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Abu-Sultaneh S, Iyer NP, Fernández A, Tume LN, Kneyber MCJ, López-Fernández YM, Emeriaud G, Ramnarayan P, Khemani RG. Framework for Research Gaps in Pediatric Ventilator Liberation. Chest 2024:S0012-3692(24)00688-3. [PMID: 38852880 DOI: 10.1016/j.chest.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/03/2024] [Accepted: 05/11/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND The 2023 International Pediatric Ventilator Liberation Clinical Practice Guidelines provided evidence-based recommendations to guide pediatric critical care providers on how to perform daily aspects of ventilator liberation. However, because of the lack of high-quality pediatric studies, most recommendations were conditional based on very low to low certainty of evidence. RESEARCH QUESTION What are the research gaps related to pediatric ventilator liberation that can be studied to strengthen the evidence for future updates of the guidelines? STUDY DESIGN AND METHODS We conducted systematic reviews of the literature in eight predefined Population, Intervention, Comparator, Outcome (PICO) areas related to pediatric ventilator liberation to generate recommendations. Subgroups responsible for each PICO question subsequently identified major research gaps by synthesizing the literature. These gaps were presented at an international symposium at the Pediatric Acute Lung Injury and Sepsis Investigators meeting in spring 2022 for open discussion. Feedback was incorporated, and final evaluation of research gaps are summarized herein. Although randomized controlled trials (RCTs) represent the highest level of evidence, the panel sought to highlight areas where alternative study designs also may be appropriate, given challenges with conducting large multicenter RCTs in children. RESULTS Significant research gaps were identified in six broad areas related to pediatric ventilator liberation. Several of these areas necessitate multicenter RCTs to provide definitive results, whereas other gaps can be addressed with multicenter observational studies or quality improvement initiatives. Furthermore, a need for some physiologic studies in several areas remains, particularly regarding newer diagnostic methods to improve identification of patients at high risk of extubation failure. INTERPRETATION Although pediatric ventilator liberation guidelines have been created, the certainty of evidence remains low and multiple research gaps exist that should be bridged through high-quality RCTs, multicenter observational studies, and quality improvement initiatives.
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Affiliation(s)
- Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine Indianapolis, IN.
| | - Narayan Prabhu Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Analía Fernández
- Division of Critical Care Medicine, Hospital General de Agudos "C. Durand," Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Lyvonne N Tume
- Edge Hill University Health Research Institute, Ormskirk, England
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Yolanda M López-Fernández
- Pediatric Critical Care Division, Department of Pediatrics, Cruces University Hospital, BioBizkaia Health Research Institute, Bizkaia, Spain
| | - Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
| | - Padmanabhan Ramnarayan
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
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Flink RC, Newth CJL, Hotz JC, Kneyber MCJ, Ross PA, de Jongh FH, van Kaam AH, Khemani RG. Effort and work-of-breathing parameters strongly correlate with increased resistance in an animal model. Pediatr Res 2023; 94:944-949. [PMID: 36977768 DOI: 10.1038/s41390-023-02576-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Effort of Breathing (EOB) calculations may be a reliable alternative to Work of Breathing (WOB) calculations in which Respiratory Inductance Plethysmography (RIP) replaces spirometry. We sought to compare EOB and WOB measurements in a nonhuman primate model of increasing extrathoracic inspiratory resistance simulating upper airway obstruction (UAO). METHODS RIP, spirometry, and esophageal manometry were measured in spontaneously breathing, intubated Rhesus monkeys utilizing 11 calibrated resistors randomly applied for 2-min. EOB was calculated breath-by-breath as Pressure Rate Product (PRP) and Pressure Time Product (PTP). WOB was calculated from the Pressure-Volume curve based on spirometry (WOBSPIR) or RIP flow (WOBRIP). RESULTS WOB, PRP and PTP showed similar linear increases when exposed to higher levels of resistive loads. When comparing WOBSPIR to WOBRIP, a similar strong correlation was seen for both signals as resistance increased and there were no statistically significant differences. CONCLUSION EOB and WOB parameters utilizing esophageal manometry and RIP, independent of spirometry, showed a strong correlation as a function of increasing inspiratory resistance in nonhuman primates. This allows several potential monitoring possibilities for non-invasively ventilated patients or situations where spirometry is not available. IMPACT EOB and WOB parameters showed a strong correlation as a function of increasing inspiratory resistance in nonhuman primates. There was a strong correlation between spirometry-based WOB versus RIP-based WOB. To date, it has remained untested as to whether EOB is a reliable alternative for WOB and if RIP can replace spirometry in these measurements. Our results enable additional potential monitoring possibilities for non-invasively ventilated patients or situations where spirometry is not available. Where spirometry is not available, there is no need to apply a facemask post extubation to a spontaneously breathing, non-intubated infant to make objective EOB measurements.
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Affiliation(s)
- Rutger C Flink
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Christopher J L Newth
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Justin C Hotz
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital Groningen, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
| | - Patrick A Ross
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robinder G Khemani
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Vishwa CR, Nallasamy K, Angurana SK, Bansal A, Jayashree M. Pressure support versus continuous positive airway pressure for predicting successful liberation from invasive ventilation in children: an open label, randomized non-inferiority trial. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 14:100219. [PMID: 37492415 PMCID: PMC10363498 DOI: 10.1016/j.lansea.2023.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/18/2023] [Accepted: 05/08/2023] [Indexed: 07/27/2023]
Abstract
Background Pressure support (PS) as a spontaneous breathing trial (SBT) was considered inferior to continuous positive airway pressure (CPAP) and T-piece because PS underestimated post-extubation work of breathing in physiologic studies. We aimed to compare PS and CPAP as SBT methods for assessing clinical outcomes in children. Methods This was an open label randomized non-inferiority trial conducted between December 2019 and August 2021 among children aged 1 month to 12 years deemed ready for weaning after at least 48 h of invasive ventilation in PICU. Children were randomized to undergo a 2-h SBT with PS of 8 cm H2O in addition to PEEP 5-6 cm H2O or CPAP (5-6 cm H2O). The primary outcome was successful liberation from invasive ventilation for 72 h after first SBT. Secondary outcomes included first SBT pass rate, need for post-extubation respiratory support (high flow oxygen and/or non-invasive ventilation), and length of PICU stay. Findings Of the 247 enrolled children, 244 completed the trial (121 in PS and 123 in CPAP group). Median (IQR) age was 24 (9, 84) months. Median (IQR) duration of invasive ventilation before randomization was 4.5 (3, 6.5) days. Successful liberation from invasive ventilation after first SBT occurred in 97 (80.2%) children in PS and 93 (75.6%) children in CPAP group [difference 4.6; 95% CI (-5.8, 15); p = 0.39]. First SBT pass rate between PS and CPAP [111 (91.7%) versus 105 (85.4%); difference 6.3; 95% CI (-1.6, 14.3); p = 0.12] was similar. Need for post-extubation respiratory support [52 (43%) versus 49 (40%)], rate of reintubation within 72 h [14 (11.6%) versus 12 (9.8%)] and median (IQR) length of PICU stay [9 (6, 15) versus 8 (5.5, 13) days] were comparable. Four (1.6%) children, all in CPAP group had unfavourable outcome (1 died, 3 discontinued care). Interpretation In invasively ventilated children, 2-h SBT with pressure support was non-inferior to CPAP in predicting successful liberation from invasive ventilation. Funding None.
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Shimatani T, Kyogoku M, Ito Y, Takeuchi M, Khemani RG. Fundamental concepts and the latest evidence for esophageal pressure monitoring. J Intensive Care 2023; 11:22. [PMID: 37217973 DOI: 10.1186/s40560-023-00671-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
Transpulmonary pressure is an essential physiologic concept as it reflects the true pressure across the alveoli, and is a more precise marker for lung stress. To calculate transpulmonary pressure, one needs an estimate of both alveolar pressure and pleural pressure. Airway pressure during conditions of no flow is the most widely accepted surrogate for alveolar pressure, while esophageal pressure remains the most widely measured surrogate marker for pleural pressure. This review will cover important concepts and clinical applications for esophageal manometry, with a particular focus on how to use the information from esophageal manometry to adjust or titrate ventilator support. The most widely used method for measuring esophageal pressure uses an esophageal balloon catheter, although these measurements can be affected by the volume of air in the balloon. Therefore, when using balloon catheters, it is important to calibrate the balloon to ensure the most appropriate volume of air, and we discuss several methods which have been proposed for balloon calibration. In addition, esophageal balloon catheters only estimate the pleural pressure over a certain area within the thoracic cavity, which has resulted in a debate regarding how to interpret these measurements. We discuss both direct and elastance-based methods to estimate transpulmonary pressure, and how they may be applied for clinical practice. Finally, we discuss a number of applications for esophageal manometry and review many of the clinical studies published to date which have used esophageal pressure. These include the use of esophageal pressure to assess lung and chest wall compliance individually which can provide individualized information for patients with acute respiratory failure in terms of setting PEEP, or limiting inspiratory pressure. In addition, esophageal pressure has been used to estimate effort of breathing which has application for ventilator weaning, detection of upper airway obstruction after extubation, and detection of patient and mechanical ventilator asynchrony.
