# Extubation Readiness Checklist

| Form ID | FRM-VENT-001 | Revision | 1.0 |
|---------|--------------|----------|-----|

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## Patient Information

| Field | Entry |
|-------|-------|
| Patient Name | |
| MRN | |
| Age/DOB | |
| Date | |
| Time | |

## Pre-Extubation Assessment

### Clinical Criteria

#### 1. Underlying Condition Resolved/Improved
- [ ] Yes
- [ ] No - Explain: ____________

#### 2. Hemodynamic Stability
- [ ] MAP appropriate for age without significant vasoactive support
- [ ] Heart rate stable
- [ ] No active bleeding

**Current Vasoactive Medications:**
| Medication | Dose |
|------------|------|
| | |

#### 3. Oxygenation
- [ ] FiO2 ≤ 0.40 (or ≤ 0.50 for neonates)
- [ ] PaO2/FiO2 ratio > 200
- [ ] SpO2 > 90% on current settings

**Current Settings:**
- FiO2: ______
- PEEP: ______ cmH2O
- Latest ABG: pH _____ pCO2 _____ pO2 _____ HCO3 _____

#### 4. Ventilation
- [ ] PaCO2 acceptable for patient
- [ ] Peak pressure ≤ 20 cmH2O (or age-appropriate)
- [ ] Spontaneous breathing on minimal support

**Current Settings:**
- Mode: ______
- Rate: ______
- PIP/PS: ______ cmH2O
- Spontaneous rate: ______

#### 5. Spontaneous Breathing Trial (if performed)
- [ ] Performed
- [ ] Not performed

**If performed:**
- Duration: ______ minutes
- Mode: [ ] T-piece [ ] CPAP [ ] PS/CPAP
- Tolerated: [ ] Yes [ ] No

#### 6. Airway Protection
- [ ] Adequate cough reflex
- [ ] Appropriate gag reflex
- [ ] Manageable secretions
- [ ] Alert/appropriate neurological status

**Secretion Description:**
- Amount: [ ] Minimal [ ] Moderate [ ] Copious
- Character: ____________

#### 7. Sedation Status
- [ ] Minimal or weaning sedation
- [ ] Able to follow commands (if age-appropriate)

**Current Sedation:**
| Medication | Dose | Last Given |
|------------|------|------------|
| | | |

#### 8. Metabolic Status
- [ ] Adequate nutrition
- [ ] No significant electrolyte imbalances
- [ ] Normal temperature

**Latest Labs:**
- Na: _____ K: _____ Cl: _____ HCO3: _____
- Ca: _____ Mg: _____ Phos: _____

#### 9. Post-Extubation Plan
- [ ] Non-invasive support planned: ______
- [ ] High-flow nasal cannula available
- [ ] Room air trial planned
- [ ] RT available at bedside for extubation

### Special Considerations

#### For Neonates:
- [ ] Caffeine on board (if applicable)
- [ ] Weight > 500g (or institution-specific threshold)
- [ ] Postmenstrual age considerations addressed

#### For Long-Term Ventilation:
- [ ] Airway evaluation performed (if >7 days intubated)
- [ ] Consider subglottic edema risk
- [ ] Dexamethasone considered (if appropriate)

## Contraindications to Extubation

- [ ] Active seizures
- [ ] Neuromuscular blockade
- [ ] Recent airway surgery
- [ ] Significant facial/airway trauma or edema
- [ ] Other: ____________

## Physician Review

**Attending Physician Notified:** [ ] Yes [ ] No

**Extubation Approved:** [ ] Yes [ ] No

**If No, reason:** ____________

## Extubation Procedure

**Extubation Date/Time:** ____________

**Post-Extubation Support:**
- [ ] Room air
- [ ] Nasal cannula: ______ L/min
- [ ] High-flow nasal cannula: ______ L/min, FiO2: ______
- [ ] CPAP: ______ cmH2O
- [ ] BiPAP: IPAP ______ EPAP ______

**Immediate Post-Extubation Assessment (within 1 hour):**
- SpO2: ______ %
- RR: ______ breaths/min
- HR: ______ bpm
- Work of breathing: [ ] Minimal [ ] Moderate [ ] Severe
- Stridor: [ ] None [ ] Mild [ ] Moderate [ ] Severe

## Signatures

| Role | Name | Signature | Date/Time |
|------|------|-----------|-----------|
| RN | | | |
| RT | | | |
| MD/NP | | | |

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*Form FRM-VENT-001 Rev 1.0*