Accuracy of an Extubation Readiness Test in Predicting Successful Extubation in Children With Acute Respiratory Failure From Lower Respiratory Tract Disease

Ventilator Liberation Practices in Pediatric Cardiac Critical Care

Background: Mechanical ventilation is common in critically ill children with cardiac disease, but literature focused on ventilator liberation practices for this unique pediatric subpopulation is limited. We aimed to describe current ventilator liberation practices in critically ill children with cardiac disease. Methods: Through the Pediatric Cardiac Critical Care Consortium, an electronic survey was distributed to pediatric ICU attending physicians caring for patients with cardiac disease evaluating institutional protocols and individual practices around ventilator liberation including criteria for extubation readiness testing (ERT), ERT components, spontaneous breathing trial (SBT) method and duration, timing of extubation, and postextubation respiratory support. Results: We received 133 responses representing 47 hospitals. ERT eligibility screening and SBT protocols were reported at 22 (47%) and 26 (55%) of the 47 institutions, respectively. Most respondents used SBTs in their assessment of extubation readiness (95%) and pressure support augmentation to CPAP for SBT (92%). Most respondents reported a maximum dose threshold for epinephrine (81%), above which they would not extubate. Some indices used for determination of extubation readiness were used by nearly all respondents: pulse oximetry (92%), serum lactate (86%), and arterial pH (85%); but some respondents also report using mixed venous saturation (68%), ventricular function (62%), near-infrared spectroscopy (62%), and systemic atrioventricular valve regurgitation (53%). Reported use of noninvasive respiratory support (NRS) after extubation was common, up to 90% in selected subgroups. There was wide variation in the type of NRS used in all populations. Conclusions: ERT eligibility screening and SBT protocols were reported in only half of the institutions surveyed, and notable variation exists between parameters surrounding extubation readiness assessment and postextubation respiratory support. These data suggest opportunities to increase protocol development to align with established clinical practice guidelines around ERT and conduct multi-center quality improvement to identify best practices for ventilator liberation in this patient population.

Extubation Failure in the PICU: A Virtual Pediatric Systems Database Study, 2017-2021

OBJECTIVES

Extubation failure (EF) in PICU patients is reintubation within 48, 72, or 96 hours of planned extubation (EF48, EF72, and EF96, respectively). Standardized sedation protocols, extubation readiness testing, and noninvasive respiratory support are used to improve efficient liberation from mechanical ventilation (MV). We therefore aimed to review EF rates, time to failure, and the use of noninvasive respiratory support after extubation, 2017-2021.

DESIGN

Retrospective analysis of patients admitted to PICUs contributing to the Virtual Pediatric Systems (VPS, LLC) database, 2017-2021.

SETTING

One hundred thirty-six participating PICUs.

PATIENTS

All patients admitted to participating PICUs between January 1, 2017, and December 31, 2021, who had MV and met inclusion criteria for planned extubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 111,229 planned extubations with 5,143 reintubations within 48 hours. The EF48, EF72, and EF96 rates were 4.6%, 5.3%, and 5.8%, respectively. Higher rates of EF were associated with age younger than 6 months, underlying genetic conditions, medical comorbidities, or cardiac surgery. Failed extubation was also associated with higher Pediatric Risk of Mortality III scores, longer duration of MV, and longer PICU and hospital lengths of stay. From 2017 to 2021, there was an increase in the use of high-flow nasal cannula oxygen therapy after extubation from 16.6% to 20.2%.

CONCLUSIONS

In the VPS 2017-2021 dataset, we have found that the overall EF rates (EF48-EF96) have improved over this 5-year period. We are not able to assess the clinical benefit of this change, but it is evident that over the same period, there has been a concomitant increase in the use of postextubation noninvasive respiratory support. Further work is needed to look at the interaction of these effects in contemporary PICU practice.

Extubation Failure in Neonates Following Congenital Cardiac Surgery: Multicenter Retrospective Cohort, 2017-2020

OBJECTIVES

Extubation failure (EF) in neonates recovering from congenital cardiac surgery is associated with morbidity and mortality. Adding continuous physiologic monitoring data and risk analytics algorithms to clinical factors has the potential to assist clinicians in identifying those neonates at high risk for EF. We aimed to evaluate the association of two physiologic risk analytics algorithms evaluating the probability of inadequate delivery of oxygen index (IDo2) and inadequate ventilation of carbon dioxide index (IVco2) with EF in neonates receiving mechanical ventilation (MV) after cardiac surgery. A secondary aim was to evaluate the clinical factors associated with EF.

DESIGN

Multicenter retrospective cohort study.

SETTING

Eight international pediatric cardiac ICUs.

PATIENTS

Neonates (age < 1 mo at the time of surgery) receiving MV for longer than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from 736 neonates were analyzed with 102 (13.9%) having EF (defined as reintubation within 48 hr of extubation). In multivariable analysis (odds ratio [OR] and 95% CI), preoperative respiratory support (OR, 1.72 [95% CI, 1.11-2.67]) was associated with greater odds of EF. In all, 611 neonates had pre-extubation IDo2 data and 478 neonates had both pre-extubation IDo2 and IVco2 data. In multivariable analysis of patients with both pre-extubation IDo2 and IVco2 data, single ventricle anatomy (OR, 2.50 [95% CI, 1.27-4.92]) and high IDo2 (≥ 25) or high IVco2 (≥ 50) in the 2 hours preceding extubation (OR, 1.77 [95% CI, 1.01-3.12]) were associated with greater odds of EF.

CONCLUSIONS

In this 2017-2020 cohort, EF is high in post-cardiac surgery neonates receiving at least 48 hours of MV. The IDo2 and IVco2 algorithms may be useful in assessing risk of EF in such neonates.

Best practice peri-extubation bundle reduces neonatal and infant extubation failure after cardiac surgery

INTRODUCTION

Extubation failure after neonatal cardiac surgery is associated with increased intensive care unit length of stay, morbidity, and mortality. We performed a quality improvement project to create and implement a peri-extubation bundle, including extubation readiness testing, spontaneous breathing trial, and high-risk criteria identification, using best practices at high-performing centers to decrease neonatal and infant extubation failure by 20% from a baseline of 15.7% to 12.6% over a 2-year period.

METHODS

Utilising the transparency of the Pediatric Cardiac Critical Care Consortium database, five centres were identified as high performers, having better-than-expected neonatal extubation success rates with the balancing metric of as-expected or better-than-expected mechanical ventilation duration. Structured interviews were conducted with cardiac intensive care unit physician leadership at the identified centers to determine centre-specific extubation practices. Data from those interviews underwent qualitative content analysis which was used to develop a peri-extubation bundle. The bundle was implemented at a single-centre 17-bed cardiac intensive care unit. Extubation failure, defined as reintubation within 48 hours of extubation for anything other than a procedure, ventilator days and bundle compliance was tracked.

RESULTS

There was a 41.4% decrease in extubation failure following bundle implementation (12 failures of 76 extubations pre-implantation; 6 failures of 65 extubations post-implementation). Bundle compliance was 95.4%. There was no difference in ventilator days (p = 0.079) between groups.

CONCLUSION

Implementation of a peri-extubation bundle created from best practices at high-performing centres reduced extubation failure by 41.4% in neonates and infants undergoing congenital heart surgery.