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Affiliation(s)
- Tatsutoshi Shimatani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima-shi, Hiroshima, Japan.
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Miyako Kyogoku
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yukie Ito
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Robinder G Khemani
- Pediatric ICU, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., CA, Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 1975, USA
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Abu-Sultaneh S, Khemani RG. Reply to Havan et al. Am J Respir Crit Care Med 2023; 207:1405-1406. [PMID: 36930956 PMCID: PMC10595459 DOI: 10.1164/rccm.202303-0363le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Affiliation(s)
- Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Robinder G. Khemani
- Keck School of Medicine, University of Southern California, Los Angeles, California; and
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
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Ng P, Tan HL, Ma YJ, Sultana R, Long V, Wong JJM, Lee JH. Tests and Indices Predicting Extubation Failure in Children: A Systematic Review and Meta-analysis. Pulm Ther 2023; 9:25-47. [PMID: 36459328 PMCID: PMC9931987 DOI: 10.1007/s41030-022-00204-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/31/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
| | - Herng Lee Tan
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yi-Jyun Ma
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | | | - Judith J-M Wong
- Duke-NUS Medical School, Singapore, Singapore.,Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore, Singapore. .,Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
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Raj I, Kumar Nagaiah S. Ultrasonography of Diaphragm to Predict Extubation Outcome. Cureus 2023; 15:e36514. [PMID: 37090312 PMCID: PMC10120388 DOI: 10.7759/cureus.36514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Background and objectives An intensivist's decision, when it comes to weaning off a patient from mechanical ventilation and extubation, is based on many criteria. Problems can be associated with both prolonged ventilation and early extubation. Therefore, for optimal functioning of the diaphragm, the primary inspiratory muscle, it is important to resume spontaneous ventilation after extubation irrespective of the cause of respiratory failure. Thus, diaphragmatic parameters can prove useful in predicting the rate of success of extubation. However, till date in our institute, extubation has been done using only the standard parameters; hence, in this study, diaphragmatic parameters obtained by ultrasonography-diaphragmatic thickening fraction (dTF) and diaphragmatic excursion (DE) have been studied to predict extubation outcome. The objectives of this study are to (1) measure the diaphragmatic thickening fraction (dTF) in % and diaphragmatic excursion (DE) in cm before and after the spontaneous breathing trial (SBT) and (2) compare dTF and DE with standard extubation parameters in order to predict extubation outcome. Materials and methods This is a prospective, double-blind, observational study. The number of patients involved was 41. After obtaining ethical committee clearance, informed consent was taken from the patients' attendants. In this study, we divided doctors into the treating team and the research team. The treating team comprised the primary doctors working in the intensive care unit (ICU), and they evaluated the patients' readiness for pressure support ventilation. The research team performed diaphragmatic ultrasonography on those patients who met the inclusion criteria. The treating team was blinded to the dTF and DE results obtained by the research team. Prior to extubation, all the patients had to satisfy the standard extubation criteria followed at R. L. Jalappa Hospital and Research Centre (RLJH), Kolar Results We observed that 68.29 (%) of the patients with normal dTF and DE values and 21.95(%) with slightly lower dTF and DE values were extubated successfully, and 7.31 (%) with normal dTF and DE values were reintubated; 2.43 (%) were extubated onto non-invasive ventilation (NIV). Conclusion From our study, we have concluded that bedside ultrasonography of the diaphragm, that is the measurement of diaphragm for dTF and DE always compliments the standard criteria for extubation and can be used for weaning the patients from mechanical ventilation, as bedside ultrasonography is not only easy and convenient but also a reliable parameter in predicting the outcome of weaning, however, it cannot be used as a sole criteria.
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Affiliation(s)
- Ishita Raj
- Anaesthesiology, Sri Devaraj Urs Medical College, Kolar, IND
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Bhalla A, Baudin F, Takeuchi M, Cruces P. Monitoring in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S112-S123. [PMID: 36661440 PMCID: PMC9980912 DOI: 10.1097/pcc.0000000000003163] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Monitoring is essential to assess changes in the lung condition, to identify heart-lung interactions, and to personalize and improve respiratory support and adjuvant therapies in pediatric acute respiratory distress syndrome (PARDS). The objective of this article is to report the rationale of the revised recommendations/statements on monitoring from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We included studies focused on respiratory or cardiovascular monitoring of children less than 18 years old with a diagnosis of PARDS. We excluded studies focused on neonates. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. We identified 342 studies for full-text review. Seventeen good practice statements were generated related to respiratory and cardiovascular monitoring. Four research statements were generated related to respiratory mechanics and imaging monitoring, hemodynamics monitoring, and extubation readiness monitoring. CONCLUSIONS PALICC-2 monitoring good practice and research statements were developed to improve the care of patients with PARDS and were based on new knowledge generated in recent years in patients with PARDS, specifically in topics of general monitoring, respiratory system mechanics, gas exchange, weaning considerations, lung imaging, and hemodynamic monitoring.
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Affiliation(s)
- Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Florent Baudin
- Hospices civils de Lyon, Hôpital Femme Mère Enfant, Service de réanimation pédiatrique, Bron F-69500, France
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile; and Pediatric Intensive Care Unit, Hospital el Carmen de Maipú, Santiago, Chile
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Knox KE, Hotz JC, Newth CJL, Khoo MCK, Khemani RG. A 30-Minute Spontaneous Breathing Trial Misses Many Children Who Go On to Fail a 120-Minute Spontaneous Breathing Trial. Chest 2023; 163:115-127. [PMID: 36037984 PMCID: PMC9993340 DOI: 10.1016/j.chest.2022.08.2212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/09/2022] [Accepted: 08/18/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The optimal length of spontaneous breathing trials (SBTs) in children is unknown. RESEARCH QUESTIONS What are the most common reasons for SBT failure in children, and when do they occur? Can clinical parameters at the 30-min mark of a 120-min SBT predict outcome? STUDY DESIGN AND METHODS We performed a secondary analysis of a clinical trial in pediatric ARDS, in which 2-h SBTs are conducted daily. SBT failure is based on objective criteria, including esophageal manometry for effort of breathing, categorized as passage, early failure (≤ 30 min), or late failure (30-120 min). Spirometry was used to calculate respiratory rate (RR), tidal volume (Vt), and rapid shallow breathing index (RSBI), in addition to pulse oximetry and capnography. Predictive models evaluated parameters at 30 min against SBT outcome, using receiver operating characteristic plots and area under the curve. RESULTS We included 100 children and 305 SBTs, with 42% of SBTs being successful, 32% failing within 30 min, and 25% failing between 30 and 120 min. Of the patients passing SBTs at 30 min, 40% went on to fail by 120 min. High respiratory effort (esophageal manometry) was present in > 80% of failed SBTs. At the 30-min mark, there were no clear thresholds for RR, Vt, RSBI, Fio2, oxygen saturation, or capnography that could reliably predict SBT outcome. Multivariable modeling identified RR (P < .001) and RSBI > 7 (P = .034) at 30 min, pre-SBT inspiratory pressure level (P = .009), and pre-SBT retractions (P = .042) as predictors for SBT failure, but this model performed poorly in an independent validation set with the receiver operating characteristic plot crossing the reference line (area under the curve, 0.67). INTERPRETATION A 30-min SBT may be too short in children recovering from pediatric ARDS because many go on to fail between 30 and 120 min. Reassuring values of Vt, RR, and gas exchange at 30 min do not reliably predict SBT passage at 2 h, likely because they do not capture the effort of breathing. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03266016; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Kelby E Knox
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Michael C K Khoo
- Department of Biomedical Engineering, University of Southern California Viterbi School of Engineering, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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10
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Abu-Sultaneh S, Iyer NP, Fernández A, Gaies M, González-Dambrauskas S, Hotz JC, Kneyber MCJ, López-Fernández YM, Rotta AT, Werho DK, Baranwal AK, Blackwood B, Craven HJ, Curley MAQ, Essouri S, Fioretto JR, Hartmann SMM, Jouvet P, Korang SK, Rafferty GF, Ramnarayan P, Rose L, Tume LN, Whipple EC, Wong JJM, Emeriaud G, Mastropietro CW, Napolitano N, Newth CJL, Khemani RG. Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document. Am J Respir Crit Care Med 2023; 207:17-28. [PMID: 36583619 PMCID: PMC9952867 DOI: 10.1164/rccm.202204-0795so] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/12/2022] [Indexed: 12/31/2022] Open
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.
