Ventilator-Weaning Pathway Associated With Decreased Ventilator Days in Pediatric Acute Respiratory Distress Syndrome*

Abstract

Objectives: There is limited evidence on the impact of protocolized ventilator weaning in pediatric acute respiratory distress syndrome, despite utilization in clinical trials and clinical care. We aimed to determine whether protocolized ventilator weaning shortens mechanical ventilation duration and PICU length of stay in pediatric acute respiratory distress syndrome survivors. Design: Secondary analysis of a prospective pediatric acute respiratory distress syndrome (Berlin definition) cohort from July 2011 to June 2019 analyzed using interrupted time series analysis pre- and postimplementations of a ventilator-weaning pathway. We compared duration of invasive ventilation and PICU length of stay in survivors before and after implementation of a ventilator-weaning pathway. We excluded PICU nonsurvivors and subjects with greater than 100 ventilator days. Setting: Large academic tertiary-care PICU. Patients: Children with acute respiratory distress syndrome who survived to PICU discharge with less than or equal to 100 days of invasive mechanical ventilation. Interventions: Implementation of a ventilator-weaning pathway on May 2016. Measurements and Main Results: Of 723 children with acute respiratory distress syndrome, 132 subjects died and six subjects with ventilation greater than 100 days were excluded. Of the remaining 585 subjects, 375 subjects had acute respiratory distress syndrome prior to pathway intervention and 210 after. Patients in the preintervention epoch were younger, more likely to have infectious acute respiratory distress syndrome, and had increased use of alternative ventilator modes. Pathway adoption was rapid and sustained. Controlling for temporality, pathway implementation was associated with a decrease of a median 3.6 ventilator days (95% CI, –5.4 to –1.7; p < 0.001). There was no change in the reintubation rates. Results were robust to multiple sensitivity analyses adjusting for confounders. Conclusions: Ventilator-weaning pathway implementation shortened invasive ventilation duration in pediatric acute respiratory distress syndrome survivors with no change in reintubation. The effect size of this intervention was comparable with those targeted in acute respiratory distress syndrome trials.

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

“…Use of systematic standardized ERT may improve outcomes (61). Foronda et al (62) found in a randomized controlled trial (RCT) that daily ERT in children reduced the duration of MV.…”

Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit

“…Multivariable regression was used to compare mortality and posttransfer LOS in days among cases with and without MOID with a priori defined confounders of age category, originating service, deterioration category, and pretransfer LOS, 3 which have been associated with risk of mortality in ET and were hypothesized to impact the diagnostic process in deteriorating patients. 2,24 Mortality was modeled with logistic regression. We modeled posttransfer LOS with a generalized linear model with log link, gamma family, and robust variance estimates to account for the right-skewed distribution.…”

“…We compared ET cases with and without MOID using descriptive statistics, including Fisher's exact test for categorical variables. Multivariable regression was used to compare mortality and posttransfer LOS in days among cases with and without MOID with a priori defined confounders of age category, originating service, deterioration category, and pretransfer LOS, 3 which have been associated with risk of mortality in ET and were hypothesized to impact the diagnostic process in deteriorating patients 2,24 . Mortality was modeled with logistic regression.…”

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

“…Recent single-center studies assessing physician-directed versus protocolized weaning of mechanically ventilated pediatric patients have had promising results in demonstrating feasibility and safety 23,24 and shortened time to spontaneous breathing but have had conflicting results on time to extubation. [25][26][27][28][29][30][31] In a secondary analysis of infants with lower respiratory tract disease, the SBT demonstrated a high positive predictive value for extubation success. 32 However, the authors of this study found that 34% of patients who passed their first SBT were not extubated on that day, with physician preference (26%) cited as the most common reason.…”