Weaning and extubation readiness in pediatric patients*

Newth, Christopher J. L.; Venkataraman, Shekhar T.; Willson, Douglas F.; Meert, Kathleen L.; Harrison, Rick; Dean, J. Michael; Pollack, Murray M.; Zimmerman, Jerry J.; Anand, K.J.S.; Carcillo, Joseph A.; Nicholson, Carol

doi:10.1097/pcc.0b013e318193724d

Cited by 283 publications

(244 citation statements)

References 88 publications

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“…In adults an elevated RSBI predicts failure, 15,16 whereas in children the performance and outcomes of RSBI are under debate. 3,13,20 Our results reflect the limited and conflicting pediatric literature on RSBI in children.…”

Section: Discussionsupporting

confidence: 73%

“…The pediatric literature addressing extubation readiness parameters and strategies to wean off mechanical ventilation is limited, 3 in contrast to the extensive adult-patients literature. 15 In adults SBTs are commonly used.…”

Section: Discussionmentioning

confidence: 99%

“…9 On the other hand, the rate of failed planned extubation in pediatric patients is 2-20%. 3 Identifying parameters that reliably predict readiness for extubation would improve the quality of care and decrease morbidity and complications related to mechanical ventilation. Studies in adults 10,11 and pediatric patients 12,13 have shown that patients who pass a spontaneous breathing trial (SBT) undergo an extubation readiness trial; 50 -75% are considered ready for extubation.…”

Section: See the Related Editorial On Page 445mentioning

confidence: 99%

“…Studies in adults 10,11 and pediatric patients 12,13 have shown that patients who pass a spontaneous breathing trial (SBT) undergo an extubation readiness trial; 50 -75% are considered ready for extubation. We designed and conducted a survey to determine the frequency of use of extubation readiness parameters such as air leak, rapid shallow breathing index (RSBI), airwayocclusion pressure 0.1 s after the start of inspiratory flow (P 0.1 ), and quantification of secretions and sedation, 3 the methods used, and the attitudes toward these parameters among pediatric critical care physicians.…”

Section: See the Related Editorial On Page 445mentioning

confidence: 99%

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The Use of Extubation Readiness Parameters: A Survey of Pediatric Critical Care Physicians

et al. 2013

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BACKGROUND:The pediatric literature addressing extubation readiness parameters and strategies to wean from mechanical ventilation is limited. METHODS: We designed a survey to assess the use of extubation readiness parameters among pediatric critical care physicians at academic centers in the United States. RESULTS: The overall response rate was 44.1% (417/945). The majority of respondents check for air leak and the amount of tracheal secretions. Fewer respondents use sedation score, the rapid shallow breathing index, or the airway-occlusion pressure 0.1 s after the start of inspiratory flow prior to extubation. The majority perform a spontaneous breathing trial with pressure support. The majority consider 30 cm H 2 O as the upper limit of an air leak test, and the need for endotracheal suctioning once every 2-4 hours as acceptable for extubation. In preparation for termination of mechanical ventilation the majority daily wean the ventilator rate and/or the pressure support instead of conducting a spontaneous breathing trial. CONCLUSIONS: Most pediatric critical care physicians reported assessing extubation readiness by checking air leak and suctioning need, and less often consider or perform sedation score or the rapid shallow breathing index.

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Section: Discussionsupporting

confidence: 73%

Section: Discussionmentioning

confidence: 99%

Section: See the Related Editorial On Page 445mentioning

confidence: 99%

Section: See the Related Editorial On Page 445mentioning

confidence: 99%

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The Use of Extubation Readiness Parameters: A Survey of Pediatric Critical Care Physicians

et al. 2013

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“…1 Respiratory disorders are the main cause of respiratory failure in children. [2][3][4] Although mechanical ventilation is generally lifesaving, it can be associated with adverse events if not appropriately initiated, maintained, and monitored.…”

Section: Introductionmentioning

confidence: 99%

Categorization in Mechanically Ventilated Pediatric Subjects: A Proposed Method to Improve Quality

et al. 2016

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BACKGROUND: Thousands of children require mechanical ventilation each year. Although mechanical ventilation is lifesaving, it is also associated with adverse events if not properly managed. The systematic implementation of evidence-based practice through the use of guidelines and protocols has been shown to mitigate risk, yet variation in care remains prevalent. Advances in health-care technology provided the ability to stream data about mechanical ventilation and therapeutic response. Through these advances, a computer system was developed to enable the coupling of physiologic and ventilation data for real-time interpretation. Our aim was to assess the feasibility and utility of a newly developed patient categorization and scoring system to objectively measure compliance with standards of care. METHODS: We retrospectively categorized the ventilation and oxygenation statuses of subjects within our pediatric ICU utilizing 15 rules-based algorithms. Targets were predetermined based on generally accepted practices. All patient categories were calculated and presented as a percent score (0 -100%) of acceptable ventilation, acceptable oxygenation, barotrauma-free, and volutrauma-free states. RESULTS: Two hundred twenty-two subjects were identified and analyzed encompassing 1,578 d of mechanical ventilation. Median age was 3 y, median ideal body weight was 14.7 kg, and 63% were male. The median acceptable ventilation score was 84.6%, and the median acceptable oxygenation score was 70.1% (100% being maximally acceptable). Potential for ventilator-induced lung injury was broken into 2 components: barotrauma and volutrauma. There was very little potential for barotrauma, with a median barotrauma-free state of 100%. Median potential for a volutrauma-free state was 56.1%. CONCLUSIONS: We demonstrate the first patient categorization system utilizing a coordinated data-banking system and analytics to determine patient status and a surveillance of mechanical ventilation quality. Further research is needed to determine whether interventions such as visual display of variance from goal and patient categorization summaries can improve outcomes. (ClinicalTrials.gov registration NCT02184208.)