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Affiliation(s)
- Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Narayan Prabhu Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Analía Fernández
- Pediatric Critical Care Unit, Acute Care General Hospital “Carlos G. Durand,” Buenos Aires, Argentina
| | - Michael Gaies
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Facultad de Medicina, Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
| | - Justin Christian Hotz
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
| | - Martin C. J. Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Yolanda M. López-Fernández
- Department of Pediatrics, Biocruces-Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Alexandre T. Rotta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, North Carolina
| | - David K. Werho
- Division of Pediatric Cardiology, Cardiothoracic Intensive Care, Rady Children’s Hospital, University of California, San Diego, San Diego, California
| | - Arun Kumar Baranwal
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Hannah J. Craven
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana
| | - Martha A. Q. Curley
- Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Research Institute, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sandrine Essouri
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Jose Roberto Fioretto
- Pediatric Critical Care Division, Department of Pediatrics, Botucatu Medical School, Sao Paulo State University, Botucatu, Sao Paulo, Brazil
| | - Silvia M. M. Hartmann
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Philippe Jouvet
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Steven Kwasi Korang
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gerrard F. Rafferty
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences & Medicine, and
| | - Padmanabhan Ramnarayan
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London United Kingdom
| | - Lyvonne N. Tume
- Edge Hill University Health Research Institute, Ormskirk, England
| | - Elizabeth C. Whipple
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Christopher W. Mastropietro
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | | | - Christopher J. L. Newth
- Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
| | - Robinder G. Khemani
- Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California
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11
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Duyndam A, Smit J, Houmes RJ, Heunks L, Molinger J, IJland M, van Rosmalen J, van Dijk M, Tibboel D, Ista E. No association between thickening fraction of the diaphragm and extubation success in ventilated children. Front Pediatr 2023; 11:1147309. [PMID: 37033174 PMCID: PMC10081691 DOI: 10.3389/fped.2023.1147309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/02/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction In mechanically ventilated adults, thickening fraction of diaphragm (dTF) measured by ultrasound is used to predict extubation success. Whether dTF can also predict extubation success in children is unclear. Aim To investigate the association between dTF and extubation success in children. Second, to assess diaphragm thickness during ventilation and the correlation between dTF, diaphragm thickness (Tdi), age and body surface. Method Prospective observational cohort study in children aged 0-18 years old with expected invasive ventilation for >48 h. Ultrasound was performed on day 1 after intubation (baseline), day 4, day 7, day 10, at pre-extubation, and within 24 h after extubation. Primary outcome was the association between dTF pre-extubation and extubation success. Secondary outcome measures were Tdi end-inspiratory and Tdi end-expiratory and atrophy defined as <10% decrease of Tdi end-expiratory versus baseline at pre-extubation. Correlations were calculated with Spearman correlation coefficients. Inter-rater reliability was calculated with intraclass correlation (ICC). Results Fifty-three patients, with median age 3.0 months (IQR 0.1-66.0) and median duration of invasive ventilation of 114.0 h (IQR 55.5-193.5), were enrolled. Median dTF before extubation with Pressure Support 10 above 5 cmH2O was 15.2% (IQR 9.7-19.3). Extubation failure occurred in six children, three of whom were re-intubated and three then received non-invasive ventilation. There was no significant association between dTF and extubation success; OR 0.33 (95% CI; 0.06-1.86). Diaphragmatic atrophy was observed in 17/53 cases, in three of extubation failure occurred. Children in the extubation failure group were younger: 2.0 months (IQR 0.81-183.0) vs. 3.0 months (IQR 0.10-48.0); p = 0.045. At baseline, pre-extubation and post-extubation there was no significant correlation between age and BSA on the one hand and dTF, Tdi- insp and Tdi-exp on the other hand. The ICC representing the level of inter-rater reliability between the two examiners performing the ultrasounds was 0.994 (95% CI 0.970-0.999). The ICC of the inter-rater reliability between the raters in 36 paired assessments was 0.983 (95% CI 0.974-0.990). Conclusion There was no significant association between thickening fraction of the diaphragm and extubation success in ventilated children.
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Affiliation(s)
- Anita Duyndam
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Correspondence: Anita Duyndam
| | - Joke Smit
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Robert Jan Houmes
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Leo Heunks
- Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeroen Molinger
- Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Division of Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
| | - Marloes IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Monique van Dijk
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dick Tibboel
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Erwin Ista
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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12
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Abu-Sultaneh S, Iyer NP, Fernández A, Gaies M, González-Dambrauskas S, Hotz JC, Kneyber MCJ, López-Fernández YM, Rotta AT, Werho DK, Baranwal AK, Blackwood B, Craven HJ, Curley MAQ, Essouri S, Fioretto JR, Hartmann SMM, Jouvet P, Korang SK, Rafferty GF, Ramnarayan P, Rose L, Tume LN, Whipple EC, Wong JJM, Emeriaud G, Mastropietro CW, Napolitano N, Newth CJL, Khemani RG. Operational Definitions Related to Pediatric Ventilator Liberation. Chest 2022; 163:1130-1143. [PMID: 36563873 DOI: 10.1016/j.chest.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Common, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices. RESEARCH QUESTION Can we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches? STUDY DESIGN AND METHODS A panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions. RESULTS In eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support. INTERPRETATION We propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.
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Affiliation(s)
- Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN.
| | - Narayan Prabhu Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Analía Fernández
- Pediatric Critical Care Unit, Hospital General de Agudos "C. Durand" Ciudad Autónoma de Buenos Aires, Argentina
| | - Michael Gaies
- Department of Pediatrics, Division of Pediatric Cardiology, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, OH
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network) and Departamento de Pediatría Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Justin Christian Hotz
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Yolanda M López-Fernández
- Department of Pediatrics, Pediatric Critical Care Division, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC
| | - David K Werho
- Division of Pediatric Cardiology, Cardiothoracic Intensive Care, UC San Diego, Rady Children's Hospital, San Diego, CA
| | - Arun Kumar Baranwal
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Hannah J Craven
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN
| | - Martha A Q Curley
- Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA; Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sandrine Essouri
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
| | - Jose Roberto Fioretto
- Department of Pediatrics, Pediatric Critical Care Division, Botucatu Medical School-UNESP-São Paulo State University, Botucatu, SP, Brazil
| | - Silvia M M Hartmann
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA
| | - Philippe Jouvet
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
| | - Steven Kwasi Korang
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA; Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gerrard F Rafferty
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences & Medicine, King's College London, London, England
| | - Padmanabhan Ramnarayan
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England
| | - Lyvonne N Tume
- Edge Hill University Health Research Institute, Ormskirk, England
| | - Elizabeth C Whipple
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN
| | | | - Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
| | - Christopher W Mastropietro
- Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN
| | | | - Christopher J L Newth
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA; Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA; Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
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13
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Abstract
OBJECTIVES To map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards. DATA SOURCES CINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. STUDY SELECTION Abstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed. DATA EXTRACTION None. DATA SYNTHESIS Weaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient's respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation. CONCLUSIONS Current literature suggests using a structured approach that includes a daily assessment of patient's readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.
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14
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Pediatric Ventilation Liberation: A Survey of International Practice Among 555 Pediatric Intensivists. Crit Care Explor 2022; 4:e0756. [PMID: 36082374 PMCID: PMC9444408 DOI: 10.1097/cce.0000000000000756] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Pediatric ventilation liberation has limited evidence, likely resulting in wide practice variation. To inform future work, practice patterns must first be described.
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15
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van Dijk J, Koopman AA, de Langen LB, Dijkstra S, Burgerhof JGM, Blokpoel RGT, Kneyber MCJ. Effect of pediatric ventilation weaning technique on work of breathing. Respir Res 2022; 23:184. [PMID: 35831900 PMCID: PMC9281016 DOI: 10.1186/s12931-022-02106-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/01/2022] [Indexed: 12/04/2022] Open
Abstract
Background Ventilator liberation is one of the most challenging aspects in patients with respiratory failure. Most patients are weaned through a transition from full to partial respiratory support, whereas some advocate using a continuous spontaneous ventilation (CSV). However, there is little scientific evidence supporting the practice of pediatric ventilator liberation, including the timing of onset of and the approach to weaning mode. We sought to explore differences in patient effort between a pressure controlled continuous mode of ventilation (PC-CMV) [in this cohort PC assist/control (PC-A/C)] with a reduced ventilator rate and CSV, and to study changes in patient effort with decreasing PS. Methods In this prospective physiology cross-over study, we randomized children < 5 years to first PC-A/C with a 25% reduction in ventilator rate, or CSV (continuous positive airway pressure [CPAP] + PS). Patients were then crossed over to the other arm. Patient effort was measured by calculating inspiratory work of breathing (WOB) using the Campbell diagram (WOBCampbell), and by pressure–rate-product (PRP) and pressure–time-product (PTP). Respiratory inductance plethysmography (RIP) was used to calculate the phase angle. Measurements were obtained at baseline, during PC-A/C and CPAP + PS, and during decreasing set PS (maximum -6 cmH2O).
