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

Abstract

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.

Operational Definitions Related to Pediatric Ventilator Liberation

“…As part of a larger project to establish clinical practice guidelines for pediatric ventilator liberation, 7 we assembled a multi-professional panel of international experts in pediatric ventilator liberation. This work included systematic reviews of the literature to identify the most common definitions for interventions and outcomes related to pediatric ventilator liberation.…”

Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children

“…To prepare this report, we used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline (eTable 1 in Supplement 1). This review was conducted as part of a project to develop clinical practice guidelines for ventilator liberation in children . The protocol for the systematic review is registered in PROSPERO (CRD42021228702).…”

“… 5 This review was conducted as part of a project to develop clinical practice guidelines for ventilator liberation in children. 6 , 7 The protocol for the systematic review is registered in PROSPERO ( CRD42021228702 ). Details of the protocol for the systematic review can be accessed at https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42021228702 .…”

Comparison of carbon dioxide control during pressure controlled versus pressure regulated volume controlled ventilation in children (CoCO2): protocol for a pilot digital randomized controlled trial

“…These changes can aggravate cerebral ischemia or swelling and pulmonary arterial hypertension. Prolonged intubation and delayed weaning increase the risk of chronic lung disease, prolonged PICU stay, critical illness neuromyopathy, and worse patient-centred outcomes 8 .…”