Framework for Research Gaps in Pediatric Ventilator Liberation

BACKGROUND

The 2023 International Pediatric Ventilator Liberation Clinical Practice Guidelines provided evidence-based recommendations to guide pediatric critical care providers on how to perform daily aspects of ventilator liberation. However, because of the lack of high-quality pediatric studies, most recommendations were conditional based on very low to low certainty of evidence.

RESEARCH QUESTION

What are the research gaps related to pediatric ventilator liberation that can be studied to strengthen the evidence for future updates of the guidelines?

STUDY DESIGN AND METHODS

We conducted systematic reviews of the literature in eight predefined Population, Intervention, Comparator, Outcome (PICO) areas related to pediatric ventilator liberation to generate recommendations. Subgroups responsible for each PICO question subsequently identified major research gaps by synthesizing the literature. These gaps were presented at an international symposium at the Pediatric Acute Lung Injury and Sepsis Investigators meeting in spring 2022 for open discussion. Feedback was incorporated, and final evaluation of research gaps are summarized herein. Although randomized controlled trials (RCTs) represent the highest level of evidence, the panel sought to highlight areas where alternative study designs also may be appropriate, given challenges with conducting large multicenter RCTs in children.

RESULTS

Significant research gaps were identified in six broad areas related to pediatric ventilator liberation. Several of these areas necessitate multicenter RCTs to provide definitive results, whereas other gaps can be addressed with multicenter observational studies or quality improvement initiatives. Furthermore, a need for some physiologic studies in several areas remains, particularly regarding newer diagnostic methods to improve identification of patients at high risk of extubation failure.

INTERPRETATION

Although pediatric ventilator liberation guidelines have been created, the certainty of evidence remains low and multiple research gaps exist that should be bridged through high-quality RCTs, multicenter observational studies, and quality improvement initiatives.

Clinical practices related to liberation from mechanical ventilation in Latin American pediatric intensive care units: survey of the Sociedad Latino-Americana de Cuidados Intensivos Pediátricos Mechanical Ventilation Liberation Group

OBJECTIVE

To address the current practice of liberating patients from invasive mechanical ventilation in pediatric intensive care units, with a focus on the use of standardized protocols, criteria, parameters, and indications for noninvasive respiratory support postextubation.

METHODS

Electronic research was carried out from November 2021 to May 2022 in Ibero-American pediatric intensive care units. Physicians and respiratory therapists participated, with a single representative for each pediatric intensive care unit included. There were no interventions.

RESULTS

The response rate was 48.9% (138/282), representing 10 Ibero-American countries. Written invasive mechanical ventilation liberation protocols were available in only 34.1% (47/138) of the pediatric intensive care units, and their use was associated with the presence of respiratory therapists (OR 3.85; 95%CI 1.79 - 8.33; p = 0.0008). The most common method of liberation involved a gradual reduction in ventilatory support plus a spontaneous breathing trial (47.1%). The mean spontaneous breathing trial duration was 60 - 120 minutes in 64.8% of the responses. The presence of a respiratory therapist in the pediatric intensive care unit was the only variable associated with the use of a spontaneous breathing trial as the primary method of liberation from invasive mechanical ventilation (OR 5.1; 95%CI 2.1 - 12.5). Noninvasive respiratory support protocols were not frequently used postextubation (40.4%). Nearly half of the respondents (43.5%) reported a preference for using bilevel positive airway pressure as the mode of noninvasive ventilation postextubation.

CONCLUSION

A high proportion of Ibero-American pediatric intensive care units lack liberation protocols. Our study highlights substantial variability in extubation readiness practices, underscoring the need for standardization in this process. However, the presence of a respiratory therapist was associated with increased adherence to guidelines.

The Decision to Extubate: The Association between Clinician Impressions and Objective Extubation Readiness Criteria in a Pediatric Intensive Care Unit

Objective  Objective tools such as spontaneous breathing trials (SBT) aim to identify patients ready for extubation and shorten the length of mechanical ventilation (MV). Despite passing an SBT, patients sometimes are not extubated based on clinicians' subjective impressions. In this article, we explored the factors that influence the decision to extubate among pediatric intensivists and their association with objective criteria. Design  This is a single-center prospective observational study. Setting  This study was conducted in an academic, multidisciplinary 20-bed pediatric intensive care unit (PICU). Patients  The study group involves mechanically ventilated, orally intubated patients admitted to the PICU from January 1 to June 30, 2019. Measurements and Main Results  Objective clinical data were collected for 650 MV days. Attending surveys about extubation readiness were completed for 419 (64.5%) MV days and 63 extubation events. Extubation occurred on 42% of days after passing an SBT. The primary reasons patients who passed an SBT were not extubated on days were unresolved lung pathology (66.6%) and fluid overload (37.6%). On days without extubation, there was no association between a specific reason for not extubating and SBT result ( p  > 0.05). Conclusions  In this single-center study, the decision to extubate was not strongly associated with passing an SBT, indicating that clinician impressions, namely unresolved lung pathology and fluid overload, outweighed objective measures for determining extubation readiness. To mitigate morbidities and costs associated with unnecessarily prolonged intubations, a better-defined extubation readiness process is needed to guide the decision to extubate in the pediatric population.

Implementing the Pediatric Ventilator Liberation Guidelines Using the Most Current Evidence

Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation varies widely. As a first step to minimizing that variation, the first evidence-based pediatric ventilator liberation guidelines were published in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay before clinical guidelines reach widespread clinical practice. As such, it is important to consider barriers and facilitators using a systematic approach during implementation planning and design. In this narrative review, we will (1) summarize guideline recommendations, (2) discuss recent evidence and identify practice gaps relating to those recommendations, and (3) hypothesize about potential barriers and facilitators to their implementation in clinical practice.

Factors Associated With Successful Extubation Readiness Testing in Children With Congenital Heart Disease

BACKGROUND

In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate the potential for liberation from mechanical ventilation. There is a paucity of data that suggests what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with certain mechanical ventilator parameters.

METHODS

Data on daily ERT assessments were recorded as part of a quality improvement project. In accordance with our respiratory therapist-driven ventilator protocol, patients were assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate the differences in levels of respiratory support. The primary outcome was ERT success.

RESULTS

A total of 780 ERTs from 320 subjects (median [interquartile range] age 2.5 [0.6-6.5] months and median weight [interquartile range] 4.2 [3.3-6.9] kg) were evaluated. A total of 528 ERTs (68%) were passed, 306 successful ERTs (58%) resulted in extubation, and 30 subjects (9.4%) were re-intubated. There were statistically significant differences in the ERT pass rate for ventilator mode, peak inspiratory pressure, Δ pressure, PEEP, mean airway pressure ([Formula: see text]), and dead-space-to-tidal-volume ratio (all P < .001) but not for [Formula: see text]. ERT success decreased with increases in peak inspiratory pressure, Δ pressure, PEEP, [Formula: see text], and dead-space-to-tidal-volume ratio. Logistic regression revealed neonates, Δ pressure ≥ 11 cm H2O, and [Formula: see text] > 10 cm H2O were associated with a decreased odds of ERT success, whereas children ages 1-5 years and an [Formula: see text] of 0.31-0.40 had increased odds of ERT success.