Results Thirty-six subjects with a median age of 4.4 (IQR 1.5–11.9) months and median ventilation time of 4.9 (IQR 3.4–7.0) days were included. Nearly all patients (94.4%) were admitted with primary respiratory failure. WOBCampbell during baseline [0.67 (IQR 0.38–1.07) Joules/L] did not differ between CSV [0.49 (IQR 0.17–0.83) Joules/L] or PC-A/C [0.47 (IQR 0.17–1.15) Joules/L]. Neither PRP, PTP, ∆Pes nor phase angle was different between the two ventilator modes. Reducing pressure support resulted in a statistically significant increase in patient effort, albeit that these differences were clinically negligible. Conclusions Patient effort during pediatric ventilation liberation was not increased when patients were in a CSV mode of ventilation compared to a ventilator mode with a ventilator back-up rate. Reducing the level of PS did not lead to clinically relevant increases in patient effort. These data may aid in a better approach to pediatric ventilation liberation.
Trial registration clinicaltrials.gov NCT05254691. Registered 24 February 2022 Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02106-6.
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Affiliation(s)
- Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Limme B de Langen
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Sandra Dijkstra
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
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Lundstrom JA, Khemani RG, Hotz J, Newth CJL, Achanta S, Gentile MA, Hedin DS. Development of a Pleural Pressure Catheter via Continuous Fiberoptic Esophageal Pressure Measurements. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:3269-3272. [PMID: 36086635 DOI: 10.1109/embc48229.2022.9871790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
There is growing research showing the importance of measuring esophageal pressure as a surrogate for pleural pressure for patients on mechanical ventilators. The most common measurement method uses a balloon catheter, whose accuracy can vary based on patient anatomy, balloon position, balloon inflation, and the presence of other tubes in the esophagus. The authors present the development and initial testing results of a new combination catheter, utilizing fiberoptic pressure sensing to provide more accurate esophageal pressure measurements and allowing for the incorporation of a feeding tube and temperature sensor.
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ALTINKAYA ÇAVUŞ M, GÖKBULUT BEKTAŞ Ş, SİPAHİOĞLU H, ERTÜRK ZARARSIZ G, TURAN S. Diyafram ultrasonografisinin weaning başarısını tahmin etmedeki gücü. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1037159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Amaç: Bu çalışmada amaç; diyafram kalınlığının weaning üzerine etkilerini ultrasonografi (USG) ile değerlendirmektir.
Gereç ve Yöntem: Prospektif olarak yapılan bu çalışmada; hastaların demografik özellikleri, yoğun bakıma yatış ve mekanik ventilasyon endikasyonları, ek hastalıkları, diyafram kalınlığı, Sıralı Organ Yetmezliği Değerlendirmesi (SOFA) skoru ve Basitleştirilmiş Akut Fizyoloji Skoru (SAPS) II, mortalite oranı, periferik oksijen satürasyonu (SpO2), IMV süresi, dakika hacmi, solunum sayısı (RR), ekspiratuar hacimleri, RSBI değerleri kaydedildi.Hastalar invaziv mekanik ventilatör (IMV) basınç desteği (PS) modunda 30 dakika boyunca spontan olarak ventile edildi . Diyafram kalınlığı (DT), B moduna ayarlanmış 7-10 MHz lineer ultrason probu kullanılarak ölçüldü. Sağ hemidiyafram, 8. ve 10. interkostal boşluklar arasındaki midaksiller çizgide diyafram ve göğüs kafesinin birleştiği bölgede görüntülendi. Ölçümler sonrasında hastalar stabil hale geldikten sonra 1 saat boyunca T-tüpe alındı. T-tüpte spontan solunum denemeleri (SBT)'ni başarıyla tamamlayan hastalar ekstübe edildi. Hastalar başarılı ve başarısız weaning olmak üzere 2 gruba ayrıldı.
Bulgular: Toplam 72 hasta çalışmaya dahil edilme kriterlerini sağlayarak değerlendirilmeye alındı. Hastaların 4 tanesi 24 saatten daha kısa süre IMV desteği aldığı için çalışma dışı bırakıldı. Diyafram kalınlık indeksi (DTI) ve diyafram kalınlaşma fraksiyonu (DTF) oranlarında gruplar arasında bir farklılık gözlenmedi. İnspirasyon sonunu diyafram kalınlığı (DTV) ve ekspirasyon sonunu diyafram kalınlığı (DFRV) olarak tanımlanan diyaframın kalınlık ölçümleri başarılı weaning grubunda daha yüksekti. Weaning başarısını tahmin etmek için DTV'nin en iyi eşik değeri 0.72, DFRV değeri 0.669 olarak bulundu.
Sonuç: Weaning başarısı diyafram fonksiyonları, diyafram kalınlık parametreleri ve akciğer kapasiteleri ile yakından ilişkilidir. USG, diyaframı değerlendirmek için kullanılabilecek pratik, hasta başı uygulanabilen, noninvaziv bir yöntemdir. DTV ve DFRV weaning sürecinde başarıyı tahmin edebilecek parametreler arasındadır. DTF ve DTI weaning başarısını öngörmede yetersiz bulundu.
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Affiliation(s)
- Mine ALTINKAYA ÇAVUŞ
- Department of Intensive Care, University of Health Sciences, Kayseri City Hospital, Kayseri, Turkey
| | | | - Hilal SİPAHİOĞLU
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, KAYSERİ SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | | | - Sema TURAN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
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Hames DL, Sleeper LA, Bullock KJ, Feins EN, Mills KI, Laussen PC, Salvin JW. Associations With Extubation Failure and Predictive Value of Risk Analytics Algorithms With Extubation Readiness Tests Following Congenital Cardiac Surgery. Pediatr Crit Care Med 2022; 23:e208-e218. [PMID: 35184097 PMCID: PMC9058191 DOI: 10.1097/pcc.0000000000002912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Extubation failure is associated with morbidity and mortality in children following cardiac surgery. Current extubation readiness tests (ERT) do not consider the nonrespiratory support provided by mechanical ventilation (MV) for children with congenital heart disease. We aimed to identify factors associated with extubation failure in children following cardiac surgery and assess the performance of two risk analytics algorithms for patients undergoing an ERT. DESIGN Retrospective cohort study. SETTING CICU at a tertiary-care children's hospital. PATIENTS Children receiving MV greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six hundred fifty encounters were analyzed with 49 occurrences (8%) of reintubation. Extubation failure occurred most frequently within 6 hours of extubation. On multivariable analysis, younger age (per each 3-mo decrease: odds ratio [OR], 1.06; 95% CI, 1.001-1.12), male sex (OR, 2.02; 95% CI, 1.03-3.97), Society of Thoracic Surgery-European Association for Cardiothoracic Surgery category 5 procedure (p equals to 0.005), and preoperative respiratory support (OR, 2.08; 95% CI, 1.09-3.95) were independently associated with unplanned reintubation. Our institutional ERT had low sensitivity to identify patients at risk for reintubation (23.8%; 95% CI, 9.7-47.6%). The addition of the inadequate delivery of oxygen (IDO2) index to the ERT increased the sensitivity by 19.0% (95% CI, -2.5 to 40.7%; p = 0.05), but the sensitivity remained low and the accuracy of the test dropped by 8.9% (95% CI, 4.7-13.1%; p < 0.01). CONCLUSIONS Preoperative respiratory support, younger age, and more complex operations are associated with postoperative extubation failure. IDO2 and IVCO2 provide unique cardiorespiratory monitoring parameters during ERTs but require further investigation before being used in clinical evaluation for extubation failure.
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Affiliation(s)
- Daniel L. Hames
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin J. Bullock
- Department of Respiratory Care, Boston Children’s Hospital, Boston, MA
| | - Eric N. Feins
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Kimberly I. Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Peter C. Laussen
- Department of Anesthesia, Boston Children’s Hospital, Boston, MA
- Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Joshua W. Salvin
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
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Egbuta C, Evans F. Weaning from ventilation and extubation of children in critical care. BJA Educ 2022; 22:104-110. [PMID: 35211327 PMCID: PMC8847847 DOI: 10.1016/j.bjae.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 01/22/2023] Open
Affiliation(s)
- C. Egbuta
- Boston Children's Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Corresponding author:
| | - F. Evans
- Boston Children's Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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Kishore R, Jhamb U. Effect of Protocolized Weaning and Spontaneous Breathing Trial vs Conventional Weaning on Duration of Mechanical Ventilation: A Randomized Controlled Trial. Indian J Crit Care Med 2021; 25:1059-1065. [PMID: 34963728 PMCID: PMC8664023 DOI: 10.5005/jp-journals-10071-23944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Identifying ventilated patients ready for extubation is a challenge for clinicians. Premature extubation increases risks of reintubation while delayed weaning increases complications of prolonged ventilation. We compared the duration of mechanical ventilation (MV) and extubation failure in children extubated using a weaning protocol based on pressure support spontaneous breathing trial (PS SBT) vs those extubated after nonprotocolized physician-directed weaning. Patients and methods A prospective randomized controlled trial was conducted in the pediatric intensive care unit of a tertiary care hospital in children ventilated for ≥24 hours. All eligible patients underwent daily screening and were randomized once found fit. The intervention group underwent PS SBT of 2 hours duration followed by a T-piece trial and extubation. Controls underwent conventional weaning with synchronized intermittent mandatory ventilation mode and a T-piece trial before extubation. Results Eighty patients were randomized into two groups of 40 each. About 77.5% of patients passed the PS SBT on the first attempt. No statistical difference was found either in the duration of MV between the two groups [median (interquartile range) in days: 4.77 (2.89, 9.46) in controls and 4.94 (2.23, 6.35) in cases, p = 0.62] or in the rate of extubation failure (13% and 10.5%, p = 1). Mortality was found to be significantly higher in the reintubated patients compared to those not reintubated in both groups (p = 0.002 in cases and 0.005 in controls). Conclusion Weaning using PS SBT-based protocol though did not shorten the duration of MV, it was found to be safe for assessing extubation readiness and did not increase extubation failure (CTRI no—CTRI/2018/04/013270). How to cite this article Kishore R, Jhamb U. Effect of Protocolized Weaning and Spontaneous Breathing Trial vs Conventional Weaning on Duration of Mechanical Ventilation: A Randomized Controlled Trial. Indian J Crit Care Med 2021;25(9):1059–1065.
