Weaning and extubation readiness in pediatric patients

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.

Clinical study on the predictive utility of high flow CPAP in weaning from prolonged mechanical ventilation in critical paediatric surgery patients

INTRODUCTION AND OBJECTIVES

Weaning paediatric patients from mechanical ventilation (MV) often results in extubation failure (EF) (14%-22%) and 2% of patients will require tracheostomy (2%).

METHODS

We performed an observational study in 115 critically ill patients in whom a novel high-flow CPAP (CPAP-ANRI) system was connected to the tracheal tube during ventilation (CPAP + TI). After extubation, the same system was connected to various interfaces.

RESULTS

Mean (± SD) age was 31 ± 49 months, PRISM-III score was 2.9 ± 2.4, and duration of intermittent positive pressure ventilation with tracheal intubation (IPPV + TI) was 6 ± 5.6 days followed by CPAP + TI for 1.4 ± 1.7 days. The initial rate of EF was 10.4% for either haemodynamic (n = 4) or respiratory (n= 8) reasons, although the final rate of EF requiring tracheostomy was only 0.8%. After progressing from IPPV + TI to CPAP + TI, PO2/FiO2 values in successfully extubated patients immediately increased by 27% (p < 0.0003) vs only 13% (p > 0.3) in patients presenting EF. Switching to CPAP + TI increased the percentage of patients with pO2/FiO2 > 200, particularly in patients with heart disease, in whom >30% increase in pO2/FiO2 over baseline had a positive predictive value for successful extubation (AUC = 0.708; p = 0.056).

CONCLUSIONS

The CPAP-ANRI device is a simple respiratory aid that is highly effective in optimizing cardiopulmonary interaction to facilitate weaning from MV and identifying most cases in which extubation is likely to be successful.

Transitions in intensive care: Investigating critical slowing down post extubation

Complex biological systems undergo sudden transitions in their state, which are often preceded by a critical slowing down of dynamics. This results in longer recovery times as systems approach transitions, quantified as an increase in measures such as the autocorrelation and variance. In this study, we analysed paediatric patients in intensive care for whom mechanical ventilation was discontinued through removal of the endotracheal tube (extubation). Some patients failed extubation, and required a re-intubation within 48 hours. We investigated whether critical slowing down could be observed post failed extubations, prior to re-intubation. We tested for significant increases (p <.05) between extubation and re-intubation, in the variance and autocorrelation, over the time series data of heart rate, respiratory rate and mean blood pressure. The autocorrelation of the heart rate showed a significantly higher proportion of increases in the group that failed extubation, compared who those who did not. It also showed a significantly higher magnitude of increase for the failed extubation group in a t-test. Moreover, incorporating these magnitudes significantly improved the fit of a logistic regression model when compared to a model that solely used the mean and standard deviation of the vital signs. While immediate clinical utility is limited, the work marks an important first step towards using dynamical systems theory to understand the dynamics of signals measured at the bedside during intensive care.

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.

Comparison of Immediate Outcomes of Pulmonary Valve-Sparing and Transannular Patch Techniques for Correction of Tetralogy of Fallot

Objectives

This study primarily aimed to compare the mechanical ventilation durations between pulmonary valve-sparing and transannular patch repair techniques in the surgical correction of Tetralogy of Fallot. Secondary objectives included comparison of demographic characteristics, cardiopulmonary bypass parameters, postoperative vasoactive inotrope requirements, incidence of cardiac conduction abnormalities, echocardiographic findings, intensive care unit and hospitalisation durations, reoperations rates, morbidity and mortality between the 2 approaches.

Methods

This retrospective cohort study was conducted at the Royal Hospital, Muscat, Oman, between January 2016 and December 2019. This study included 102 paediatric patients who underwent complete surgical correction of Tetralogy of Fallot over 3 years, either by a pulmonary valve-sparing technique (Group 1, n = 43) or by transannular patch repair (Group 2, n = 59). Data for both primary and secondary outcomes were extracted from hospital records.

Results

Mechanical ventilation duration was significantly shorter in Group 1 (P = 0.039). Patients in Group 1 were generally older, with shorter cardiopulmonary bypass and aortic clamp times, lower inotrope scores, and shorter chest tube retention, intensive care unit and hospitalisation periods. Junctional ectopic tachycardia and severe pulmonary regurgitation were significantly more common in Group 2, while right ventricular outflow tract peak pressure gradients were higher in Group 1. Multivariate analysis identified patient weight as the only independent predictor of mechanical ventilation duration.

Conclusion

Pulmonary valve preservation was associated with better early outcomes, including reduced mechanical ventilation duration, lower vasoactive inotrope scores, decreased postoperative arrhythmias and shorter hospital stay.

Pre-extubation Dexamethasone: Does It Merely Muffle Stridor or Provide Real Benefit for Mechanically Ventilated Children?

How to cite this article: Lolam V. Pre-extubation Dexamethasone: Does It Merely Muffle Stridor or Provide Real Benefit for Mechanically Ventilated Children? Indian J Crit Care Med 2024;28(11):997-998.