CONCLUSIONS

ERT pass rates decreased as ventilator support increased; however, some subjects were able to pass ERT despite high ventilator support. We found that [Formula: see text] was associated with ERT success and that protocols should consider using [Formula: see text] instead of PEEP thresholds for ERT eligibility. Cyanotic lesions were not associated with ERT success, which suggests that patients with cyanotic heart disease can be included in ERT protocols.

Evaluation of renal near-infrared spectroscopy for predicting extubation outcomes in the pediatric intensive care setting

Background

In pediatric intensive care units, extubation failure following invasive mechanical ventilation poses significant health risks. Determining readiness for extubation in children can minimize associated morbidity and mortality. This study investigates the potential role of renal near-infrared spectroscopy (RrSO2) in predicting extubation failure in pediatric patients.

Methods

A total of 84 patients aged between 1 month and 18 years, mechanically ventilated for at least 24 h, were included in this prospective study. RrSO2 levels were measured using near-infrared spectroscopy before and during an extubation readiness test (ERT). The primary outcome measure was extubation failure, defined as a need for reintubation within 48 h.

Results

Of the 84 patients, 71 (84.6%) were successfully extubated, while 13 (15.4%) failed extubation. RrSO2 was found to be lower in the failed extubation group, also decrease in RrSO2 values during ERT was significantly greater in patients with extubation failure. ROC analysis indicated a decrease in ΔRrSO2 of more than 6.15% from baseline as a significant predictor of extubation failure, with a sensitivity of 0.984 and a specificity of 0.889.

Conclusion

Monitoring changes in RrSO2 values may serve as a helpful tool to predict extubation failure in pediatric patients. Further multi-center research is warranted to improve the generalizability and reliability of these findings.

Effects of the First Spontaneous Breathing Trial in Children With Tracheostomy and Long-Term Mechanical Ventilation

BACKGROUND

Weaning and liberation from mechanical ventilation in pediatric patients with tracheostomy and long-term mechanical ventilation constitute a challenging process due to diagnosis heterogeneity and significant variability in the clinical condition. We aimed to evaluate the physiological response during the first attempt of a spontaneous breathing trial (SBT) and to compare variables in subjects who failed or passed the SBT.

METHODS

This was a prospective observational study in tracheostomized children with long-term mechanical ventilation admitted to the Hospital Josefina Martinez, Santiago, Chile, between 2014-2020. Cardiorespiratory variables such as breathing pattern, use of accessory respiratory muscles, heart rate, breathing frequency, and oxygen saturation were registered at baseline and throughout a 2-h SBT with or without positive pressure depending on an SBT protocol. Comparison of demographic and ventilatory variables between groups (SBT failure and success) was performed.

RESULTS

A total of 48 subjects were analyzed (median [IQR] age of 20.5 [17.0-35.0] months, 60% male). Chronic lung disease was the primary diagnosis in 60% of subjects. Eleven (23%) total subjects failed the SBT (< 2 h), with an average failure time of 69 ± 29 min. Subjects who failed the SBT had a significantly higher breathing frequency, heart rate, and end-tidal CO2 than subjects who succeeded (P < .001). In addition, subjects who failed the SBT had significantly shorter duration of mechanical ventilation before the SBT, higher proportion unassisted SBT, and higher rate of deviation SBT protocol in comparison with subjects who succeeded.

CONCLUSIONS

Conducting an SBT to evaluate the tolerance and cardiorespiratory response in tracheostomized children with long-term mechanical ventilation is feasible. Time on mechanical ventilation before the first attempt and type of SBT (with or without positive pressure) could be associated with SBT failure.

Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative

OBJECTIVES

Assess clinical outcomes following PICU Liberation ABCDEF Bundle utilization.

DESIGN

Prospective, multicenter, cohort study.

SETTING

Eight academic PICUs.

PATIENTS

Children greater than 2 months with expected PICU stay greater than 2 days and need for mechanical ventilation (MV).

INTERVENTIONS

ABCDEF Bundle implementation.

MEASUREMENT AND MAIN RESULTS

Over an 11-month period (3-mo baseline, 8-mo implementation), Bundle utilization was measured for 622 patients totaling 5,017 PICU days. Risk of mortality was quantified for 532 patients (4,275 PICU days) for correlation between Bundle utilization and MV duration, PICU length of stay (LOS), delirium incidence, and mortality. Utilization was analyzed as subject-specific (entire PICU stay) and day-specific (single PICU day). Median overall subject-specific utilization increased from 50% during the 3-month baseline to 63.9% during the last four implementation months ( p < 0.001). Subject-specific utilization for elements A and C did not change; utilization improved for B (0-12.5%; p = 0.007), D (22.2-61.1%; p < 0.001), E (17.7-50%; p = 0.003), and F (50-79.2%; p = 0.001). We observed no association between Bundle utilization and MV duration, PICU LOS, or delirium incidence. In contrast, on adjusted analysis, every 10% increase in subject-specific utilization correlated with mortality odds ratio (OR) reduction of 34%, p < 0.001; every 10% increase in day-specific utilization correlated with a mortality OR reduction of 1.4% ( p = 0.006).

CONCLUSIONS

ABCDEF Bundle is applicable to children. Although enhanced Bundle utilization correlated with decreased mortality, increased utilization did not correlate with duration of MV, PICU LOS, or delirium incidence. Additional research in the domains of comparative effectiveness, implementation science, and human factors engineering is required to understand this clinical inconsistency and optimize PICU Liberation concept integration into clinical practice.

Prevalence, Risk Factors, and Outcomes of Airway Versus Non-Airway Pediatric Extubation Failure

BACKGROUND

Pediatric extubation failure is associated with morbidity and mortality. The most common cause is upper-airway obstruction. Subglottic edema is common, but upper-airway obstruction can occur from the oral cavity to the trachea. Dichotomous categorization of extubation failure as airway versus non-airway may help identify risk factors as well as strategies that translate to lower extubation failure rates.

METHODS

This was as single-center, retrospective cohort study of invasive mechanical ventilation encounters within a quality improvement database between October 1, 2017-November 30, 2020. Utilizing a 3-physician adjudication process, all extubation failures were categorized as airway versus non-airway. Primary outcome was failure subtype prevalence. Secondary outcome was failure subtype risk factors. Clinical outcomes were explored.

RESULTS

The all-cause extubation failure rate was 10% in a cohort of 844 encounters. Airway and non-airway extubation failure represented 60.7% and 39.3%, respectively. Most airway failures were due to upper-airway obstruction (84.3%)-35.3% were supraglottic, 25.5% subglottic, and 23.5% mixed. Other causes of airway failure were airway patency/secretions (11.8%) and aspiration (3.9%). Non-airway failures were attributed to respiratory failure (75.8%), encephalopathy (15.2%), and other (9%). All-cause extubation failure was associated with dysgenetic/syndromic comorbidity (P = .005), ≥ 3 concurrent comorbid conditions (P = .007), indication for invasive ventilation (P < .001), and longer invasive mechanical ventilation duration (P < .001). Airway extubation failure was significantly associated with the presence of a respiratory comorbidity (P = .01) and Glasgow coma scale < 10 (P = .02). No significant non-airway failure risk factors were identified. Longer pediatric ICU (PICU) stay (P < .001) and PICU mortality (P < .001) were associated with all-cause extubation failure. No significant outcome associations with extubation failure subtype were identified.