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Affiliation(s)
- Rashmi Kishore
- Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India
| | - Urmila Jhamb
- Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India
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21
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Diaphragm Activity Pre and Post Extubation in Ventilated Critically Ill Infants and Children Measured With Transcutaneous Electromyography. Pediatr Crit Care Med 2021; 22:950-959. [PMID: 34534162 DOI: 10.1097/pcc.0000000000002828] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Swift extubation is important to prevent detrimental effects of invasive mechanical ventilation but carries the risk of extubation failure. Accurate tools to assess extubation readiness are lacking. This study aimed to describe the effect of extubation on diaphragm activity in ventilated infants and children. Our secondary aim was to compare diaphragm activity between failed and successfully extubated patients. DESIGN Prospective, observational study. SETTING Single-center tertiary neonatal ICU and PICU. PATIENTS Infants and children receiving invasive mechanical ventilation longer than 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Diaphragm activity was measured with transcutaneous electromyography, from 15 minutes before extubation till 180 minutes thereafter. Peak and tonic activity, inspiratory amplitude, inspiratory area under the curve, and respiratory rate were calculated from the diaphragm activity waveform. One hundred forty-seven infants and children were included (median postnatal age, 1.9; interquartile range, 0.9-6.7 wk). Twenty patients (13.6%) failed extubation within 72 hours. Diaphragm activity increased rapidly after extubation and remained higher throughout the measurement period. Pre extubation, peak (end-inspiratory) diaphragm activity and tonic (end-inspiratory) diaphragm activity were significantly higher in failure, compared with success cases (5.6 vs 7.0 μV; p = 0.04 and 2.8 vs 4.1 μV; p = 0.04, respectively). Receiver operator curve analysis showed the highest area under the curve for tonic (end-inspiratory) diaphragm activity (0.65), with a tonic (end-inspiratory) diaphragm activity greater than 3.4 μV having a combined sensitivity and specificity of 55% and 77%, respectively, to predict extubation outcome. After extubation, diaphragm activity remained higher in patients failing extubation. CONCLUSIONS Diaphragm activity rapidly increased after extubation. Patients failing extubation had a higher level of diaphragm activity, both pre and post extubation. The predictive value of the diaphragm activity variables alone was limited. Future studies are warranted to assess the additional value of electromyography of the diaphragm in combined extubation readiness assessment.
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Baalaaji ARM. Weaning from Mechanical Ventilation in Children: Are We Getting It Right? Indian J Crit Care Med 2021; 25:974-975. [PMID: 34963712 PMCID: PMC8664013 DOI: 10.5005/jp-journals-10071-23974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
How to cite this article: Baalaaji ARM. Weaning from Mechanical Ventilation in Children: Are We Getting It Right? Indian J Crit Care Med 2021;25(9):974-975.
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Affiliation(s)
- AR Mullai Baalaaji
- Department of Pediatric Critical Care, Kovai Medical Centerand Hospital, Coimbatore, Tamil Nadu, India
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24
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Abstract
Despite the accepted importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are often not clear, although a trial of spontaneous breathing on CPAP without pressure support seems an appropriate prerequisite in many cases. Several indexes have been developed to predict weaning and extubation success, but the available literature suggests they offer little or no improvement over clinical judgment. New techniques for assessing readiness for weaning and predicting extubation success are being developed but are far from general acceptance in pediatric practice. While there have been some excellent physiologic, observational, and even randomized controlled trials on aspects of pediatric ventilator liberation, robust research data are lacking. Given the lack of data in many areas, a determined approach that combines systematic review with consensus opinion of international experts could generate high-quality recommendations and terminology definitions to guide clinical practice and highlight important areas for future research in weaning, extubation readiness, and liberation from mechanical ventilation following pediatric respiratory failure.
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Affiliation(s)
- Christopher Jl Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California. .,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
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Diaphragmatic activity and neural breathing variability during a 5-min endotracheal continuous positive airway pressure trial in extremely preterm infants. Pediatr Res 2021; 89:1810-1817. [PMID: 32942291 PMCID: PMC7533985 DOI: 10.1038/s41390-020-01159-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Extremely preterm infants are often exposed to endotracheal tube continuous positive airway pressure (ETT-CPAP) trials to assess extubation readiness. The effects of ETT-CPAP trial on their diaphragmatic activity (Edi) and breathing variability is unknown. METHODS Prospective observational study enrolling infants with birth weight ≤1250 g undergoing their first extubation attempt. Diaphragmatic activity, expressed as the absolute minimum (Edi min) and maximum values (Edi max), area under the Edi signal, and breath-by-breath analyses for breath areas, amplitudes, widths, and neural inspiratory and expiratory times, were analyzed during mechanical ventilation (MV) and ETT-CPAP. Neural breathing variability of each of these parameters was also calculated and compared between MV and ETT-CPAP. RESULTS Thirteen infants with median (interquartile range) birth weight of 800 g [610-920] and gestational age of 25.4 weeks [24.4-26.3] were included. Diaphragmatic activity significantly increased during ETT-CPAP when compared to MV:Edi max (44.2 vs. 38.1 μV), breath area (449 vs. 312 μV·s), and amplitude (10.12 vs. 7.46 μV). Neural breathing variability during ETT-CPAP was characterized by increased variability for amplitude and area under the breath, and decreased for breath time and width. CONCLUSIONS A 5-min ETT-CPAP in extremely preterm infants undergoing extubation imposed significant respiratory load with changes in respiratory variability. IMPACT ETT-CPAP trials are often used to assess extubation readiness in extremely preterm infants, but its effects upon their respiratory system are not well known. Diaphragmatic activity analysis demonstrated that these infants are able to mount an important response to a short trial. A 5-min trial imposed a significant respiratory load evidenced by increased diaphragmatic activity and changes in breathing variability. Differences in breathing variability were observed between successful and failed extubations, which should be explored further in extubation readiness investigations. This type of trial cannot be recommended for preterm infants in clinical practice until clear standards and accuracy are established.
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26
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Fiatt M, Bosio AC, Neves D, Symanski da Cunha R, Fonseca LT, Celeste RK. Accuracy of a spontaneous breathing trial for extubation of neonates. J Neonatal Perinatal Med 2020; 14:375-382. [PMID: 33337394 DOI: 10.3233/npm-200573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prevalence of extubation failure in neonates may be up to 80%, but evidence to determine if a neonate is ready for extubation remains unclear. We aim to evaluate a spontaneous breathing trial accuracy with minimum pressure support to predict success in neonates' extubation and identify variables related to failures. METHODS This is a diagnostic accuracy study based on a cohort study in an intensive care unit with all eligible newborn infants subjected to invasive mechanical ventilation for at least 24 hours submitted to the trial for 10 minutes before extubations. The outcome was failures of extubations, considered if reintubation was needed until 72 hours. RESULTS The incidence of failure was 14.7%among 170 extubations. There were 145 successful extubations; of these, 140 also passed the trial with a sensitivity of 96.5%(95%CI: 92.1-98.9). Of the 25 extubations that eventually failed, 16 failed the test with a specificity of 64.0%(95%CI: 42.5-82.0). The negative predictive value was 76.2%, and the positive predictive value was 94%. In stratifying by weight, the accuracy was >98.7%for neonates weighting >2500 g, but 72.5%for those weighing <1250 g. Extubation failures occurred more frequently in smaller (p = 0.01), preterm infants (p = 0.17), with longer ventilation time (p = 0.05), and having a hemodynamically significant persistent arterial duct (p = 0.01), compared with infants whose extubation was successful. CONCLUSION The spontaneous breathing trial with minimum pressure support ventilation seems to predict extubation success with great accuracy in full-term and larger neonates.
