Extubation To Permit Self-Weaning From Ventilator Support When Possible:
Infants and Small Children

 

The protocol for successful extubation of “unweanable” infants with NMD type 1 (e.g. SMA type 1) is similar to that for adults in that even though unweanable and uncooperative, the infant can be successfully extubated to continuous noninvasive ventilatory support (CNVS) if certain criteria are satisfied. Pressure-preset ventilation using active ventilator circuits and non-vented nasal interfaces are used. It should be recognized that extubation for infants and small children is more difficult for the following reasons:

 

  1. Infants cannot cooperate so getting them in synchrony with their ventilators is problematic when they are awake.

  2. Infants cannot use volume-preset ventilation via a mouthpiece or air stack to maintain lung compliance and increase cough peak flows.

  3. Infants cannot optimally use mechanical insufflation-exsufflation (MIE) although the “cough track” setting on the CoughAssist[TM] machine facilitates synchrony with MIE.

 

Despite these difficulties, upon receiving positive pressure insufflations, these infants quickly learn to grunt to create lung recoil pressure to facilitate secretion expulsion and they quickly become accustomed to nasal NVS, and within days, they are irritable and resistant to going to sleep until they are placed back on nasal NVS.

 

All of the aspects of management for successful extubation is as for adults including the need for aggressive MIE via airway tube pre-extubation and via oronasal interface and performed by the family post-extubation.