CONCLUSIONS

Airway extubation failure prevalence was 1.5 times higher than non-airway failure. Potential risk factors for airway failure were identified. These findings are hypothesis generating for future study focused on key evidence gaps and pragmatic bedside application.

Tests and Indices Predicting Extubation Failure in Children: A Systematic Review and Meta-analysis

INTRODUCTION

There is lack of consensus on what constitutes best practice when assessing extubation readiness in children. This systematic review aims to synthesize data from existing literature on pre-extubation assessments and evaluate their diagnostic accuracies in predicting extubation failure (EF) in children.

METHODS

A systematic search in PubMed, EMBASE, Web of Science, CINAHL, and Cochrane was performed from inception of each database to 15 July 2021. Randomized controlled trials or observational studies that studied the association between pre-extubation assessments and extubation outcome in the pediatric intensive care unit population were included. Meta-analysis was performed for studies that report diagnostic tests results of a combination of parameters.

RESULTS

In total, 41 of 11,663 publications screened were included (total patients, n = 8111). Definition of EF across studies was heterogeneous. Fifty-five unique pre-extubation assessments were identified. Parameters most studied were: respiratory rate (RR) (13/41, n = 1945), partial pressure of arterial carbon dioxide (10/41, n = 1379), tidal volume (13/41, n = 1945), rapid shallow breathing index (RBSI) (9/41, n = 1400), and spontaneous breathing trials (SBT) (13/41, n = 5652). Meta-analysis shows that RSBI, compliance rate oxygenation pressure (CROP) index, and SBT had sensitivities ranging from 0.14 to 0.57. CROP index had the highest sensitivity [0.57, 95% confidence interval (CI) 0.4-0.73] and area under curve (AUC, 0.98). SBT had the highest specificity (0.93, 95% CI 0.92-0.94).

CONCLUSIONS

Pre-extubation assessments studied thus far remain poor predictors of EF. CROP index, having the highest AUC, should be further explored as a predictor of EF. Standardizing the EF definition will allow better comparison of pre-extubation assessments.

Fitness checklist model for spontaneous breathing tests in pediatrics

OBJECTIVE

To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit.

METHODS

This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests.

RESULTS

The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%.

CONCLUSION

The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

Association Between Pressure Support During Extubation Readiness Testing and Time to First Extubation in Children With Congenital Heart Disease

BACKGROUND

Extubation readiness testing (ERT) is often performed in children with congenital heart disease prior to liberation from mechanical ventilation. The ideal ERT method in this population is unknown. We recently changed our ERT method from variable (10, 8, or 6 cm H2O, depending on endotracheal tube size) to fixed (5 cm H2O) pressure support (PS). Our study assessed the association between this change and time to first extubation and need for re-intubation.

METHODS

We studied 2 temporally distinct cohorts, one where ERT was conducted with variable PS and another using PS fixed at 5 cm H2O. Data were prospectively collected as part of a quality improvement project. The primary outcome was time to first extubation. Secondary outcomes were need for re-intubation and percentage of successful ERTs. We performed Poisson regression or logistic regression for the association between PS during ERT and time to first extubation or re-intubation, respectively.

RESULTS

We included 320 subjects, 186 in the variable PS group and 152 in fixed PS group. In unadjusted analysis, median time to first extubation was longer in the fixed PS group compared to the variable PS group (4.1 [2.0-7.1] d vs 3.1 [1.1-5.9] d, P = .02), and there was no difference in re-intubation rate (11% vs 8%, P = .34). Subjects in the fixed PS group were significantly more likely to be mechanically ventilated after cardiac arrest, have a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of 4 or 5, be extubated on day shift, receive enteral feeds at extubation, have higher respiratory support at extubation, and higher dead-space-to-tidal-volume ratio. After controlling for these variables in multivariable regression, we found no association between the choice of PS and time to first extubation or re-intubation.

CONCLUSIONS

The use of a fixed PS of 5 cm H2O instead of variable PS during ERT was not associated with longer time to first extubation or extubation failure.

Monitoring in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

Monitoring is essential to assess changes in the lung condition, to identify heart-lung interactions, and to personalize and improve respiratory support and adjuvant therapies in pediatric acute respiratory distress syndrome (PARDS). The objective of this article is to report the rationale of the revised recommendations/statements on monitoring from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2).

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

We included studies focused on respiratory or cardiovascular monitoring of children less than 18 years old with a diagnosis of PARDS. We excluded studies focused on neonates.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. We identified 342 studies for full-text review. Seventeen good practice statements were generated related to respiratory and cardiovascular monitoring. Four research statements were generated related to respiratory mechanics and imaging monitoring, hemodynamics monitoring, and extubation readiness monitoring.

CONCLUSIONS

PALICC-2 monitoring good practice and research statements were developed to improve the care of patients with PARDS and were based on new knowledge generated in recent years in patients with PARDS, specifically in topics of general monitoring, respiratory system mechanics, gas exchange, weaning considerations, lung imaging, and hemodynamic monitoring.

Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document

Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients' readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of ⩾80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.

Predictive parameters and model for extubation outcome in pediatric patients

Background

Prolonged mechanical ventilation is associated with significant morbidity in critically ill pediatric patients. In addition, extubation failure and deteriorating respiratory status after extubation contribute to increased morbidity. Well-prepared weaning procedures and accurate identification of at-risk patients using multimodal ventilator parameters are warranted to improve patient outcomes. This study aimed to identify and assess the diagnostic accuracy of single parameters and to develop a model that can help predict extubation outcomes.

Materials and methods

This prospective observational study was conducted at a university hospital between January 2021 and April 2022. Patients aged 1 month to 15 years who were intubated for more than 12 h and deemed clinically ready for extubation were enrolled. A weaning process with a spontaneous breathing trial (SBT), with or without minimal setting, was employed. The ventilator and patient parameters during the weaning period at 0, 30, and 120 min and right before extubation were recorded and analyzed.

Results

A total of 188 eligible patients were extubated during the study. Of them, 45 (23.9%) patients required respiratory support escalation within 48 h. Of 45, 13 (6.9%) were reintubated. The predictors of respiratory support escalation consisted of a nonminimal-setting SBT [odds ratio (OR) 2.2 (1.1, 4.6), P = 0.03], >3 ventilator days [OR 2.4 (1.2, 4.9), P = 0.02], occlusion pressure (P0.1) at 30 min ≥0.9 cmH₂O [OR 2.3 (1.1, 4.9), P = 0.03], and exhaled tidal volume per kg at 120 min ≤8 ml/kg [OR 2.2 (1.1, 4.6), P = 0.03]; all of these predictors had an area under the curve (AUC) of 0.72. A predictive scoring system to determine the probability of respiratory support escalation was developed using a nomogram.

Conclusion

The proposed predictive model, which integrated both patient and ventilator parameters, showed a modest performance level (AUC 0.72); however, it could facilitate the process of patient care.

Clinical Challenges in Pediatric Ventilation Liberation: A Meta-Narrative Review

OBJECTIVES

To map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards.

DATA SOURCES

CINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register.