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Affiliation(s)
- M Fiatt
- Hospital Criança Conceição, Neonatal Intensive Care Unit, Porto Alegre, Brazil
| | - A C Bosio
- Hospital Criança Conceição, Neonatal Intensive Care Unit, Porto Alegre, Brazil
| | - D Neves
- Hospital Criança Conceição, Neonatal Intensive Care Unit, Porto Alegre, Brazil
| | - R Symanski da Cunha
- Hospital Criança Conceição, Neonatal Intensive Care Unit, Porto Alegre, Brazil
| | - L T Fonseca
- Hospital Criança Conceição, Neonatal Intensive Care Unit, Porto Alegre, Brazil
| | - R K Celeste
- Departamento de Odontologia Preventiva e Social, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Abstract
OBJECTIVES Mechanical ventilation of patients with acute respiratory distress syndrome should balance lung and diaphragm protective principles, which may be difficult to achieve in routine clinical practice. Through a Phase I clinical trial, we sought to determine whether a computerized decision support-based protocol (real-time effort-driven ventilator management) is feasible to implement, results in improved acceptance for lung and diaphragm protective ventilation, and improves clinical outcomes over historical controls. DESIGN Interventional nonblinded pilot study. SETTING PICU. PATIENTS Mechanically ventilated children with acute respiratory distress syndrome. INTERVENTIONS A computerized decision support tool was tested which prioritized lung-protective management of peak inspiratory pressure-positive end-expiratory pressure, positive end-expiratory pressure/FIO2, and ventilatory rate. Esophageal manometry was used to maintain patient effort in a physiologic range. Protocol acceptance was reported, and enrolled patients were matched 4:1 with respect to age, initial oxygenation index, and percentage of immune compromise to historical control patients for outcome analysis. MEASUREMENTS AND MAIN RESULTS Thirty-two patients were included. Acceptance of protocol recommendations was over 75%. One-hundred twenty-eight matched historical controls were used for analysis. Compared with historical controls, patients treated with real-time effort-driven ventilator management received lower peak inspiratory pressure-positive end-expiratory pressure and tidal volume, and higher positive end-expiratory pressure when FIO2 was greater than 0.60. Real-time effort-driven ventilator management was associated with 6 more ventilator-free days, shorter duration until the first spontaneous breathing trial and 3 fewer days on mechanical ventilation among survivors (all p ≤ 0.05) in comparison with historical controls, while maintaining no difference in the rate of reintubation. CONCLUSIONS A computerized decision support-based protocol prioritizing lung-protective ventilation balanced with reduction of controlled ventilation to maintain physiologic levels of patient effort can be implemented and may be associated with shorter duration of ventilation.
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Diaphragm Atrophy During Pediatric Acute Respiratory Failure Is Associated With Prolonged Noninvasive Ventilation Requirement Following Extubation. Pediatr Crit Care Med 2020; 21:e672-e678. [PMID: 32433439 DOI: 10.1097/pcc.0000000000002385] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Diaphragm atrophy is evident during invasive ventilation for pediatric acute respiratory failure, but with unknown significance. We hypothesized that diaphragm atrophy in pediatric acute respiratory failure is associated with prolonged noninvasive positive pressure ventilation following extubation. DESIGN Prospective observational study. SETTING Single-center academic PICU. PATIENTS Invasively ventilated children with acute respiratory failure. INTERVENTIONS Diaphragm ultrasound was performed within 36 hours after intubation and repeated within 48 hours preceding extubation. Rapid shallow breathing index at 15 and 30 minutes of a spontaneous breathing trial and negative inspiratory force were collected in a subset of patients concurrently with the ultrasound measurements. MEASUREMENTS AND MAIN RESULTS Diaphragm thickness at end-expiration was measured to assess for diaphragm atrophy during mechanical ventilation. Percentage change in diaphragm thickness at end-expiration was defined as baseline diaphragm thickness at end-expiration minus final, preextubation diaphragm thickness at end-expiration divided by baseline diaphragm thickness at end-expiration. The primary outcome measure was duration of noninvasive positive pressure ventilation following extubation with prolonged use defined as noninvasive positive pressure ventilation use for greater than 24 hours postextubation. Among 56 children, 47 (median age, 15.5 mo; interquartile range, 6-53 mo) had diaphragm thickness at end-expiration measured within 48 hours prior to extubation. Fourteen (30%) had prolonged noninvasive positive pressure ventilation use with median duration 110 hours (interquartile range, 52-130 hr). The median percentage change of diaphragm thickness at end-expiration from baseline among those with and without prolonged noninvasive positive pressure ventilation use was -20% (interquartile range, -32% to -10%) versus -7% (interquartile range, -21% to 0%) (p = 0.04). CONCLUSIONS Diaphragm atrophy is associated with prolonged postextubation noninvasive positive pressure ventilation in children with acute respiratory failure. Serial bedside diaphragm ultrasound may identify children at risk for prolonged noninvasive positive pressure ventilation use after extubation.
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Knox KE, Nava-Guerra L, Hotz JC, Newth CJL, Khoo MCK, Khemani RG. High Breath-by-Breath Variability Is Associated With Extubation Failure in Children. Crit Care Med 2020; 48:1165-1174. [PMID: 32697487 PMCID: PMC7755301 DOI: 10.1097/ccm.0000000000004418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Extubation failure is multifactorial, and most tools to assess extubation readiness only evaluate snapshots of patient physiology. Understanding variability in respiratory variables may provide additional information to inform extubation readiness assessments. DESIGN Secondary analysis of prospectively collected physiologic data of children just prior to extubation during a spontaneous breathing trial. Physiologic data were cleaned to provide 40 consecutive breaths and calculate variability terms, coefficient of variation and autocorrelation, in commonly used respiratory variables (i.e., tidal volume, minute ventilation, and respiratory rate). Other clinical variables included diagnostic and demographic data, median values of respiratory variables during spontaneous breathing trials, and the change in airway pressure during an occlusion maneuver to measure respiratory muscle strength (maximal change in airway pressure generated during airway occlusion [PiMax]). Multivariable models evaluated independent associations with reintubation and prolonged use of noninvasive respiratory support after extubation. SETTING Acute care, children's hospital. PATIENTS Children were included from the pediatric and cardiothoracic ICUs who were greater than 37 weeks gestational age up to and including 18 years who were intubated greater than or equal to 12 hours with planned extubation. We excluded children who had a contraindication to an esophageal catheter or respiratory inductance plethysmography bands. INTERVENTIONS Noninterventional study. MEASUREMENTS AND MAIN RESULTS A total of 371 children were included, 32 of them were reintubated. Many variability terms were associated with reintubation, including coefficient of variation and autocorrelation of the respiratory rate. After controlling for confounding variables such as age and neurologic diagnosis, both coefficient of variation of respiratory rate(p < 0.001) and low PiMax (p = 0.002) retained an independent association with reintubation. Children with either low PiMax or high coefficient of variation of respiratory rate had a nearly three-fold higher risk of extubation failure, and when these children developed postextubation upper airway obstruction, reintubation rates were greater than 30%. CONCLUSIONS High respiratory variability during spontaneous breathing trials is independently associated with extubation failure in children, with very high rates of extubation failure when these children develop postextubation upper airway obstruction.
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Affiliation(s)
- Kelby E Knox
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Leonardo Nava-Guerra
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Neonatology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Michael C K Khoo
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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A Respiratory Therapist-Driven Pathway Improves Timeliness of Extubation Readiness Assessment in a Single PICU. Pediatr Crit Care Med 2020; 21:e513-e521. [PMID: 32343110 DOI: 10.1097/pcc.0000000000002326] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Our smart aim was to decrease the time between when a mechanically ventilated patient was eligible for and when they underwent their first extubation readiness test (delta time) by 50% within 3 months through the development and implementation of a respiratory therapist-driven extubation readiness test pathway. DESIGN Quality improvement project. SETTING Single, tertiary care, 24-bed, academic PICU. PATIENTS Pediatric patients admitted to the PICU and requiring mechanical ventilation for a primary pulmonary process. INTERVENTIONS We developed an extubation readiness test pathway that consisted of an eligibility screen and a standard testing process. Patients were screened every 3 hours. Upon passing the screen and being cleared by a prescriber, a test was initiated. No clinical management was dictated to prescribers. MEASUREMENTS AND MAIN RESULTS The preintervention and intervention cohorts included 109 and 43 mechanical ventilation courses, respectively. The mean delta time decreased from 33.77 hours to 2.92 hours after pathway implementation (p = 0.000). The medical length of stay decreased from 196.6 to 177.2 hours (p = 0.05). There were no statistically significant changes in duration of mechanical ventilation until first extubation (112.9 vs 122.3 hr; p = 0.651) and 48-hour extubation failure rate (16.5% vs 4.8%; p = 0.056). The sensitivity and positive predictive value for the extubation readiness test were 89.5% and 94.4%, respectively. The mean for all process compliance measures was 91.5%. CONCLUSIONS A respiratory therapist-driven extubation readiness test pathway can be safely implemented in a large, academic PICU. The pathway resulted in earlier extubation readiness testing without increasing key balancing measures-the duration of mechanical ventilation, PICU length of stay, or the extubation failure rate.
