care nurses and specialist registrars over two study days. The nurses were quite defensive about their practice, some saying that there were some babies who would fail extubation whatever the nurse did. It was also suggested that the nurses always aimed to extubate at the time of cares and there was only an accidental delay on occasion. Other nurses defended their practice of deliberately leaving the babies an hour after ‘all cares’ before extubating. Interestingly, it is normal practice not to do ‘all cares’ prior to taking off CPAP support, as this is felt to stress and tire the baby too much. The consultants were supportive of a change in the management of extubation on the strength of the audit and the common sense rationale of leaving the baby to recover from its cares. In conjunction with the audit the consultants reviewed their caffeine policy. As a result of the interest and information generated by the audit of current practice the nursing guideline has been changed, the caffeine dose has been increased and an interprofessional extubation interest group has been formed. The group will more comprehensively audit elective extubations over a longer period with a view to developing best practice in collaborative extubation.
Conclusion Extubation of very low birth weight neonates is a routine event on neonatal intensive care units yet there is very little documented evidence about how it is done. It is hoped that the much larger audit will inform our practice further.
References Booth, C., Premkumar, M.H., Yannoulis, A., Thomson, M., Harrison, M., Edwards, A.D., 2006. Sustainable use of continuous positive airway pressure in extremely preterm infants during the first week after delivery. Arch. Dis. Child. Fetal Neonatal Ed. 91, 398e402. Boxwell, G., 2006. Neonatal Intensive Care Nursing. Routledge, London. Goldsmith, J., Karotkin, E.H., 2003. Assisted Ventilation of the Neonate, sixth ed. WB Saunders, Philadelphia. Greenough, A., Milner, A.D., 2003. Neonatal Respiratory Disorders. Arnold, London. Greenspan, J.S., Shaffer, T.H., 2006. Ventilator-induced airway injury; a critical consideration during mechanical ventilation of the infant. Neonatal Netw. 25 (3), 159e166.
Collaborative extubation
169
Merenstein, G., Gardner, S., 2002. Handbook of Neonatal Intensive Care, sixth ed. Mosby, Philadelphia. Morley, C.J., Davis, P.G., Doyle, L.W., Brion, L., Hascoet, J.-M., Carlin, J.B., 2007. A randomized controlled trial of nasal continuous positive airway pressure or intubation or ventilation for very preterm infants at birth: the coin trial. Acta Paediatr. 96 (Suppl. 456), 233. Owen, L.S., Morley, C.J., Davis, P.G., 2007. Neonatal nasal intermittent positive pressure ventilation: what do we know in 2007? Arch. Dis. Child. Fetal Neonatal Ed. 92, 414e418.
Sinha, S., Donn, S.M., 2000. Weaning from assisted ventilation: art or science? Arch. Dis. Child. Fetal Neonatal Ed. 83, 64e70. Steer, P.A., Flenady, V.J., Lee, T.C., Tudehope, D.I., Charles, B.G., 2004. Periextubation caffeine in preterm neonates; a randomized dose response trial. J. Paediatr. Child Health 39 (7), 511e515 Sept-Oct. Sweet, D., Bevilacqua, G., Carnielli, V., Greisen, G., Plavka, R., Saugstad, O.D., Simeone, M., Speer, C., Valls-i-Soler, A., Halliday, H., 2007. European consensus guidelines on the management of neonatal respiratory distress syndrome. J. Perinat. Med. 35 (3), 175e186.
Available online at www.sciencedirect.com
www.elsevier.com/jneo
Collaborative extubation; best practice? Karina Vandertak* Medway Maritime Hospital, Gillingham, Kent ME7 5NY, United Kingdom Available online 31 July 2008
KEYWORDS Extubation; Premature; Interprofessional collaboration; Guidelines; Handling; Audit; Caffeine
Abstract Extubation of very low birth weight (VLBW) neonates is a crucial stage in their and their families’ lives. Despite this, there are very little nursing studies published regarding the care of the baby around the time of extubation. The author hypothesised that successful extubation is a collaborative effort between nursing and medical staff, the actions of the nurse being highly influential. In order to test this hypothesis the author carried out an audit over 2 months of planned extubations of VLBW neonates. Following a literature review a number of medical and nursing parameters were identified to be included in the audit. Although only 11 babies were reviewed the findings have resulted in the change in both the medical and nursing guideline. Results showed that the successful extubations were given a higher dose of caffeine. Findings around the nursing issue of handling were most notable as every baby which failed extubation had ‘all cares’ at the time of the procedure. All of the successful babies had ‘all cares’ 1e2 h pre-extubation. ª 2008 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Introduction It is well known that mandatory ventilation is harmful to neonatal lungs (Sweet et al., 2007; Greenspan and Shaffer, 2006). There has been recent interest in early CPAP with studies by Booth et al. (2006) and the COIN study (Morley et al., 2007). This has prompted the author to look at the extubation success of very low birth weight pre-term neonates on her unit.