STUDY SELECTION

Abstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed.

DATA EXTRACTION

None.

DATA SYNTHESIS

Weaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient's respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation.

CONCLUSIONS

Current literature suggests using a structured approach that includes a daily assessment of patient's readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.

Pediatric Ventilation Liberation: Bundled Extubation Readiness and Analgosedation Pathways Decrease Mechanical Ventilation Duration and Benzodiazepine Exposure

BACKGROUND

Recent studies reported that children on mechanical ventilation who were managed with an analgosedation approach and standardized extubation readiness testing experienced better outcomes, including decreased delirium and invasive mechanical ventilation duration.

METHODS

This was a quality improvement project in a 24-bed pediatric ICU within a single center, including subjects ≤ 18 years old who required invasive mechanical ventilation via an oral or nasal endotracheal tube. The aim was to decrease the invasive mechanical ventilation duration for all the subjects by 25% within 9 months through the development and implementation of bundled benzodiazepine-sparing analgosedation and extubation readiness testing clinical pathways.

RESULTS

In the pre-implementation cohort, there were 274 encounters, with 253 (92.3%) that met inclusion for ending in an extubation attempt. In the implementation cohort, there were 367 encounters with 332 (90.5%) that ended in an extubation attempt. The mean invasive mechanical ventilation duration decreased by 23% (Pre 3.95 d vs Post 3.1 d; P = .039) after the implementation without a change in the mean pediatric ICU length of stay (Pre 7.5 d vs Post 6.5 d; P = .42). No difference in unplanned extubation (P > .99) or extubation failure rates (P = .67) were demonstrated. Sedation levels as evaluated by the mean State Behavioral Scale were similar (Pre -1.0 vs Post -1.1; P = .09). The median total benzodiazepine dose administered decreased by 75% (Pre 0.4 vs Post 0.1 mg/kg/ventilated day; P < .001). No difference in narcotic withdrawal (Pre 17.8% vs Post 16.4%; P = .65) or with delirium treatment (Pre 5.5% vs Post 8.7%; P = .14) was demonstrated.

CONCLUSIONS

A multidisciplinary, bundled benzodiazepine-sparing analgosedation and extubation readiness testing approach resulted in a reduction in mechanical ventilation duration and benzodiazepine exposure without impacting key balancing measures. External validity needs to be evaluated in similar centers and consensus on best practices developed.

Respiratory Therapist-Driven Extubation Readiness Testing in a Single Pediatric ICU

BACKGROUND

There is currently no standardized way to determine suitability for extubation of pediatric ICU (PICU) patients, potentially resulting in prolonged duration of mechanical ventilation. We aimed to design and implement a protocol for screening all intubated PICU patients for extubation readiness.

METHODS

We adopted the quality improvement (QI) Model for Improvement with Plan-Do-Study-Act (PDSA) cycles to achieve this aim. This QI project was conducted over 11 months in a multidisciplinary PICU. Outcome measures included the (1) development of a standardized extubation readiness test (ERT) that was acceptable and safe; (2) performance of ERT on > 80% of all mechanically ventilated subjects; and (3) maintenance or reduction in mechanical ventilation duration, extubation failure (non-elective re-intubation within 48 h of extubation), and need for rescue noninvasive ventilation (NIV). Balancing measures were to ensure (1) no compromise of the subject's clinical status; and (2) acceptability of the ERT workflow by medical, nursing, and respiratory therapist (RT) teams.

RESULTS

Four PDSA cycles were necessary to achieve the aims of this study. During the QI period, 438 subjects were admitted to the PICU. The ERT was championed by the RTs who conducted the test during office hours. ERT performance increased from 0% (baseline) to 90% (fourth PDSA cycle). Extubation failure rate after implementing ERT was reduced compared to baseline (4/31 [12.9%] vs 3/127 [2.4%], P = .01), whereas need for rescue NIV (3/31 [9.7%] vs 10/127 [7.9%], P = .74) and duration of mechanical ventilation (2 [1-7] d vs 1 [1-3] d, P = .09) were unchanged. PICU length of stay was reduced after implementing ERT (5 [3-10] d vs 3 [1-6] d, P = .01). No subject was destabilized as a result of ERT, and PICU staff found the workflow acceptable.

CONCLUSIONS

An acceptable and safe ERT protocol was implemented and found to improve outcomes in PICU subjects on mechanical ventilation.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Point of care diaphragm ultrasound in mechanically ventilated children: A predictive tool to detect extubation failure

BACKGROUND

Children should be weaned from the ventilator once their clinical condition improves. Extubation failure is associated with poorer clinical outcomes in children. Predictive indicators of successful extubation are needed. This study aims to evaluate the predictive value of ultrasonographic diaphragm imaging could help predict weaning success.

METHODS

In this prospective, observational study conducted between March and December 2021, children between 1 month and 10 years of age who were mechanically ventilated for more than 48 h were included. Diaphragm ultrasound (DUS) examinations were performed at the end of 2-h extubation readiness test (ERT). The end-inspiratory thickness (DTi), end-expiratory thickness (DTe), diaphragmatic thickening fraction (DTF), diaphragmatic excursion (DE), inspiratory slope (IS), and expiratory slope (ES) were evaluated.

RESULTS

Twenty-four (60%) patients were successfully extubated, while 16 (40%) required invasive or noninvasive mechanical ventilation support which were classified as failed extubation group. Three of the sixteen patients in the failed extubation group required reintubation. DTF was significantly greater in the successful weaning group (55.05 ± 23.75% vs. 30.9 ± 10.38%) (p < 0.001). DE was significantly greater in the successful weaning group (14 ± 4.4 mm vs. 11.05 ± 3.25 mm) (p < 0.001). DTF and DE were found to have a sensitivity and specificity of 91.67%, 87.50%, 83.33%, and 81.25%, respectively.

CONCLUSION

Diaphragm ultrasound is a feasible and promising tool to guide physicians during weaning from invasive mechanical ventilation. Among all DUS measurements, the DE and DTF indexes showed better performance in extubation failure than other diaphragmatic parameters.

Associations With Extubation Failure and Predictive Value of Risk Analytics Algorithms With Extubation Readiness Tests Following Congenital Cardiac Surgery

OBJECTIVES

Extubation failure is associated with morbidity and mortality in children following cardiac surgery. Current extubation readiness tests (ERT) do not consider the nonrespiratory support provided by mechanical ventilation (MV) for children with congenital heart disease. We aimed to identify factors associated with extubation failure in children following cardiac surgery and assess the performance of two risk analytics algorithms for patients undergoing an ERT.

DESIGN

Retrospective cohort study.

SETTING

CICU at a tertiary-care children's hospital.

PATIENTS

Children receiving MV greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Six hundred fifty encounters were analyzed with 49 occurrences (8%) of reintubation. Extubation failure occurred most frequently within 6 hours of extubation. On multivariable analysis, younger age (per each 3-mo decrease: odds ratio [OR], 1.06; 95% CI, 1.001-1.12), male sex (OR, 2.02; 95% CI, 1.03-3.97), Society of Thoracic Surgery-European Association for Cardiothoracic Surgery category 5 procedure (p equals to 0.005), and preoperative respiratory support (OR, 2.08; 95% CI, 1.09-3.95) were independently associated with unplanned reintubation. Our institutional ERT had low sensitivity to identify patients at risk for reintubation (23.8%; 95% CI, 9.7-47.6%). The addition of the inadequate delivery of oxygen (IDO2) index to the ERT increased the sensitivity by 19.0% (95% CI, -2.5 to 40.7%; p = 0.05), but the sensitivity remained low and the accuracy of the test dropped by 8.9% (95% CI, 4.7-13.1%; p < 0.01).