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.

An algorithm for discontinuing mechanical ventilation in boys with x-linked myotubular myopathy after positive response to gene therapy: the ASPIRO experience

X-linked myotubular myopathy (XLMTM) is a rare, life-threatening congenital myopathy. Most (80%) children with XLMTM have profound muscle weakness and hypotonia at birth resulting in severe respiratory insufficiency, the inability to sit up, stand or walk, and early mortality. At birth, 85-90% of children with XLMTM require mechanical ventilation, with more than half requiring invasive ventilator support. Historically, ventilator-dependent children with neuromuscular-derived respiratory failure of this degree and nature, static or progressive, are not expected to achieve complete independence from mechanical ventilator support. In the ASPIRO clinical trial (NCT03199469), participants receiving a single intravenous dose of an investigational gene therapy (resamirigene bilparvovec) started showing significant improvements in daily hours of ventilation support compared with controls by 24 weeks post-dosing, and 16 of 24 dosed participants achieved ventilator independence between 14 and 97 weeks after dosing. At the time, there was no precedent or published guidance for weaning chronically ventilated children with congenital neuromuscular diseases off mechanical ventilation. When the first ASPIRO participants started showing dramatically improved respiratory function, the investigators initiated efforts to safely wean them off ventilator support, in parallel with primary protocol respiratory outcome measures. A group of experts in respiratory care and physiology and management of children with XLMTM developed an algorithm to safely wean children in the ASPIRO trial off mechanical ventilation as their respiratory muscle strength increased. The algorithm developed for this trial provides recommendations for assessing weaning readiness, a stepwise approach to weaning, and monitoring of children during and after the weaning process.

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.

Development of a clinical prediction tool for extubation failure in pediatric cardiac intensive care unit

Introduction/objective

Extubation failure in pediatric patients with congenital or acquired heart diseases increases morbidity and mortality. This study aimed to develop a clinical risk score for predicting extubation failure to guide proper clinical decision-making and management.

Methods

We conducted a retrospective study. This clinical prediction score was developed using data from the Pediatric Cardiac Intensive Care Unit (PCICU) of the Faculty of Medicine, Chiang Mai University, Thailand, from July 2016 to May 2022. Extubation failure was defined as the requirement for re-intubation within 48 h after extubation. Multivariable logistic regression was used for modeling. The score was evaluated in terms of discrimination and calibration.

Results

A total of 352 extubation events from 270 patients were documented. Among these, 40 events (11.36%) were extubation failure. Factors associated with extubation failure included history of pneumonia (OR: 4.14, 95% CI: 1.83-9.37, p = 0.001), history of re-intubation (OR: 5.99, 95% CI: 2.12-16.98, p = 0.001), and high saturation in physiologic cyanosis (OR: 5.94, 95% CI: 1.87-18.84, p = 0.003). These three factors were utilized to develop the risk score. The score showed acceptable discrimination with an area under the curve (AUC) of 0.77 (95% CI: 0.69-0.86), and good calibration.

Conclusion

The derived Pediatric CMU Extubation Failure Prediction Score (Ped-CMU ExFPS) could satisfactorily predict extubation failure in pediatric cardiac patients. Employing this score could promote proper personalized care. We suggest conducting further external validation studies before considering implementation in practice.

Factors associated with prolonged mechanical ventilation in children with pulmonary failure: Cohort study from the LARed Network registry

OBJECTIVES

To identify factors associated with prolonged mechanical ventilation (pMV) in pediatric patients in pediatric intensive care units (PICUs).

DESIGN

Secondary analysis of a prospective cohort.

SETTING

PICUs in centers that are part of the LARed Network between April 2017 and January 2022.

PARTICIPANTS

Pediatric patients on mechanical ventilation (IMV) due to respiratory causes. We defined IMV time greater than the 75th percentile of the global cohort.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Demographic data, diagnoses, severity scores, therapies, complications, length of stay, morbidity, and mortality.

RESULTS

1698 children with MV of 8±7 days were included, and pIMV was defined as 9 days. Factors related to admission were age under 6 months (OR 1.61, 95% CI 1.17-2.22), bronchopulmonary dysplasia (OR 3.71, 95% CI 1.87-7.36), and fungal infections (OR 6.66, 95% CI 1.87-23.74), while patients with asthma had a lower risk of pIMV (OR 0.30, 95% CI 0.12-0.78). Regarding evolution and length of stay in the PICU, it was related to ventilation-associated pneumonia (OR 4.27, 95% CI 1.79-10.20), need for tracheostomy (OR 2.91, 95% CI 1.89-4.48), transfusions (OR 2.94, 95% CI 2.18-3.96), neuromuscular blockade (OR 2.08, 95% CI 1.48-2.93), high-frequency ventilation (OR 2.91, 95% CI 1.89-4.48), and longer PICU stay (OR 1.13, 95% CI 1.10-1.16). In addition, mean airway pressure greater than 13cmH2O was associated with pIMV (OR 1.57, 95% CI 1.12-2.21).