* The Oliver Fisher Neonatal Unit, Medway Maritime Hospital, Windmill Road, Gillingham, Kent ME7 5NY, United Kingdom. Tel.: þ44 01634 825125; fax: þ44 01634 825126. E-mail address: [email protected]
The unit has a paragraph on extubation within the nursing guidelines at the end of the intubation guideline. Unlike the other guidelines this paragraph is not referenced. The author reviewed the literature to find evidence for this guideline. Nursing journals were more concerned about fixing endotracheal tubes to prevent accidental extubation. The nursing textbooks also had very little references, for example, Merenstein and Gardner (2002) simply says CPAP can be useful. Boxwell (2006) mentions differing practices of endotracheal suctioning around the time of extubation, without references for this. It seems that extubation is seen by nurses as a medical activity, although on the author’s unit it is the nurses who extubate. The unit did not have a medical
1355-1841/$ - see front matter ª 2008 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2008.05.001
Collaborative extubation
167
Table 1 Details of baby Ventilation prior to extubation Pre-extubation gas Caffeine Lines Grade of nurse Cares Position of baby post-extubation Post-extubation gas Sequalae
Gestation birth weight age at extubation Mode settings FiO2 R.R. pH pCO2 SBC BE Loading to ext. interval maintenance UVC UAC PA PIV LL Band 5 Jr./Snr. band 6 Jr./Snr. band 7 Before extubation post-extubation Supine prone Side lying pH pCO2 SBC BE
guideline for extubation, but did have a guideline for weaning ventilation. This guideline states its aim as ‘to maintain normal blood gases’ rather than aiming to extubate! The medical journals look at extubation from the viewpoint of ventilator weaning (Sinha and Donn, 2000), the use of CPAP (Owen et al., 2007) and caffeine (Steer et al., 2004). All of which have been shown to influence extubation success. These areas are also addressed in the medical textbooks (Goldsmith and Karotkin, 2003), (Greenough and Milner, 2003). The lack of comment about the handling of the babies, positioning and suction in the medical literature suggests that the doctors see this as either irrelevant or the domain of the nurses.
The objective of the review The author has always considered the successful extubation of a VLBW neonate as collaboration between medical and nursing staff, requiring experience, skill and good judgement. With the aim of stimulating discussion within the unit, the author undertook a short review of current extubation practice prior to presenting a respiratory study day, in-house, to doctors and intensive care nurses on the unit.
A
Planned extubations
success failure
Chart A
Planned extubations.
Method Parameters for the audit were identified from the nursing and medical literature, the unit guidelines and observations from practice. A data collection template was designed (Table 1). The parameters were gestation, age and birth weight of the baby, the ventilator settings, including oxygen fraction at time of extubation, blood gas prior to and after extubation, interval of caffeine loading and time of extubation, caffeine maintenance dose, grade of nurse, time of cares prior to and post-extubation, position after extubation, time nil by mouth and access lines. Sequelae were also collected. Data was collected over a 6 week period from all planned extubations under 32 weeks gestation, retrospectively using the notes and charts. The results were then collated in the ‘failed’ or ‘successful’ groups. For ease of comparison the MAP ventilator settings were used, as some babies were on high frequency oscillation and some on conventional ventilation. The results for each group were then combined to give a mean or percentage.
Results Eleven neonates under 31 weeks were electively extubated during the review period. Five were unsuccessful; requiring re-intubation within 48 h. Six were successful, remaining off the ventilator for the rest of their stay (Chart A). The mean gestation, the ventilator MAP, the lines, blood gases and period nil by mouth were similar in each group. The caffeine load to extubation interval mean was 2 days in each group. The caffeine maintenance was 11 mg/kg in the failed group and 15.8 mg/kg in the successful group. Post-extubation positioning was similar in both groups; 4/6 (66%) prone in the successes, 3/5 (60%) in the failures.
168 Table 2
K. Vandertak Audit results
Mean results*
Success
Fail
Mean airway pressure* Gestation* Oxygen requirement* Caffeine maintenance dose* Post-extubation position-prone Post-extubation position- sup/side Time interval; extubation to next cares* Time interval; preextubation cares until extubation* Grade of nurse extubating e band 7 Grade of nurse e senior band 6 Grade of nurse e junior band 6 Grade of nurse e band 5 Nil by mouth interval
7 26.6 weeks 26.5% 15.8 mg
6.6 25.6 weeks 28% 11 mg
4/6
3/5
2/6
2/5
5.5 h
7.4 h
2.1 h
0h
0
0
1
2
3
2
2 4h
1 4h
The * indicates the results represented by a mean and the results with no * are actual values.