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Effectiveness of Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation vs Noninvasive High-Frequency Oscillatory Ventilation as Support After Extubation of Neonates Born Extremely Preterm or With More Severe Respiratory Failure

Zhu

Shi

et al. 2023

JAMA Netw Open

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ImportanceThe NASONE (Nasal Oscillation Post-Extubation) trial showed that noninvasive high-frequency oscillatory ventilation (NHFOV) slightly reduces the duration of invasive mechanical ventilation (IMV) in preterm infants, whereas NHFOV and noninvasive intermittent positive pressure ventilation (NIPPV) result in fewer reintubations than nasal continuous positive airway pressure (NCPAP). It is unknown whether NHFOV is similarly effective in extremely preterm neonates or in those with more severe respiratory failure (based on the duration of previous ventilation and CO2 levels).ObjectiveTo clarify whether NHFOV is better than NIPPV and NCPAP in reducing the duration of IMV in extremely preterm neonates or those with severe respiratory failure.Design, Setting, and ParticipantsThis study is a predefined secondary analyses of a multicenter randomized clinical trial that was performed at tertiary academic neonatal intensive care units (NICUs) in China. Participants included neonates enrolled in the NASONE trial between December 2017 and May 2021 and belonging to 3 predefined subgroups: (1) born at less than or equal to 28 weeks’ (plus 6 days) gestation, (2) invasively ventilated for more than 1 week from birth, and (3) with CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Data analysis was performed in August 2022.InterventionNCPAP, NIPPV, or NHFOV since the first extubation and until NICU discharge, with airway pressure higher in NHFOV than in NIPPV and than in NCPAP.Main Outcomes and MeasuresThe co–primary outcomes were total duration of IMV during the NICU stay, need for reintubation, and ventilator-free days calculated as per the original trial protocol. Outcomes were analyzed on an intention-to-treat basis as for the whole trial, and subgroup analyses followed the original statistical plan.ResultsAmong 1137 preterm infants, 455 (279 boys [61.3%]) were born at 28 weeks’ gestation or less, 375 (218 boys [58.1%]) underwent IMV for more than 1 week from birth, and 307 (183 boys [59.6%]) had CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Both NIPPV and NHFOV were associated with significantly fewer reintubations (risk difference range, −28% [95% CI, −39% to −17%] to −15% [95% CI, −25% to −4%]; number needed to treat, 3-7 infants) and early reintubations (risk difference range, −24% [95% CI, −35% to −14%] to −20% [95% CI, −30% to −10%]) than NCPAP, and these reintubations were less frequently due to refractory hypoxemia. IMV was shorter in the NIPPV and NHFOV groups (mean difference range, −5.0 days [95% CI, −6.8 to −3.1 days] to −2.3 days [95% CI, −4.1 to −0.4 days]) than in the NCPAP group. Co–primary outcomes were not different between NIPPV and NHFOV; there was no significant interaction effect. Infants in the NHFOV group showed significantly less moderate-to-severe bronchopulmonary dysplasia than infants in the NCPAP group (range, −12% to −10%; number needed to treat, 8-9 infants) and better postextubation gas exchange in all subgroups. The 3 interventions were provided at different mean airway pressure and were equally safe.Conclusions and RelevanceThe subgroup analyses of extremely preterm or more ill infants confirm the results obtained in the whole population: NIPPV and NHFOV appeared equally effective in reducing duration of IMV compared with NCPAP.Trial RegistrationClinicalTrials.gov Identifier: NCT03181958

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Weaning and extubation readiness in pediatric patients*

Cited by 283 publications

References 88 publications

The Use of Extubation Readiness Parameters: A Survey of Pediatric Critical Care Physicians

The Use of Extubation Readiness Parameters: A Survey of Pediatric Critical Care Physicians

Categorization in Mechanically Ventilated Pediatric Subjects: A Proposed Method to Improve Quality

Effectiveness of Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation vs Noninvasive High-Frequency Oscillatory Ventilation as Support After Extubation of Neonates Born Extremely Preterm or With More Severe Respiratory Failure

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