Extubation Readiness Practices and Barriers to Extubation in Pediatric Subjects

Krasinkiewicz, Johnny M; Friedman, Matthew L; Slaven, James E.; Lutfi, Riad; Abu‐Sultaneh, Samer; Tori, Alvaro J

doi:10.4187/respcare.08332

Cited by 12 publications

(8 citation statements)

References 39 publications

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“…Some of this variability relates to provider preferences, patient population, and the lack of clear clinical practice guidelines (15)(16)(17)(18)(19). However, there are likely PICU-specific resources and characteristics, which may result in unwarranted variation in ventilator liberation practices (20).…”

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confidence: 99%

Ventilation Liberation Practices Among 380 International PICUs

Loberger

Campbell

Colleti

et al. 2022

Critical Care Explorations

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OBJECTIVES: 1) Characterize the prevalence of ventilator liberation protocol use in international PICUs, 2) identify the most commonly used protocol elements, and 3) estimate an international extubation failure rate and use of postextubation noninvasive respiratory support modes. DESIGN: International cross-sectional study. SUBJECTS: Nontrainee pediatric medical and cardiac critical care physicians. SETTING: Electronic survey. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Responses represented 380 unique PICUs from 47 different countries. Protocols for Spontaneous Breathing Trial (SBT) practice (50%) and endotracheal tube cuff management (55.8%) were the only protocols used by greater than or equal to 50% of PICUs. Among PICUs screening for SBT eligibility, physicians were most commonly screened (62.7%) with daily frequency (64.2%). Among those with an SBT practice protocol, SBTs were most commonly performed by respiratory therapists/physiotherapists (49.2%) and least commonly by nurses (4.9%). Postextubation respiratory support protocols were not prevalent (28.7%). International practice variation was significant for most practices surveyed. The estimated median international extubation failure was 5% (interquartile range, 2.3–10%). A majority of respondents self-reported use of planned high-flow nasal cannula in less than or equal to 50% (84.2%) and planned noninvasive ventilation in less than or equal to 20% of extubations (81.6%). CONCLUSIONS: Variability in international pediatric ventilation liberation practice is high, and prevalence of protocol implementation is generally low. There is a need to better understand elements that drive clinical outcomes and opportunity to work on standardizing pediatric ventilation liberation practices worldwide.

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confidence: 99%

Ventilation Liberation Practices Among 380 International PICUs

Loberger

Campbell

Colleti

et al. 2022

Critical Care Explorations

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“…Krasinkiewicz et al reported that compromised neurological status can cause delaying in extubation. In fact, these patients either received higher doses of medication for sedation and management of pain or were unable to protect their airway for neurologic causes (24). This trend was confirmed in a similar study by Mayordomo-Colunga et al, which concluded that neurological disorders may influence extubation due to pharyngeal hypotonia and inability to properly protect airway (34).…”

Section: Prognostic Factors For Extubation Failurementioning

confidence: 76%

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

et al. 2022

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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.

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“…Out of the studies that presented the indications for intubation (17/41 studies) [ 4 , 19 , 20 , 22 , 23 , 25 – 27 , 39 , 41 , 43 , 46 , 51 – 53 , 55 , 56 ], intubation due to respiratory pathologies were cited to be the most common indication ( n = 3070/4131). In studies that presented reasons for admissions (22/41 studies) [ 19 – 21 , 23 , 24 , 29 – 35 , 37 , 42 , 44 , 45 , 47 – 50 , 53 , 54 ], respiratory diseases were also the most common reason for PICU admission ( n = 1372/3917).…”

Section: Resultsmentioning

confidence: 99%

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

Tan

et al. 2022

Pulm Ther

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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. Supplementary Information The online version contains supplementary material available at 10.1007/s41030-022-00204-w.

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Extubation Readiness Practices and Barriers to Extubation in Pediatric Subjects

Cited by 12 publications

References 39 publications

Ventilation Liberation Practices Among 380 International PICUs

Ventilation Liberation Practices Among 380 International PICUs

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

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

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