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Gasping at Straws: Role of Pressure Support During Spontaneous Breathing Trials in Children. Pediatr Crit Care Med 2020; 21:699-700. [PMID: 32618868 PMCID: PMC7338036 DOI: 10.1097/pcc.0000000000002328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Spontaneous Breathing and Imposed Work During Pediatric Mechanical Ventilation: A Bench Study. Pediatr Crit Care Med 2020; 21:e449-e455. [PMID: 32427436 DOI: 10.1097/pcc.0000000000002309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To calculate imposed work of breathing during simulated spontaneous breathing at a given tidal volume across the range of normal length or shortened pediatric endotracheal tube sizes and endotracheal tubes with an intraluminal catheter in situ. DESIGN In vitro study. SETTING Research laboratory. INTERVENTIONS A bench model (normal compliance, no airway resistance) simulating sinusoid flow spontaneous breathing used to calculate imposed work of breathing for various endotracheal tube sizes (3.0-7.5 mm). Imposed work of breathing was calculated by integrating inspiratory tidal volume over the end-expiratory difference between the positive end-expiratory pressure and the tracheal pressure. Measurements were taken at different combinations of set spontaneous tidal volume (2.5, 5.0, 7.5, and 10 mL/kg), age-appropriate inspiratory times, length of endotracheal tube, and presence of intraluminal catheter. MEASUREMENTS AND MAIN RESULTS Overall median imposed work of breathing (Joules/L) was not significantly different between the four age groups: 0.047 Joules/L (interquartile range, 0.020-0.074 Joules/L) for newborns, 0.077 Joules/L (interquartile range, 0.032-0.127 Joules/L) for infants, 0.109 Joules/L (interquartile range, 0.0399-0.193 Joules/L) for small children, and 0.077 Joules/L (interquartile range, 0.032-0.132 Joules/L) for adolescents. Shortening the endotracheal tubes resulted in a significant difference in reduction in overall imposed work of breathing, but the absolute reduction was most notable in small children (0.030 Joules/L) and the least effect in neonates (0.016 Joules/L). Overall imposed work of breathing increased in each age group when an intraluminal catheter was in situ: 91.09% increase in imposed work of breathing in neonates to 0.168 Joules/L, 84.98% in infants to 0.142 Joules/L, 81.98% in small children to 0.219 Joules/L, and 55.45% in adolescents to 0.140 Joules/L. CONCLUSIONS Calculated imposed work of breathing were not different across the range of endotracheal tube sizes. The low imposed work of breathing values found in this study might be appreciated as clinically irrelevant. Our findings add to the change in reasoning that it is appropriate to perform spontaneous breathing trials without pressure support. Nonetheless, our findings on the measured imposed work of breathing values need to be confirmed in a clinical study.
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Abdel Rahman DA, Saber S, El-Maghraby A. Diaphragm and Lung Ultrasound Indices in Prediction of Outcome of Weaning from Mechanical Ventilation in Pediatric Intensive Care Unit. Indian J Pediatr 2020; 87:413-420. [PMID: 32036590 PMCID: PMC7223651 DOI: 10.1007/s12098-019-03177-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 12/27/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To predict the added value of diaphragmatic and lung ultrasound indices (US) in anticipation of the outcome of mechanical ventilation of pediatric patients in the intensive care unit. METHODS This prospective study was conducted in Zagazig University, Pediatric Hospitals, PICU; Egypt. One hundred six mechanically ventilated children aged between 1 mo to 170 mo were included in the study. All patients were candidates for weaning and have been given a chance for spontaneous breathing trial (SBT), during which diaphragmatic and lung US was performed for them. The diaphragm thickening fraction (DTF), the diaphragmatic excursion and the lung US score (LUS), that included 4 US aeration forms, were assessed. RESULTS There were statistically significant differences between patients with failed weaning and those with successful weaning regarding DTF, diaphragmatic excursion and LUS (p < 0.001). The best cut-off value of DTF, diaphragmatic excursion, and LUS for predicting weaning failure was ≥23.175%, ≥ 6.2 mm, and ≥ 12 with an AUC (area under curve) of 0.932, 0.876, and 0.934, respectively. CONCLUSIONS Diaphragmatic and lung US add a quick, accurate and non-invasive indices to the weaning readiness parameters compared to the other standard parameters alone. So, it is recommended to be added to the predictive parameters of weaning outcome.
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Affiliation(s)
- Dalia A Abdel Rahman
- Department of Pediatrics, Faculty of Medicine, Sednawy Hospital, Zagazig University, Zagazig, Egypt.
| | - S Saber
- Department of Radiology, Faculty of Medicine, Sednawy Hospital, Zagazig University, Zagazig, Egypt
| | - A El-Maghraby
- Department of Radiology, Faculty of Medicine, Sednawy Hospital, Zagazig University, Zagazig, Egypt
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Khemani RG, Hotz JC, Klein MJ, Kwok J, Park C, Lane C, Smith E, Kohler K, Suresh A, Bornstein D, Elkunovich M, Ross PA, Deakers T, Beltramo F, Nelson L, Shah S, Bhalla A, Curley MAQ, Newth CJL. A Phase II randomized controlled trial for lung and diaphragm protective ventilation (Real-time Effort Driven VENTilator management). Contemp Clin Trials 2019; 88:105893. [PMID: 31740425 DOI: 10.1016/j.cct.2019.105893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/05/2019] [Accepted: 11/14/2019] [Indexed: 11/18/2022]
Abstract
Lung Protective Mechanical Ventilation (MV) of critically ill adults and children is lifesaving but it may decrease diaphragm contraction and promote Ventilator Induced Diaphragm Dysfunction (VIDD). An ideal MV strategy would balance lung and diaphragm protection. Building off a Phase I pilot study, we are conducting a Phase II controlled clinical trial that seeks to understand the evolution of VIDD in critically ill children and test whether a novel computer-based approach (Real-time Effort Driven ventilator management (REDvent)) can balance lung and diaphragm protective ventilation to reduce time on MV. REDvent systematically adjusts PEEP, FiO2, inspiratory pressure, tidal volume and rate, and uses real-time measures from esophageal manometry to target normal levels of patient effort of breathing. This trial targets 276 children with pulmonary parenchymal disease. Patients are randomized to REDvent vs. usual care for the acute phase of MV (intubation to first Spontaneous Breathing Trial (SBT)). Patients in either group who fail their first SBT will be randomized to REDvent vs usual care for weaning phase management (interval from first SBT to passing SBT). The primary clinical outcome is length of weaning, with several mechanistic outcomes. Upon completion, this study will provide important information on the pathogenesis and timing of VIDD during MV in children and whether this computerized protocol targeting lung and diaphragm protection can lead to improvement in intermediate clinical outcomes. This will form the basis for a larger, Phase III multi-center study, powered for key clinical outcomes such as 28-day ventilator free days. Clinical Trials Registration: NCT03266016.
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Affiliation(s)
- Robinder G Khemani
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America.
| | - Justin C Hotz
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Margaret J Klein
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Jeni Kwok
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Caron Park
- University of Southern California, Keck School of Medicine, Department of Preventative Medicine, United States of America
| | - Christianne Lane
- University of Southern California, Keck School of Medicine, Department of Preventative Medicine, United States of America
| | - Erin Smith
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Kristen Kohler
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Anil Suresh
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Dinnel Bornstein
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Marsha Elkunovich
- University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America; Children's Hospital of Los Angeles, Department of Emergency Medicine, United States of America
| | - Patrick A Ross
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Timothy Deakers
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Fernando Beltramo
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Lara Nelson
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Shilpa Shah
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Anoopindar Bhalla
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Martha A Q Curley
- Children's Hospital Philadelphia, University of Pennsylvania, United States of America
| | - Christopher J L Newth
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
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Liberation From Mechanical Ventilation After Cardiac Surgery in Infants and Children: Need for Better Definitions and Approach. Pediatr Crit Care Med 2019; 20:990-992. [PMID: 31580275 DOI: 10.1097/pcc.0000000000002032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Dijk J, Blokpoel RGT, Koopman AA, Dijkstra S, Burgerhof JGM, Kneyber MCJ. The effect of pressure support on imposed work of breathing during paediatric extubation readiness testing. Ann Intensive Care 2019; 9:78. [PMID: 31267228 PMCID: PMC6606677 DOI: 10.1186/s13613-019-0549-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Paediatric critical care practitioners often make use of pressure support (PS) to overcome the perceived imposed work of breathing (WOBimp) during an extubation readiness test (ERT). However, no paediatric data are available that shows the necessity of adding of pressure support during such tests. We sought to measure the WOBimp during an ERT with and without added pressure support and to study its clinical correlate. This was a prospective study in spontaneously breathing ventilated children < 18 years undergoing ERT. Using tracheal manometry, WOBimp was calculated by integrating the difference between positive end-expiratory pressure (PEEP) and tracheal pressure (Ptrach) over the measured expiratory tidal volume (VTe) under two paired conditions: continuous positive airway pressure (CPAP) with and without PS. Patients with post-extubation upper airway obstruction were excluded. RESULTS A total of 112 patients were studied. Median PS during the ERT was 10 cmH2O. WOBimp was significantly higher without PS (median 0.27, IQR 0.20-0.50 J/L) than with added PS (median 0.00, IQR 0.00-0.11 J/L). Although there were statistically significant changes in spontaneous breath rate [32 (23-42) vs. 37 (27-46) breaths/min, p < 0.001] and higher ET-CO2 [5.90 (5.38-6.65) vs. 6.23 (5.55-6.94) kPa, p < 0.001] and expiratory Vt decreased [7.72 (6.66-8.97) vs. 7.08 (5.82-8.08) mL/kg, p < 0.001] in the absence of PS, these changes appeared clinically irrelevant since the Comfort B score remained unaffected [12 (10-13) vs. 12 (10-13), P = 0.987]. Multivariable analysis showed that changes in WOBimp occurred independent of endotracheal tube size. CONCLUSIONS Withholding PS during ERT does not lead to clinically relevant increases in WOBimp, irrespective of endotracheal tube size.