CONCLUSIONS

Factors related to IMV duration greater than 9 days in pediatric patients in PICUs were identified in terms of admission, evolution, and length of stay.

Predicting Duration of Invasive Mechanical Ventilation in the Pediatric ICU

BACKGROUND

Timely ventilator liberation can prevent morbidities associated with invasive mechanical ventilation in the pediatric ICU (PICU). There currently exists no standard benchmark for duration of invasive mechanical ventilation in the PICU. This study sought to develop and validate a multi-center prediction model of invasive mechanical ventilation duration to determine a standardized duration of invasive mechanical ventilation ratio.

METHODS

This was a retrospective cohort study using registry data from 157 institutions in the Virtual Pediatric Systems database. The study population included encounters in the PICU between 2012-2021 involving endotracheal intubation and invasive mechanical ventilation in the first day of PICU admission who received invasive mechanical ventilation for > 24 h. Subjects were stratified into a training cohort (2012-2017) and 2 validation cohorts (2018-2019/2020-2021). Four models to predict the duration of invasive mechanical ventilation were trained using data from the first 24 h, validated, and compared.

RESULTS

The study included 112,353 unique encounters. All models had observed-to-expected (O/E) ratios close to one but low mean squared error and R2 values. The random forest model was the best performing model and achieved an O/E ratio of 1.043 (95% CI 1.030-1.056) and 1.004 (95% CI 0.990-1.019) in the validation cohorts and 1.009 (95% CI 1.004-1.016) in the full cohort. There was a high degree of institutional variation, with single-unit O/E ratios ranging between 0.49-1.91. When stratified by time period, there were observable changes in O/E ratios at the individual PICU level over time.

CONCLUSIONS

We derived and validated a model to predict the duration of invasive mechanical ventilation that performed well in aggregated predictions at the PICU and the cohort level. This model could be beneficial in quality improvement and institutional benchmarking initiatives for use at the PICU level and for tracking of performance over time.

Author Reply: Lung Ultrasound Score-Does It Really Predict Extubation Failure?

How to cite this article: Rajbanshi LK, Bajracharya A, Devkota D. Author Reply-lung Ultrasound Score-Does It Really Predict Extubation Failure? Indian J Crit Care Med 2023;27(11):857-858.

Optimal timing of extubation in preterm infants

In neonatal intensive care, endotracheal intubation is usually performed as an urgent or semi-urgent procedure in infants with critical or unstable conditions related to progressive respiratory failure. Extubation is not. Patients undergoing extubation are typically stable, with improved respiratory function. The key elements to facilitating extubation are to recognize improvement in respiratory status, promote weaning of mechanical ventilation, and accurately identify readiness for removal of the endotracheal tube. Therefore, extubation should be a planned and well-organized procedure. In this review, we will appraise the evidence for existing predictors of extubation readiness and provide patient-specific, pathophysiology-derived strategies to optimize the timing and success of extubation in neonates, with a focus on extremely preterm infants.

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.

Predictive factors for extubation success in very low and extremely low birth weight preterm infants

Background

Although invasive mechanical ventilation (IMV) has contributed to the survival of preterm infants with extremely low birth weight (ELBW), it is also associated with unsatisfactory clinical outcomes when used for prolonged periods. This study aimed to identify factors that may be decisive for extubation success in very low birth weight (VLBW) and extremely low birth weight (ELBW) preterm infants.

Methods

The cohort study included preterm infants with gestational age (GA) <36 weeks, birth weight (BW) <1500 grams who underwent IMV, born between 2015 and 2018. The infants were allocated into two groups: extubation success (SG) or failure (FG). A stepwise logistic regression model was created to determine variables associated with successful extubation.

Results

Eighty-three preterm infants were included. GA and post-extubation arterial partial pressure of carbon dioxide (PaCO2) were predictive of extubation success. Infants from FG had lower GA and BW, while those from SG had higher weight at extubation and lower post-extubation PaCO2.

Discussion

Although we found post-extubation PaCO2 as an extubation success predictor, which is a variable representative of the moment after the primary outcome, this does not diminish its clinical relevance since extubation does not implicate in ET removal only; it also involves all the aspects that take place within a specified period (72 hours) after the planned event.

Conclusion

GA and post-extubation PaCO2 were predictors for extubation success in VLBW and ELBW preterm infants. Infants who experienced extubation failure had lower birth weight and higher FiO2 prior to extubation.

Pressure support versus continuous positive airway pressure for predicting successful liberation from invasive ventilation in children: an open label, randomized non-inferiority trial

Background

Pressure support (PS) as a spontaneous breathing trial (SBT) was considered inferior to continuous positive airway pressure (CPAP) and T-piece because PS underestimated post-extubation work of breathing in physiologic studies. We aimed to compare PS and CPAP as SBT methods for assessing clinical outcomes in children.

