nicu-picu/Forms/Ventilator-Weaning/FRM-VENT-001-Extubation-Readiness-Checklist.md

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