CONCLUSIONS

Preoperative respiratory support, younger age, and more complex operations are associated with postoperative extubation failure. IDO2 and IVCO2 provide unique cardiorespiratory monitoring parameters during ERTs but require further investigation before being used in clinical evaluation for extubation failure.

Ventilation Weaning and Extubation Readiness in Children in Pediatric Intensive Care Unit: A Review

Ventilation is one of the most common procedures in critically ill children admitted to the pediatric intensive care units (PICUs) and is associated with potential severe side effects. The longer the mechanical ventilation, the higher the risk of infections, mortality, morbidity and length of stay. Protocol-based approaches to ventilation weaning could have potential benefit in assisting the physicians in the weaning process but, in pediatrics, clear significant outcome difference related to their use has yet to be shown. Extubation failure occurs in up to 20% of patients in PICU with evidences demonstrating its occurrence related to a worse patient outcome including higher mortality. Various clinical approaches have been described to decide the best timing for extubation which can usually be achieved by performing a spontaneous breathing trial before the extubation. No clear evidence is available over which technique best predicts extubation failure. Within this review we summarize the current strategies of ventilation weaning and extubation readiness evaluation employed in the pediatric setting in order to provide an updated view on the topic to guide intensive care physicians in daily clinical practice. We performed a thorough literature search of main online scientific databases to identify principal studies evaluating different strategies of ventilation weaning and extubation readiness including pediatric patients receiving mechanical ventilation. Various strategies are available in the literature both for ventilation weaning and extubation readiness assessment with unclear clear data supporting the superiority of any approach over the others.

Effect of Protocolized Weaning and Spontaneous Breathing Trial vs Conventional Weaning on Duration of Mechanical Ventilation: A Randomized Controlled Trial

Background

Identifying ventilated patients ready for extubation is a challenge for clinicians. Premature extubation increases risks of reintubation while delayed weaning increases complications of prolonged ventilation. We compared the duration of mechanical ventilation (MV) and extubation failure in children extubated using a weaning protocol based on pressure support spontaneous breathing trial (PS SBT) vs those extubated after nonprotocolized physician-directed weaning.

Patients and methods

A prospective randomized controlled trial was conducted in the pediatric intensive care unit of a tertiary care hospital in children ventilated for ≥24 hours. All eligible patients underwent daily screening and were randomized once found fit. The intervention group underwent PS SBT of 2 hours duration followed by a T-piece trial and extubation. Controls underwent conventional weaning with synchronized intermittent mandatory ventilation mode and a T-piece trial before extubation.

Results

Eighty patients were randomized into two groups of 40 each. About 77.5% of patients passed the PS SBT on the first attempt. No statistical difference was found either in the duration of MV between the two groups [median (interquartile range) in days: 4.77 (2.89, 9.46) in controls and 4.94 (2.23, 6.35) in cases, p = 0.62] or in the rate of extubation failure (13% and 10.5%, p = 1). Mortality was found to be significantly higher in the reintubated patients compared to those not reintubated in both groups (p = 0.002 in cases and 0.005 in controls).

Conclusion

Weaning using PS SBT-based protocol though did not shorten the duration of MV, it was found to be safe for assessing extubation readiness and did not increase extubation failure (CTRI no—CTRI/2018/04/013270).

How to cite this article

Kishore R, Jhamb U. Effect of Protocolized Weaning and Spontaneous Breathing Trial vs Conventional Weaning on Duration of Mechanical Ventilation: A Randomized Controlled Trial. Indian J Crit Care Med 2021;25(9):1059–1065.

Extubation in the pediatric intensive care unit: predictive methods. An integrative literature review

For extubation in pediatric patients, the evaluation of readiness is strongly recommended. However, a device or practice that is superior to clinical judgment has not yet been accurately determined. Thus, it is important to conduct a review on the techniques of choice in clinical practice to predict extubation failure in pediatric patients. Based on a search in the PubMed®, Biblioteca Virtual em Saúde, Cochrane Library and Scopus databases, we conducted a survey of the predictive variables of extubation failure most commonly used in clinical practice in pediatric patients. Of the eight predictors described, the three most commonly used were the spontaneous breathing test, the rapid shallow breathing index and maximum inspiratory pressure. Although the disparity of the data presented in the studies prevented statistical treatment, it was still possible to describe and analyze the performance of these tests.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

Progression of Respiratory Support Following Pediatric Extubation

OBJECTIVES

High-flow nasal cannula and noninvasive positive pressure ventilation have become ubiquitous in contemporary PICUs. Practice patterns associated with the use of these modalities have not been well described. In this study, we aimed to describe the use of high-flow nasal cannula and noninvasive positive pressure ventilation in children after extubation and analyze the progression of usage in association with patient factors. Our secondary aim was to describe interventions used for postextubation stridor.

DESIGN

Single-center retrospective cohort study.

SETTING

A 36-bed quaternary medical-surgical PICU.

PATIENTS

Mechanically ventilated pediatric patients admitted between April 2017 and March 2018. Exclusions were patients in the cardiac ICU, patients requiring a tracheostomy or chronic ventilatory support, and patients with limited resuscitation status.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data regarding respiratory modality use was collected for the first 72 hours after extubation. There were 427 patients included in the analysis; 51 patients (11.9%) were extubated to room air, 221 (51.8%) to nasal cannula, 132 (30.9%) to high-flow nasal cannula, and 23 (5.4%) to noninvasive positive pressure ventilation. By 72 hours, 314 patients (73.5%) were on room air, 52 (12.2%) on nasal cannula, 29 (6.8%) on high-flow nasal cannula, eight (1.9%) on noninvasive positive pressure ventilation, and 24 (5.6%) were reintubated. High-flow nasal cannula was the most used respiratory modality for postextubation stridor. Multivariate analysis demonstrated that longer duration of invasive mechanical ventilation increased the odds of initial high-flow nasal cannula and noninvasive positive pressure ventilation use, and a diagnosis of cerebral palsy increased the odds of escalating from high-flow nasal cannula to noninvasive positive pressure ventilation in the first 24 hours post extubation.

CONCLUSIONS

High-flow nasal cannula is commonly used immediately after pediatric extubation and the development of postextubation stridor; however, its usage sharply declines over the following 72 hours. Larger multicenter trials are needed to identify high-risk patients for extubation failure that might benefit the most from prophylactic use of high-flow nasal cannula and noninvasive positive pressure ventilation after extubation.

A Respiratory Therapist-Driven Pathway Improves Timeliness of Extubation Readiness Assessment in a Single PICU

OBJECTIVES

Our smart aim was to decrease the time between when a mechanically ventilated patient was eligible for and when they underwent their first extubation readiness test (delta time) by 50% within 3 months through the development and implementation of a respiratory therapist-driven extubation readiness test pathway.

DESIGN

Quality improvement project.