Methods

This was an open label randomized non-inferiority trial conducted between December 2019 and August 2021 among children aged 1 month to 12 years deemed ready for weaning after at least 48 h of invasive ventilation in PICU. Children were randomized to undergo a 2-h SBT with PS of 8 cm H₂O in addition to PEEP 5-6 cm H₂O or CPAP (5-6 cm H₂O). The primary outcome was successful liberation from invasive ventilation for 72 h after first SBT. Secondary outcomes included first SBT pass rate, need for post-extubation respiratory support (high flow oxygen and/or non-invasive ventilation), and length of PICU stay.

Findings

Of the 247 enrolled children, 244 completed the trial (121 in PS and 123 in CPAP group). Median (IQR) age was 24 (9, 84) months. Median (IQR) duration of invasive ventilation before randomization was 4.5 (3, 6.5) days. Successful liberation from invasive ventilation after first SBT occurred in 97 (80.2%) children in PS and 93 (75.6%) children in CPAP group [difference 4.6; 95% CI (-5.8, 15); p = 0.39]. First SBT pass rate between PS and CPAP [111 (91.7%) versus 105 (85.4%); difference 6.3; 95% CI (-1.6, 14.3); p = 0.12] was similar. Need for post-extubation respiratory support [52 (43%) versus 49 (40%)], rate of reintubation within 72 h [14 (11.6%) versus 12 (9.8%)] and median (IQR) length of PICU stay [9 (6, 15) versus 8 (5.5, 13) days] were comparable. Four (1.6%) children, all in CPAP group had unfavourable outcome (1 died, 3 discontinued care).

Interpretation

In invasively ventilated children, 2-h SBT with pressure support was non-inferior to CPAP in predicting successful liberation from invasive ventilation.

Funding

None.

Ultrasonic prediction of weaning failure in children undergoing cardiac surgery: A prospective observational study

Background and Aim

To assess the utility of ultrasonic markers like B-line score (LUS), diaphragm thickness (DT), thickening fraction (DTF), and excursion (DE) as predictors of weaning outcomes in children on mechanical ventilation (MV) after cardiac surgery.

Methods

This was a prospective observational study done in postcardiac surgical intensive care unit (ICU) of a tertiary care hospital. Children aged 1 month to 18 years, on MV after cardiac surgery from January to November 2017, were included. They were extubated after satisfying institutional weaning criteria. Ultrasound for LUS, DT, DTF, and DE was performed preoperatively, during pressure support ventilation (PSV) before extubation and 4 h after extubation.

Results

Patients were divided into weaning failure and success groups based on reintubation within 48 h of extubation. Of the 50 evaluated patients, 43 (86%) were weaned successfully and 7 (14%) had weaning failure. The left DTF during PSV was lower in patients weaning failure (0.00%, interquartile range (IQR) 0.00-14.28 vs 16.67%, IQR 8.33-22.20, P = 0. 012). The left DTF≤ 14.64% during PSV (area under receiver's operating curve 0.795, P = 0.014), 85% sensitivity, and 57% specificity (positive likelihood ratio 1.97, negative likelihood ratio 0.25) could predict weaning failure.

Conclusion

The left DTF during PSV is a good predictor of weaning failure in children on MV in postoperative ICU after congenital cardiac surgery.

Take home message

In children on mechanical ventilation after cardiac surgery, left DTF during pressure support ventilation is a good predictor of weaning failure.

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.

The end-tidal alveolar dead space fraction for risk stratification during the first week of invasive mechanical ventilation: an observational cohort study

BACKGROUND

The end-tidal alveolar dead space fraction (AVDSf = [PaCO₂-P_ETCO₂]/PaCO₂) is a metric used to estimate alveolar dead space. Higher AVDSf on the first day of mechanical ventilation is associated with mortality and fewer ventilator-free days. It is not clear if AVDSf is associated with length of ventilation in survivors, how AVDSf performs for risk stratification beyond the first day of ventilation, or whether AVDSf adds predictive value to oxygenation (oxygenation index [OI]) or severity of illness (Pediatric Risk of Mortality [PRISM III]) markers.

METHODS

Retrospective single-center observational cohort study of children and young adults receiving invasive mechanical ventilation. In those with arterial or capillary blood gases, AVDSf was calculated at the time of every blood gas for the first week of mechanical ventilation.

RESULTS

There were 2335 children and young adults (median age 5.8 years [IQR 1.2, 13.2]) enrolled with 8004 analyzed AVDSf values. Higher AVDSf was associated with mortality and longer length of ventilation in survivors throughout the first week of ventilation after controlling for OI and PRISM III. Higher OI was not associated with increased mortality until ≥ 48 h of ventilation after controlling for AVDSf and PRISM III. When using standardized variables, AVDSf effect estimates were generally higher than OI for mortality, whereas OI effect estimates were generally higher than AVDSf for the length of ventilation in survivors. An AVDSf > 0.3 was associated with a higher mortality than an AVDSf < 0.2 within each pediatric acute respiratory distress syndrome severity category. The maximum AVDSf within 12 h of intensive care unit admission demonstrated good risk stratification for mortality (AUC 0.768 [95% CI 0.732, 0.803]). AVDSf did not improve mortality risk stratification when added to PRISM III but did improve mortality risk stratification when added to the gas exchange components of PRISM III (minimum 12-h PaO₂ and maximum 12-h PCO₂) (p < 0.00001).

