690	P. Khilnani and R. Uttam

¥Increased work of breathing (tachypnea or use of accessory muscles or paradoxical breathing pattern)

¥Other signs of distress (e.g., diaphoresis, anxiety, rise in heart rate, change in mental status, and hypotension)

If the patient tolerates the spontaneous breathing trial, we can proceed to

extubate.

Step 6: Extubation

The following criteria should be met before extubation:

¥Alert or easily arousable

¥Presence of airway reßexes, manageable secretions

¥Minimal oxygen requirement less than 0.4 and PEEP less than 5 with saturations above 94%

¥Good spontaneous tidal volume with minimal pressure support (5Ð10 above PEEP depending on the tube size) during spontaneous breathing trial

¥Nil orally for at least 4 h before extubation

¥Hemodynamically stable (dopamine requirement <5 mic/kg/min)

¥PaCO2 less than 50 mmHg

¥pH 7.3Ð7.47

¥Core temperature below 38.5¡C

¥Leak around the endotracheal tube is good but not a prerequisite for extubation

¥No major metabolic derangements

Injection dexamethasone (0.2 mg/kg) q6h can be given prior to extubation, the

Þrst dose given 12 h before extubation. It can be continued 48 h after extubation. It decreases postextubation stridor.

Suggested Reading

1.Khilnani P, Singhal D. Pediatric mechanical ventilation. In: Udani S, Ugra D, Chugh K, Khilnani P, editors. IAP specialty series on pediatric intensive care. New Delhi: Jaypee; 2008. pp. 63Ð88.

Source book for the article

2.Venkataraman ST. Mechanical ventilation and respiratory care. In: Fuhrman BP, Zimmerman JJ, editors. Pediatric critical care. 3rd ed. Philadelphia: Mosby Elsevier; 2006. pp. 683Ð718.

Source book