Neuromuscular Compromise and Respiratory Failure — Extubate to NIV — Clinical Pathway: Inpatient and PICU

Neuromuscular Compromise and Respiratory Failure Clinical Pathway — Inpatient and PICU

Extubate to NIV

Consider extubation when:

  • Afebrile
  • No longer requiring supplemental oxygen (SpO2 ≥ 92%)
  • No atelectasis or infiltrates on chest X-ray
  • Suctioning needs are close to baseline
  • Off respiratory depressants
  • PIP/PEEP weaned to 1-2 cm H2O lower than non-invasive settings

Immediate Airway Clearance Post-extubation

Like general airway management, the same CPT + MI-E (CoughAssist) + Suction regimen should be used post-extubation.

For rest, consider Q4 MI-E (CoughAssist) overnight.

See Oxygenation Goals.

Extubation Guidelines

Sequence Recommendations Additional Considerations
Pre-extubation
  • Place transcutaneous monitoring (TcCO2) in preparation of extubation.
  • TcCO2 should be used to trend ventilation while adjusting NIV settings.
Immediately After Endotracheal Tube Removal
  • Extubate to continuous nasal ventilation and no supplemental O2 such as NIV with settings:
    • IPAP: 12-24 cmH2O
    • EPAP: 3-8 cmH2O using the spontaneous timed (S/T) mode with a backup rate to match the patient’s respiratory rate
    • Delta P: at least 10
  • Assess patient and begin first-line airway clearance (CPT, MI-E, suction Q2 and PRN)
  • Use SpO2 as a guide for use of MI-E and other secretion clearance techniques – wean until FiO2 returns to 0.21.
    NIV
    • IPAP: set at a pressure high enough to see visible chest rise.
    • EPAP: set at the lowest level possible to facilitate passive exhalation.
    • There should be a delta of at least 10 cmH2O between IPAP/EPAP.
    • Settings are individualized to achieve adequate inspiratory chest wall expansion and air entry, SpO2 > 92% in room air, normal or baseline pCO2 levels, improved WOB and baseline respiratory rate for the patient.
    • Mode: ST (unless patient maintained at home on different mode of ventilation) with set a backup rate.
    • The IPAP/EPAP settings should not be decreased until the patient’s FiO2 is 0.21.
  • Interface
    • Use nasal mask or home interface.
  • MI-E
    • Use as often as needed to clear lower airway secretions.
    • Use if SpO2 < 92%.
    • May need to be frequent to help clear tracheal mucus and prevent atelectasis from distal secretion movement.
  • Postural Drainage
    • Consider Trendelenburg for 15 minutes as tolerated followed up again using MI-E (CoughAssist) and suctioning if CPT and MI-E (CoughAssist) are not effective.
Acute SpO2 Desaturations
  • If SpO2 drops to < 92% acutely:
    • Perform MI-E.
    • Assess if the patient needs an extra treatment.
    • If in room air and SpO2 remains ≤ 92%: continue MI-E (Cough Assist) Q2 and PRN.
    • If patient is on oxygen therapy continue with Q2 MI-E (Cough Assist) and PRN.
  • Avoid/minimize use of supplemental oxygen.
  • Supplemental O2 indicates a V/Q mismatch and need for further airway clearance.
  • Nursing should contact Respiratory Therapy for any increases in FiO2.
Once Stable in Room Air
  • Wean airway clearance regimen as airway secretions decrease working toward a Q6 schedule or less.
  • Begin trials off NIV (in room air).
  • Goal is nocturnal support until the illness resolves or until the patient’s prior baseline has been achieved.
  • For chronically ventilated patients: Wean to an FiO2 of 0.21 or to baseline support as tolerated maintaining a SpO2 ≥ 94% and a normal or baseline CO2.