CONCLUSIONS

AVDSf is associated with mortality and length of ventilation in survivors throughout the first week of invasive mechanical ventilation. Some analyses suggest AVDSf may better stratify mortality risk than OI, whereas OI may better stratify risk for prolonged ventilation in survivors than AVDSf.

Pediatric ventilation liberation: evaluating the role of endotracheal secretions in an extubation readiness bundle

BACKGROUND

An evidence gap exists regarding the role of endotracheal secretions in pediatric extubation decisions. This study aims to evaluate whether endotracheal secretion burden independently correlates with pediatric extubation failure.

METHODS

This is a single-center, prospective cohort study of children aged <19 years requiring intubation. Nurses (RN) and respiratory therapists (RT) independently used a novel secretion assessment score focusing on secretion volume, character, and trend. We hypothesized that the RN and RT secretion scores would not correlate with extubation outcome and inter-rater reliability would be poor.

RESULTS

RN secretion character sub-score (OR 3.3, 95% CI 1.1-11.1, p = 0.048) was independently associated with extubation failure. RN and RT inter-rater reliability was poor (correlation 0.385, 95% CI 0.339-0.429, p < 0.001). A failure prediction model incorporating the RN secretion character sub-score as well as indication for mechanical ventilation and spontaneous breathing trial result demonstrated an area under the receiver operating curve of 0.817 (95% CI 0.730-0.904, p < 0.001).

CONCLUSIONS

In the general pediatric population, the RN assessment of endotracheal secretion character was independently associated with extubation failure. A model incorporating indication for mechanical ventilation, spontaneous breathing result, and RN assessment of endotracheal secretion character demonstrated reasonable accuracy in predicting failure in those clinically selected for extubation.

IMPACT

Development of comprehensive and sensitive extubation readiness bundles are key to balancing the competing risks of prolonged invasive mechanical ventilation duration and extubation failure. Evidence for clinical factors linked to extubation outcomes in children are limited. Endotracheal secretion burden is a common factor considered but has not been studied. This study supports a role for endotracheal secretion burden, as assessed by the bedside nurse, in extubation readiness bundles. Inter-rater reliability with respiratory therapists was poor. A model incorporating other key factors showed good discrimination for extubation outcome and sets the stage for prospective evaluation in the general population and diagnosis-specific subgroups.

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.

A 30-Minute Spontaneous Breathing Trial Misses Many Children Who Go On to Fail a 120-Minute Spontaneous Breathing Trial

BACKGROUND

The optimal length of spontaneous breathing trials (SBTs) in children is unknown.

RESEARCH QUESTIONS

What are the most common reasons for SBT failure in children, and when do they occur? Can clinical parameters at the 30-min mark of a 120-min SBT predict outcome?

STUDY DESIGN AND METHODS

We performed a secondary analysis of a clinical trial in pediatric ARDS, in which 2-h SBTs are conducted daily. SBT failure is based on objective criteria, including esophageal manometry for effort of breathing, categorized as passage, early failure (≤ 30 min), or late failure (30-120 min). Spirometry was used to calculate respiratory rate (RR), tidal volume (Vt), and rapid shallow breathing index (RSBI), in addition to pulse oximetry and capnography. Predictive models evaluated parameters at 30 min against SBT outcome, using receiver operating characteristic plots and area under the curve.

RESULTS

We included 100 children and 305 SBTs, with 42% of SBTs being successful, 32% failing within 30 min, and 25% failing between 30 and 120 min. Of the patients passing SBTs at 30 min, 40% went on to fail by 120 min. High respiratory effort (esophageal manometry) was present in > 80% of failed SBTs. At the 30-min mark, there were no clear thresholds for RR, Vt, RSBI, Fio2, oxygen saturation, or capnography that could reliably predict SBT outcome. Multivariable modeling identified RR (P < .001) and RSBI > 7 (P = .034) at 30 min, pre-SBT inspiratory pressure level (P = .009), and pre-SBT retractions (P = .042) as predictors for SBT failure, but this model performed poorly in an independent validation set with the receiver operating characteristic plot crossing the reference line (area under the curve, 0.67).

INTERPRETATION

A 30-min SBT may be too short in children recovering from pediatric ARDS because many go on to fail between 30 and 120 min. Reassuring values of Vt, RR, and gas exchange at 30 min do not reliably predict SBT passage at 2 h, likely because they do not capture the effort of breathing.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03266016; URL: www.

CLINICALTRIALS

gov.

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.

