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

Abstract

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.

Predictors and outcomes of extubation failures in a pediatric intensive care unit: A retrospective study

“…On the basis of the patients’ clinical condition, the attending pediatric intensive care physician made the decision to initiate the weaning and extubation protocol 7 , 18 after determining the following parameters: (i) fulfillment of the MV criterion: fraction of inspired oxygen (F iO2 ) ≤ 0.5 (50%), PaO 2 > 60 mmHg, peak inspiratory pressure ≤25 cm H 2 O, and positive end-expiratory pressure ≤8 cm H 2 O; (ii) patients with moderate MV moving toward successful completion of a spontaneous breathing test for 20–30 min with pressure support mode of ≤10 cm H 2 O and positive end-expiratory pressure of 5 cm H 2 O; (iii) decreased or no requirement for inotrope administration; (iv) balanced acid-base levels (pH ∼7.25–7.45); (v) hemodynamic stability with normal electrolytes and no fluid overload; (vi) recovery from medical status indicating the need for intubation; (vii) awake status and adequate muscle tone; and (viii) ameliorated signs and symptoms of pneumonia. Patients with laryngomalacia or tracheomalacia, gastroesophageal reflux disease with airway edema, difficult airway intubation, and an absence of leak round-tracheal intubation were administered six doses (0.5 mg/kg/dose) of dexamethasone 12 h before extubation.…”

“…Extubation failure (EF) is defined as the requirement for reintubation (placement of a breathing tube) within 48 h after prior tube removal. 7 Premature extubation, primary illness severity, etiological condition, prolonged PICU stay, prolonged use of analgesics and sedatives, and population demographics may result in 2–20% of EFs with associated unfavorable clinical outcomes and increased mortality, as reported in several studies. 8 , 9 , 10 , 11 Upper airway obstruction (UAO) is a major contributor to reported cases of EF caused by tracheal inflammation, glottis, and laryngeal edema, leading to distress and stridor.…”

“… 15 , 16 , 17 Several studies have reported operational protocols for ventilator weaning and extubation readiness to alleviate complications with EF and post-extubation stridor. 7 , 18 The complications associated with EF and the high hospitalization and treatment costs necessitate the evaluation of various associated risk factors and prophylactic benefits of dexamethasone administration to determine the probability of occurrence, increase extubation success, and avoid reintubation. In this retrospective cohort study, we aimed to evaluate potential etiological and demographic EF risk factors—such as age, primary condition, prolonged MV support, and length of stay in a PICU—leading to high morbidity and mortality.…”

Predictive parameters and model for extubation outcome in pediatric patients

“…Although protocol-based weaning is well-established in adults, no pediatric studies have shown a clear superiority of the protocol-based approach over the physician's individualized decision ( 20 ). Earlier studies have used SBTs with various methods and reported inconsistent outcomes ( 21 – 23 ). In this study, patients who successfully passed 2 h of minimal-setting SBT had a lower risk of requiring respiratory support escalation.…”

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

“…A standardised approach is key, and failure to consider these factors can result in unplanned extubation or unnecessarily prolonged duration of mechanical ventilation 8 . In addition to increased morbidity and protracted duration of ventilation, delays in ventilation weaning and tracheal extubation place a significant burden on the health system and unit resources through reduction of bed availability and increased cost [9][10][11] . In children the clinical management of ventilation weaning and tracheal extubation has historically been hampered by a lack of evidence concerning best-practice 12 .…”