SETTING

Single, tertiary care, 24-bed, academic PICU.

PATIENTS

Pediatric patients admitted to the PICU and requiring mechanical ventilation for a primary pulmonary process.

INTERVENTIONS

We developed an extubation readiness test pathway that consisted of an eligibility screen and a standard testing process. Patients were screened every 3 hours. Upon passing the screen and being cleared by a prescriber, a test was initiated. No clinical management was dictated to prescribers.

MEASUREMENTS AND MAIN RESULTS

The preintervention and intervention cohorts included 109 and 43 mechanical ventilation courses, respectively. The mean delta time decreased from 33.77 hours to 2.92 hours after pathway implementation (p = 0.000). The medical length of stay decreased from 196.6 to 177.2 hours (p = 0.05). There were no statistically significant changes in duration of mechanical ventilation until first extubation (112.9 vs 122.3 hr; p = 0.651) and 48-hour extubation failure rate (16.5% vs 4.8%; p = 0.056). The sensitivity and positive predictive value for the extubation readiness test were 89.5% and 94.4%, respectively. The mean for all process compliance measures was 91.5%.

CONCLUSIONS

A respiratory therapist-driven extubation readiness test pathway can be safely implemented in a large, academic PICU. The pathway resulted in earlier extubation readiness testing without increasing key balancing measures-the duration of mechanical ventilation, PICU length of stay, or the extubation failure rate.

Strategies to Optimize ICU Liberation (A to F) Bundle Performance in Critically Ill Adults With Coronavirus Disease 2019

OBJECTIVES

The severe acute respiratory syndrome coronavirus 2 pandemic has stretched ICU resources in an unprecedented fashion and outstripped personal protective equipment supplies. The combination of a novel disease, resource limitations, and risks to medical personnel health have created new barriers to implementing the ICU Liberation ("A" for Assessment, Prevention, and Manage pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; and "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, a proven ICU care approach that reduces delirium, shortens mechanical ventilation duration, prevents post-ICU syndrome, and reduces healthcare costs. This narrative review acknowledges barriers and offers strategies to optimize Bundle performance in coronavirus disease 2019 patients requiring mechanical ventilation.

DATA SOURCES STUDY SELECTION AND DATA EXTRACTION

The most relevant literature, media reports, and author experiences were assessed for inclusion in this narrative review including PubMed, national newspapers, and critical care/pharmacology textbooks.

DATA SYNTHESIS

Uncertainty regarding coronavirus disease 2019 clinical course, shifts in attitude, and changes in routine behavior have hindered Bundle use. A domino effect results from: 1) changes to critical care hierarchy, priorities, and ICU team composition; 2) significant personal protective equipment shortages cause; 3) reduced/restricted physical bedside presence favoring; 4) increased depth of sedation and use of neuromuscular blockade; 5) which exacerbate drug shortages; and 6) which require prolonged use of limited ventilator resources. Other identified barriers include manageable knowledge deficits among non-ICU clinicians unfamiliar with the Bundle or among PICU specialists deploying pediatric-based Bundle approaches who are unfamiliar with adult medicine. Both groups have been enlisted to augment the adult ICU work force to meet demand. Strategies were identified to facilitate Bundle performance to liberate patients from the ICU.

CONCLUSIONS

We acknowledge current challenges that interfere with comprehensive management of critically ill patients during the coronavirus disease 2019 pandemic. Rapid response to new circumstances precisely requires established safety mechanisms and protocols like the ABCDEF Bundle to increase ICU and ventilator capacity and help survivors maximize recovery from coronavirus disease 2019 as early as possible.

Pressure support ventilation, sigh adjunct to pressure support ventilation, and neurally adjusted ventilatory assist in infants after cardiac surgery: A physiologic crossover randomized study

OBJECTIVES

We sought to compare gas exchange, respiratory mechanics, and asynchronies during pressure support ventilation (PSV), sigh adjunct to PSV (PSV SIGH), and neurally adjusted ventilatory assist (NAVA) in hypoxemic infants after cardiac surgery.

DESIGN

Prospective, single-center, crossover, randomized physiologic study.

SETTING

Tertiary-care pediatric intensive care unit.

PATIENTS

Fourteen hypoxemic infants (median age 11.5 days [8.7-74]).

INTERVENTIONS

The protocol begins with a 1 hour step of PSV, followed by two consecutive steps in PSV SIGH and NAVA in random order, with a washout period of 30 minutes (PSV) between them.

MAIN RESULTS

Three infants presented an irregular Eadi signal because of diaphragmatic paralysis and were excluded from analysis. For the remaining 11 infants, PaO₂ /FiO ₂ and oxygenation index improved in PSV SIGH compared with PSV (P < 0.05) but not in NAVA compared with PSV. PSV SIGH showed increased tidal volumes and lower respiratory rate than PSV (P < 0.05), as well as a significant improvement in compliance with respiratory system indexed to body weight when compared with both PSV and NAVA (P < 0.01). No changes in mean airway pressure was registered among steps. Inspiratory time resulted prolonged for both PSV SIGH and NAVA than PSV (P < 0.05). NAVA showed the higher coefficient of variability in respiratory parameters and a significative decrease in asynchrony index when compared with both PSV and PSV SIGH (P < 0.01).

CONCLUSIONS

The adjunct of one SIGH per minute to PSV improved oxygenation and lung mechanics while NAVA provided the best patient-ventilator synchrony in infants after cardiac surgery.

[Research advances in validity of predictors for extubation outcome in children receiving invasive mechanical ventilation]

The development of invasive mechanical ventilation technology provides effective respiratory support for critically ill children. However, respiratory support is not the end of treatment as the ultimate goal is successful extubation in children. At present, some evaluation indicators before extubation including rapid shallow breathing index, maximal inspiratory pressure, and work of breathing are of high clinical value in predicting adult extubation outcome, but their evidence of evidence-based medicine is not sufficient in the field of pediatric intensive care. This paper reviews the current research on the validity of predictors for extubation outcomes in children. It shows that there is still a lack of indicators with good sensitivity and specificity for assessment before extubation in children. The studies are still in a small-sample size and single-center stage. Therefore, how to optimize evaluation before extubation and improve the success rate of extubation is the direction of joint efforts of doctors in the pediatric intensive care unit and rehabilitation medicine department.

Simulation of pressure support for spontaneous breathing trials in neonates

BACKGROUND

Endotracheal tubes used for neonates are not as resistant to breathing as originally anticipated; therefore, spontaneous breathing trials (SBTs) with continuous positive airway pressure (CPAP), without pressure support (PS), are recommended. However, PS extubation criteria have predetermined pressure values for each endotracheal tube diameter (PS 10 cmH₂O with 3.0- and 3.5-mm tubes or PS 8 cmH₂O with 4.0-mm tubes). This study aimed to assess the validity of these SBT criteria for neonates, using an artificial lung simulator, ASL 5000™ lung simulator, and a SERVO-i Universal™ ventilator (minute volume, 240-360 mL/kg/min; tidal volume, 30 mL; respiratory rate, 24-36/min; lung compliance, 0.5 mL/cmH₂O/kg; resistance, 40 cmH₂O/L/s) in an intensive care unit. We simulated a spontaneous breathing test in a 3-kg neonate after cardiac surgery with 3.0-3.5-mm endotracheal tubes. We measured the work of breathing (WOB), trigger work, and parameters of pressure support ventilation (PSV), T-piece breathing, or ASL 5000™ alone.