Operational Definitions Related to Pediatric Ventilator Liberation

BACKGROUND

Common, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices.

RESEARCH QUESTION

Can we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches?

STUDY DESIGN AND METHODS

A panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions.

RESULTS

In eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support.

INTERPRETATION

We propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.

Diaphragmatic Thickening Fraction by Ultrasound in Mechanically Ventilated Pediatric Patients: Pilot Observations During Spontaneous Breathing Trials

OBJECTIVES

In critically ill, mechanically ventilated adults, diaphragmatic atrophy and reduced diaphragmatic thickening fraction (DTF) has been associated with poor extubation outcomes. Diaphragmatic ultrasound assessment in critically ill pediatric patients shows similar results, though studies are on-going. We sought to explore the feasibility and utility of using DTF, obtained during a spontaneous breathing trial (SBT) in predicting weaning outcomes.

METHODS

We conducted a prospective, observational study in a single-center tertiary noncardiac pediatric intensive care unit (PICU) in a children's hospital. Mechanically ventilated pediatric patients were included except for those with preexisting conditions of neuromuscular weakness, diaphragm paresis, or chronic respiratory failure requiring non-invasive or invasive mechanical ventilation at baseline. A convenience sample of 38 patients were included in the study.

RESULTS

Weaning failure occurred in 10/38 (26%) instances with 9/38 (24%) occurring due to failed SBT and 1/38 (2%) due to failed extubation requiring reintubation. Median DTF was 24% (IQR: 12-33). DTF was significantly lower in instances of failed SBT, 12% compared to 27% (P < .01). The odds ratio (OR) of SBT failure utilizing: TF < 25% is 12 (CI: 1.33-108.0, Z-score: 2.22, P = .027), TV <5 mL/kg was 10.4 (CI: 1.76-61.67, Z-score: 2.58, P = .01), and combined TV <5 mL/kg and TF < 25% is 17.6 (CI: 1.19-259.61, Z-score: 2.09, P = .04).

CONCLUSIONS

Our preliminary study suggests that ultrasound measurements of diaphragm thickening fraction during spontaneous breaths in mechanically ventilated pediatric patients may be a useful addition in predicting weaning readiness.

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.

Prediction of extubation failure in the paediatric cardiac ICU using machine learning and high-frequency physiologic data

BACKGROUND

Cardiac intensivists frequently assess patient readiness to wean off mechanical ventilation with an extubation readiness trial despite it being no more effective than clinician judgement alone. We evaluated the utility of high-frequency physiologic data and machine learning for improving the prediction of extubation failure in children with cardiovascular disease.

METHODS

This was a retrospective analysis of clinical registry data and streamed physiologic extubation readiness trial data from one paediatric cardiac ICU (12/2016-3/2018). We analysed patients' final extubation readiness trial. Machine learning methods (classification and regression tree, Boosting, Random Forest) were performed using clinical/demographic data, physiologic data, and both datasets. Extubation failure was defined as reintubation within 48 hrs. Classifier performance was assessed on prediction accuracy and area under the receiver operating characteristic curve.

RESULTS

Of 178 episodes, 11.2% (N = 20) failed extubation. Using clinical/demographic data, our machine learning methods identified variables such as age, weight, height, and ventilation duration as being important in predicting extubation failure. Best classifier performance with this data was Boosting (prediction accuracy: 0.88; area under the receiver operating characteristic curve: 0.74). Using physiologic data, our machine learning methods found oxygen saturation extremes and descriptors of dynamic compliance, central venous pressure, and heart/respiratory rate to be of importance. The best classifier in this setting was Random Forest (prediction accuracy: 0.89; area under the receiver operating characteristic curve: 0.75). Combining both datasets produced classifiers highlighting the importance of physiologic variables in determining extubation failure, though predictive performance was not improved.

CONCLUSION

Physiologic variables not routinely scrutinised during extubation readiness trials were identified as potential extubation failure predictors. Larger analyses are necessary to investigate whether these markers can improve clinical decision-making.

Pediatric Ventilation Liberation: A Survey of International Practice Among 555 Pediatric Intensivists

Pediatric ventilation liberation has limited evidence, likely resulting in wide practice variation. To inform future work, practice patterns must first be described.

OBJECTIVES

Describe international pediatric ventilation liberation practices and regional practice variation.

DESIGN SETTING AND PARTICIPANTS

International cross-sectional electronic survey. Nontrainee pediatric medical and cardiac critical care physicians.

MAIN OUTCOMES AND MEASURES

Practices focusing on spontaneous breathing trial (SBT) eligibility, SBT practice, non-SBT extubation readiness bundle elements, and post-extubation respiratory support.