The experience of the nurse slightly favoured the more junior nurses for success. The interval from extubation to the first ‘all cares’ was a mean of 7.4 h in the failure group and a mean of 5.5 h in the successful group. ‘All cares’ prior to extubation interval in the failure group was 0 h. All the failures had ‘all cares’ and were extubated within the same hour. The successes had a mean interval of 2.1 h between ‘all cares’ and being extubated. None of the successes had cares at the time of extubation. A summary of the results can be seen in the Table 2.
Discussion The aim of this review was to generate discussion around ways to improve outcomes when extubating VLBW neonates as part of an interprofessional respiratory study day. The results very strongly suggested a link between handling at extubation and extubation success. The author had not expected to have such strong evidence from a very small audit. The question of what to do with this information had to be addressed. Having a small sample raised issues of validity, with the ethical question of whether a larger
sample should be audited before changing practice or should practice be changed before a larger audit. The results of the audit were sent to the unit consultants and presented to 43 intensive care nurses and specialist registrars over two study days. The nurses were quite defensive about their practice, some saying that there were some babies who would fail extubation whatever the nurse did. It was also suggested that the nurses always aimed to extubate at the time of cares and there was only an accidental delay on occasion. Other nurses defended their practice of deliberately leaving the babies an hour after ‘all cares’ before extubating. Interestingly, it is normal practice not to do ‘all cares’ prior to taking off CPAP support, as this is felt to stress and tire the baby too much. The consultants were supportive of a change in the management of extubation on the strength of the audit and the common sense rationale of leaving the baby to recover from its cares. In conjunction with the audit the consultants reviewed their caffeine policy. As a result of the interest and information generated by the audit of current practice the nursing guideline has been changed, the caffeine dose has been increased and an interprofessional extubation interest group has been formed. The group will more comprehensively audit elective extubations over a longer period with a view to developing best practice in collaborative extubation.
Conclusion Extubation of very low birth weight neonates is a routine event on neonatal intensive care units yet there is very little documented evidence about how it is done. It is hoped that the much larger audit will inform our practice further.
References Booth, C., Premkumar, M.H., Yannoulis, A., Thomson, M., Harrison, M., Edwards, A.D., 2006. Sustainable use of continuous positive airway pressure in extremely preterm infants during the first week after delivery. Arch. Dis. Child. Fetal Neonatal Ed. 91, 398e402. Boxwell, G., 2006. Neonatal Intensive Care Nursing. Routledge, London. Goldsmith, J., Karotkin, E.H., 2003. Assisted Ventilation of the Neonate, sixth ed. WB Saunders, Philadelphia. Greenough, A., Milner, A.D., 2003. Neonatal Respiratory Disorders. Arnold, London. Greenspan, J.S., Shaffer, T.H., 2006. Ventilator-induced airway injury; a critical consideration during mechanical ventilation of the infant. Neonatal Netw. 25 (3), 159e166.
Collaborative extubation
169
Merenstein, G., Gardner, S., 2002. Handbook of Neonatal Intensive Care, sixth ed. Mosby, Philadelphia. Morley, C.J., Davis, P.G., Doyle, L.W., Brion, L., Hascoet, J.-M., Carlin, J.B., 2007. A randomized controlled trial of nasal continuous positive airway pressure or intubation or ventilation for very preterm infants at birth: the coin trial. Acta Paediatr. 96 (Suppl. 456), 233. Owen, L.S., Morley, C.J., Davis, P.G., 2007. Neonatal nasal intermittent positive pressure ventilation: what do we know in 2007? Arch. Dis. Child. Fetal Neonatal Ed. 92, 414e418.
Sinha, S., Donn, S.M., 2000. Weaning from assisted ventilation: art or science? Arch. Dis. Child. Fetal Neonatal Ed. 83, 64e70. Steer, P.A., Flenady, V.J., Lee, T.C., Tudehope, D.I., Charles, B.G., 2004. Periextubation caffeine in preterm neonates; a randomized dose response trial. J. Paediatr. Child Health 39 (7), 511e515 Sept-Oct. Sweet, D., Bevilacqua, G., Carnielli, V., Greisen, G., Plavka, R., Saugstad, O.D., Simeone, M., Speer, C., Valls-i-Soler, A., Halliday, H., 2007. European consensus guidelines on the management of neonatal respiratory distress syndrome. J. Perinat. Med. 35 (3), 175e186.
Available online at www.sciencedirect.com