RESULTS

WOB displayed respiratory rate dependency under intubation. PS compensating tube resistance fluctuated with respiratory rate. At a respiratory rate of 24/min, the endotracheal tube did not greatly influence WOB under PSV and the regression line of WOB converged with the WOB of ASL 5000™ alone under PS 1 cmH₂O; however, at 36/min, endotracheal tube was resistant to breathing under PSV because trigger work increased exponentially with PS ≤ 9 cmH₂O. The regression line of WOB under PSV converged with the WOB of T-piece breathing under PS 1 cmH₂O. Furthermore, PS compensating endotracheal tube resistance was 6 cmH₂O. The WOB of ASL 5000™ alone approached that of respiratory distress syndrome (RDS); however, the pressure of patient effort was normal physiological range at PS 10 cmH₂O. PS equalizing WOB under PSV with that after extubation depended on the respiratory rate and upper airway resistance. If WOB after extubation equaled that of T-piece breathing, the PS was 0 cmH₂O regardless of the respiratory rates. If WOB after extubation approximated  to that of ASL 5000™ alone, the PS depended on the respiratory rate.

CONCLUSION

SBT strategies should be selected per neonatal respiratory rates and upper airway resistance.

Methods in the design and implementation of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial

Background

Few papers discuss the pragmatics of conducting large, cluster randomized clinical trials. Here we describe the sequential steps taken to develop methods to implement the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial that tested the effect of a nurse-implemented, goal-directed, comfort algorithm on clinical outcomes in pediatric patients with acute respiratory failure.

Methods

After development in a single institution, the RESTORE intervention was pilot-tested in two pediatric intensive care units (PICUs) to evaluate safety and feasibility. After the pilot, the RESTORE intervention was simplified to enhance reproducibility across multiple PICUs. The final RESTORE trial was developed as a cluster randomized clinical trial where the unit of randomization was the PICU, stratified by PICU size, and the unit of inference was the patient. Study execution was revised based on our Data and Safety Monitoring Board’s recommendation to consult with the Department of Health and Human Services’ Office of Human Research Protection (OHRP) on how best to consent eligible subjects. OHRP deemed that the RESTORE intervention posed greater than minimal risk and that all enrolled subjects provide consent reflecting their level of participation.

Results

Thirty-one PICUs of varying size, organization and academic affiliation participated and over 2800 critically ill infants and children supported on mechanical ventilation for acute pulmonary disease were enrolled. The primary outcome for the trial was the duration of mechanical ventilation; secondary outcomes included time awake and comfortable, total sedative exposure and iatrogenic withdrawal symptoms. Throughout the clinical trial the investigative team worked to maintain treatment fidelity, enrollment milestones and co-investigator enthusiasm. We considered the potential impact of competing clinical trials through a decision-making framework.

Conclusions

The RESTORE clinical trial was a large and complex multicenter study that has provided the necessary evidence to guide sedation practices in the field of pediatric critical care. Specific issues that were unique to this trial included level of consent, adding clinical sites to augment enrollment and evaluating the potential impact of competing clinical trials.

Trial registration

ClinicalTrials.gov, Identifiers: Pilot trial: NCT00142766; Retrospectively registerd on 2 September 2005.

Cluster randomized trial: NCT00814099. Registered on 23 December 2008.

An Interprofessional Quality Improvement Initiative to Standardize Pediatric Extubation Readiness Assessment

OBJECTIVES

Establishing protocols to wean mechanical ventilation and assess readiness for extubation, with the goal of minimizing morbidity associated with extubation failure and prolonged mechanical ventilation, have become increasingly important in contemporary PICUs. The aim of this quality improvement initiative is to establish a respiratory therapist-led daily spontaneous breathing trial protocol to standardize extubation readiness assessment and documentation in our PICU.

DESIGN

A quality improvement project.

SETTING

Single center, tertiary care Children's Hospital PICU.

PATIENTS

All intubated patients admitted to PICU requiring conventional mechanical ventilation between February 2013 and January 2016.

INTERVENTIONS

A working group of pediatric intensivists, respiratory therapists, nurses, and information technology specialists established the protocol, standardized documentation via the electronic medical record, and planned education. Daily spontaneous breathing trial protocol implementation began in February 2015. All patients on mechanical ventilation were screened daily at approximately 4 AM by a respiratory therapist to determine daily spontaneous breathing trial eligibility. If all screening criteria were met, patients were placed on continuous positive airway pressure of 5 cm H2O with pressure support of 8 cm H2O for up to 2 hours. If tolerated, patients would be extubated to supplemental oxygen delivered via nasal cannula in the morning, after intensivist approval. Daily audits were done to assess screening compliance and accuracy of documentation.

MEASUREMENTS AND MAIN RESULTS

We analyzed data from 398 mechanically ventilated patients during daily spontaneous breathing trial period (February 2015-January 2016), compared with 833 patients from the pre-daily spontaneous breathing trial period (February 2013-January 2015). During the daily spontaneous breathing trial period, daily screening occurred in 92% of patients. Extubation failure decreased from 7.8% in the pre-daily spontaneous breathing trial period to 4.5% in daily spontaneous breathing trial period. The use of high-flow nasal cannula slightly increased during the project, while there was no change in duration of mechanical ventilation or the use of noninvasive ventilation.

CONCLUSIONS

An interprofessionally developed respiratory therapist-led extubation readiness protocol can be successfully implemented in a busy tertiary care PICU without adverse events.

Factors Associated With Unplanned Extubation in Children: A Case–Control Study

Purpose:

Although several studies assess unplanned extubation (UE) in children, few have addressed determinants of UE and factors associated with reintubation in a case-controlled manner. We aimed to identify the risk factors and outcomes associated with UE in a pediatric intensive care unit.

Methods:

Cases of UE were randomly matched with control patients at a ratio of 1:4 for age, severity of illness, and admission diagnosis. For cases and controls, we also collected data associated with UE events, reintubation, and outcomes.

Results:

We analyzed 94 UE patients (0.75 UE per 100 intubation days) and found no differences in demographics between the 2 groups. Logistic regression revealed that patient agitation (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.28-4.65), continuous sedation infusion (OR: 3.27; 95% CI: 1.70-6.29), night shifts (OR: 9.16; 95% CI: 4.25-19.72), in-charge nurse experience <2 years (OR: 2.38; 95% CI: 1.13-4.99), and oxygenation index (OI) >5 (OR: 76.9; 95% CI: 16.79-352.47) were associated with UE. Risk factors for reintubation after UE included prior level of sedation (COMFORT score < 27; OR: 7.93; 95% CI: 2.30-27.29), copious secretion (OR: 11.88; 95% CI: 2.20-64.05), and OI > 5 (OR: 9.32; 95% CI: 2.45-35.48).

Conclusions:

This case–control study showed that both patient- and nurse-associated risk factors were related to UE. Risk factors associated with reintubation included lower levels of consciousness, copious secretions, and higher OI. Further evidence-based studies, including a larger sample size, are warranted to identify predisposing factors in UEs.