RESULTS

Five-hundred fifty-five responses representing 47 countries were analyzed. Most respondents reported weaning followed by an SBT (86.4%). The top SBT eligibility variables reported were positive end-expiratory pressure (95%), Fio2 (93.4%), and peak inspiratory pressure (73.9%). Most reported use of standardized pressure support regardless of endotracheal tube size (40.4%) with +10 cm H2O predominating (38.6%). SBT durations included less than or equal to 30 minutes (34.8%), 31 minutes to 1 hour (39.3%), and greater than 1 hours (26%). In assigning an SBT result, top variables were respiratory rate (94%), oxygen saturation (89.3%), and subjective work of breathing (79.8%). Most reported frequent consideration of endotracheal secretion burden (81.3%), standardized pain/sedation measurement (72.8%), fluid balance (83%), and the endotracheal air leak test as a part of extubation readiness bundles. Most reported using planned high flow nasal cannula in less than or equal to 50% of extubations (83.2%). Top subpopulations supported with planned HFNC were those with chronic lung disease (67.3%), exposed to invasive ventilation greater than 14 days (66.6%), and chronic critical illness (44.9%). Most reported using planned noninvasive ventilation (NIV) following less than or equal to 20% of extubations (79.9%). Top subpopulations supported with planned NIV were those with neuromuscular disease (72.8%), chronic lung disease (66.7%), and chronic NIV use for any reason (61.6%). Regional variation was high for most practices studied.

CONCLUSION AND RELEVANCE

International pediatric ventilation liberation practices are heterogeneous. Future study is needed to address key evidence gaps. Many practice differences were associated with respondent region, which must be considered in international study design.

Ventilator weaning and extubation practices in critically ill children: An Australian and New Zealand survey of practice

OBJECTIVES

We aimed to (i) describe current weaning and extubation practices in children (protocols to identify weaning candidates, spontaneous breathing trials, and other aspects of care such as sedation weaning) and (ii) understand responsibilities for ventilation weaning decisions across Australia and New Zealand (ANZ).

METHODS

A cross-sectional survey of ANZ intensive care units who routinely intubate and ventilate children (<18 years) was conducted. We worked with the Australian and New Zealand Intensive Care Society Paediatric Study Group to identify units and potential respondents (senior nurse representative per unit) and to administer questionnaires. Survey questions (n = 35) examined current protocols, practices, unit staffing, and decision-making responsibilities for ventilation weaning and extubation. Open-ended questions examined respondents' experiences of weaning and extubation.

RESULTS

A senior nursing respondent from 18/22 intensive care units (82%) completed the survey. Across units, most used sedation assessment tools (88%), and less often, sedation weaning tools (55%). Spontaneous awakening protocols were not used; one unit (5%) reported the use of a spontaneous breathing protocol. Two respondents reported that ventilation weaning protocols (11%) were in use, with 44% of units reporting the use of extubation protocols. Weaning and extubation practices were largely perceived as medically driven, with qualitative data demonstrating a desire from most respondents for greater shared decision-making.

CONCLUSION

In ANZ, ventilation weaning and extubation practices are largely medically driven with variation in the use of protocols to support mechanical ventilation weaning and extubation in children. Our findings highlight the importance of future research to determine the impact of greater collaboration of the multidisciplinary team on weaning practices.

Effect of pediatric ventilation weaning technique on work of breathing

Background

Ventilator liberation is one of the most challenging aspects in patients with respiratory failure. Most patients are weaned through a transition from full to partial respiratory support, whereas some advocate using a continuous spontaneous ventilation (CSV). However, there is little scientific evidence supporting the practice of pediatric ventilator liberation, including the timing of onset of and the approach to weaning mode. We sought to explore differences in patient effort between a pressure controlled continuous mode of ventilation (PC-CMV) [in this cohort PC assist/control (PC-A/C)] with a reduced ventilator rate and CSV, and to study changes in patient effort with decreasing PS.

Methods

In this prospective physiology cross-over study, we randomized children < 5 years to first PC-A/C with a 25% reduction in ventilator rate, or CSV (continuous positive airway pressure [CPAP] + PS). Patients were then crossed over to the other arm. Patient effort was measured by calculating inspiratory work of breathing (WOB) using the Campbell diagram (WOB_Campbell), and by pressure–rate-product (PRP) and pressure–time-product (PTP). Respiratory inductance plethysmography (RIP) was used to calculate the phase angle. Measurements were obtained at baseline, during PC-A/C and CPAP + PS, and during decreasing set PS (maximum -6 cmH₂O).

Results

Thirty-six subjects with a median age of 4.4 (IQR 1.5–11.9) months and median ventilation time of 4.9 (IQR 3.4–7.0) days were included. Nearly all patients (94.4%) were admitted with primary respiratory failure. WOB_Campbell during baseline [0.67 (IQR 0.38–1.07) Joules/L] did not differ between CSV [0.49 (IQR 0.17–0.83) Joules/L] or PC-A/C [0.47 (IQR 0.17–1.15) Joules/L]. Neither PRP, PTP, ∆Pes nor phase angle was different between the two ventilator modes. Reducing pressure support resulted in a statistically significant increase in patient effort, albeit that these differences were clinically negligible.

Conclusions

Patient effort during pediatric ventilation liberation was not increased when patients were in a CSV mode of ventilation compared to a ventilator mode with a ventilator back-up rate. Reducing the level of PS did not lead to clinically relevant increases in patient effort. These data may aid in a better approach to pediatric ventilation liberation.

Trial registration clinicaltrials.gov NCT05254691. Registered 24 February 2022

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02106-6.

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.

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

Background and Significance

Advances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children.

Material and Methods

A narrative review of existing literature was used.

Results

One obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics.

Conclusion

In addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.

Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how?

Comprehensive airway management of the pediatric patient with a difficult airway requires a plan for the transition back to a patent and protected airway. Multiple techniques are available to manage the periextubation period. Equally important is performing a comprehensive risk assessment and developing a strategy that optimizes the likelihood of safe extubation. This includes team-focused communication of the desired goals, critical steps in the process, and potential responses in the case of failed extubation. This review summarizes extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period.

Impairment in Preextubation Alveolar Gas Exchange Is Associated With Postextubation Respiratory Support Needs in Infants After Cardiac Surgery

OBJECTIVES:

DESIGN:

SETTING:

PATIENTS:

INTERVENTIONS:

MEASUREMENTS AND MAIN RESULTS:

CONCLUSIONS:

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.

Early extubation strategy after congenital heart surgery: 1-year single-centre experience

INTRODUCTION

Our aim was to present the initial experience with a protocol-driven early extubation strategy and to identify risk factors associated with failed spontaneous breathing trials within 12 hours after surgery.

METHODS

A single institutional retrospective study of children up to 18 years of age was conducted in post-operative cardiac surgical patients over a 1-year period. A daily spontaneous breathing trial protocol was used to assess patients' readiness for extubation. The study population (n = 129) was stratified into two age groups: infants (n = 84) and children (n = 45), and further stratified according to ventilation time: early extubation (ventilation time less than 12 h, n = 86) and deferred extubation (ventilation time more than 12 h, n = 43). Mann-Whitney U-test and binomial logistic regression were used for statistical analysis.

RESULTS

Early extubated infants had shorter ICU (4 versus 6 days, p = 0.003) and hospital length of stays (16 versus 19 days, p = 0.006), lower re-intubation rates (1 versus 7 patients, p = 0.003), and lower mortality (0 versus. 4 patients, p = 0.01) than deferred extubated infants. There was no significant difference in the studied outcomes in the children group. Malnourished infants and longer cardiopulmonary bypass times were independently associated with failed spontaneous breathing trials within 12 hours after cardiac surgery.

CONCLUSIONS

Early extubated infants after cardiac surgery had shorter ICU and hospital length of stay, without an increase in morbidity and mortality, compared to infants who deferred extubation. Nutritional status and longer cardiopulmonary bypass times were risk factors for failed spontaneous breathing trial.

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.

Predictive Value of Diaphragmatic Ultrasonography for the Weaning Outcome in Mechanically Ventilated Children Aged 1-3 Years

BACKGROUND

There are estimated 20% of mechanically ventilated patients having difficulty in weaning from the ventilators, and the weaning process accounts for 40% of the whole ventilation time. Reliable tools are urgently needed to estimate the weaning outcome. Diaphragmatic ultrasonography, as a relatively good predictive method for the adults, was measured in this study, assessing the value of each indicator of diaphragmatic ultrasonography to predict the outcomes of ventilator weaning from mechanically ventilated children of 1-3 years old.

METHODS

Between November 2018 and November 2019, children who were mechanically ventilated and ready for weaning in the pediatric intensive care unit (PICU) were enrolled in the study. Diaphragmatic ultrasonography was performed to the children to measure the right diaphragm excursion (DE), contraction velocity, thickness, and diaphragm thickening fraction (DTF), which were recorded followed by spontaneous breathing trial (SBT). The receiver operator characteristic (ROC) curves were also used to assess the value of each indicator to predict the weaning outcome.

RESULTS

During this study period, a total of 72 children were enrolled, and of them, 56 children passed the weaning process, while 16 children failed. There were significant differences in DE, contraction velocity, thickness, and DTF parameters between the weaning success group and the failure group. The areas under the ROC curves (AUC) and the optimal threshold of the above indicators were as follows: 0.72 and 8.08 mm for DE, 0.71 and 26.1% for right DTF (DTF^R), 0.71 and 20.7% for left DTF (DTF^L), 0.78 and 14.8% for minimum DTF (DTF^MIN), 0.79 and 26.1% for maximum DTF (DTF^MAX), 0.71 and 1.24 mm for maximum diaphragm thickness at the end of inspiration (Dtei^MAX), and 0.65 and 10.0 mm/s for contraction velocity.

CONCLUSION

Diaphragmatic ultrasonography is feasible in guiding ventilator weaning, and the indicators of DE, DTF, and Dtei^MAX guide the weaning more accurately. Among them, DTF may act as a more reliable predictor of weaning by avoiding the influence of diaphragm development in children.