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Affiliation(s)
- Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Sandra Dijkstra
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Internal Postal Code CA 62, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
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Duyndam A, Houmes RJ, van Rosmalen J, Tibboel D, van Dijk M, Ista E. Implementation of a nurse-driven ventilation weaning protocol in critically ill children: Can it improve patient outcome? Aust Crit Care 2019; 33:80-88. [PMID: 30876696 DOI: 10.1016/j.aucc.2019.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 12/12/2018] [Accepted: 01/15/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Critically ill children treated with invasive mechanical ventilation in a paediatric intensive care unit (PICU) may suffer from complications leading to prolonged duration of ventilation and PICU stay. OBJECTIVE The objective of this study is to find out if the use of a nurse-driven ventilation weaning protocol in a PICU can shorten the duration of mechanical ventilation. METHODS In a prospective, pretest-posttest implementation study, we implemented a nurse-driven ventilation weaning protocol and compared its outcomes with those of the usual physician-driven weaning. In the posttest period, nurses weaned the patients until extubation as per this protocol. The primary outcome was duration of ventilation. The secondary outcomes were length of PICU stay, reintubation rate, and compliance with the protocol (measured by use of the prescribed support mode). RESULTS In total, 424 patients aged from 0 to 18 years (212 pretest and 212 posttest) were included; in both groups, the median age was 3 months. The median duration of ventilation did not differ significantly between the pretest and posttest periods: 42.5 h. (interquartile range, IQR 14.3-121.3) vs. 44.5 h (IQR 12.3-107.0), respectively; p = 0.589. In the posttest period, the PICU stay was nonsignificantly shorter: 5.5 days (IQR 2-11) vs. 7 days (IQR 3-14) in the pretest period; p = 0.432. Compliance with the prescribed support mode was significantly higher in the posttest period: 69.9% vs. 55.7% in the pretest period; p = 0.005. The reintubation rate was not significantly different between the pretest and posttest periods (5% vs. 7%, respectively; p = 0.418). The extubation rate during nights was higher in the posttest period but not significantly different (p = 0.097). CONCLUSIONS Implementation of a nurse-driven weaning protocol did not result in a significantly shorter duration of invasive mechanical ventilation but was safe and successful. The reintubation rate did not significantly increase compared with usual care.
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Affiliation(s)
- Anita Duyndam
- Intensive Care, Erasmus MC - Sophia Children's Hospital Rotterdam, the Netherlands.
| | - Robert Jan Houmes
- Intensive Care, Erasmus MC - Sophia Children's Hospital Rotterdam, the Netherlands
| | | | - Dick Tibboel
- Intensive Care, Erasmus MC - Sophia Children's Hospital Rotterdam, the Netherlands
| | - Monique van Dijk
- Intensive Care, Erasmus MC - Sophia Children's Hospital Rotterdam, the Netherlands
| | - Erwin Ista
- Intensive Care, Erasmus MC - Sophia Children's Hospital Rotterdam, the Netherlands
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Sasaki M, Yamaguchi Y, Miyashita T, Matsuda Y, Ohtsuka M, Yamaguchi O, Goto T. Simulation of pressure support for spontaneous breathing trials in neonates. Intensive Care Med Exp 2019; 7:10. [PMID: 30737561 PMCID: PMC6368635 DOI: 10.1186/s40635-019-0223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 01/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endotracheal tubes used for neonates are not as resistant to breathing as originally anticipated; therefore, spontaneous breathing trials (SBTs) with continuous positive airway pressure (CPAP), without pressure support (PS), are recommended. However, PS extubation criteria have predetermined pressure values for each endotracheal tube diameter (PS 10 cmH2O with 3.0- and 3.5-mm tubes or PS 8 cmH2O with 4.0-mm tubes). This study aimed to assess the validity of these SBT criteria for neonates, using an artificial lung simulator, ASL 5000™ lung simulator, and a SERVO-i Universal™ ventilator (minute volume, 240-360 mL/kg/min; tidal volume, 30 mL; respiratory rate, 24-36/min; lung compliance, 0.5 mL/cmH2O/kg; resistance, 40 cmH2O/L/s) in an intensive care unit. We simulated a spontaneous breathing test in a 3-kg neonate after cardiac surgery with 3.0-3.5-mm endotracheal tubes. We measured the work of breathing (WOB), trigger work, and parameters of pressure support ventilation (PSV), T-piece breathing, or ASL 5000™ alone. RESULTS WOB displayed respiratory rate dependency under intubation. PS compensating tube resistance fluctuated with respiratory rate. At a respiratory rate of 24/min, the endotracheal tube did not greatly influence WOB under PSV and the regression line of WOB converged with the WOB of ASL 5000™ alone under PS 1 cmH2O; however, at 36/min, endotracheal tube was resistant to breathing under PSV because trigger work increased exponentially with PS ≤ 9 cmH2O. The regression line of WOB under PSV converged with the WOB of T-piece breathing under PS 1 cmH2O. Furthermore, PS compensating endotracheal tube resistance was 6 cmH2O. The WOB of ASL 5000™ alone approached that of respiratory distress syndrome (RDS); however, the pressure of patient effort was normal physiological range at PS 10 cmH2O. PS equalizing WOB under PSV with that after extubation depended on the respiratory rate and upper airway resistance. If WOB after extubation equaled that of T-piece breathing, the PS was 0 cmH2O regardless of the respiratory rates. If WOB after extubation approximated to that of ASL 5000™ alone, the PS depended on the respiratory rate. CONCLUSION SBT strategies should be selected per neonatal respiratory rates and upper airway resistance.
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Affiliation(s)
- Makoto Sasaki
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan.
| | - Yoshikazu Yamaguchi
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Tetsuya Miyashita
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Yuko Matsuda
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Masahide Ohtsuka
- Department of Critical Care Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Osamu Yamaguchi
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
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The authors reply. Crit Care Med 2018; 45:e333-e334. [PMID: 28212236 DOI: 10.1097/ccm.0000000000002224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Extubation Readiness Tests on Pediatric Critical Care Setting: Questions Still Unanswered? Crit Care Med 2018; 45:e333. [PMID: 28212235 DOI: 10.1097/ccm.0000000000002199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chiusolo F, Fanelli V, Ciofi Degli Atti ML, Conti G, Tortora F, Pariante R, Ravà L, Grimaldi C, de Ville de Goyet J, Picardo S. CPAP by helmet for treatment of acute respiratory failure after pediatric liver transplantation. Pediatr Transplant 2018; 22. [PMID: 29171131 DOI: 10.1111/petr.13088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 11/28/2022]
Abstract
ARF after pediatric liver transplantation accounts for high rate of morbidity and mortality associated with this procedure. The role of CPAP in postoperative period is still unknown. The aim of the study was to describe current practice and risk factors associated with the application of helmet CPAP. In this retrospective observational cohort study, 119 recipients were divided into two groups based on indication to CPAP after extubation. Perioperative variables were studied, and determinants of CPAP application were analyzed in a multivariate logistic model. Sixty patients (60/114) developed ARF and were included in the CPAP group. No differences were found between the two groups for primary disease, graft type, and blood product transfused. At multivariate analysis, weight <11 kg (OR = 2.9; 95% CI = 1.1-7.3; P = .026), PaO2 /FiO2 <380 before extubation (OR = 5.4; 95% CI = 2.1-13.6; P < .001), need of vasopressors (OR = 2.6; 95% CI = 1.1-6.4; P = .038), and positive fluid balance >148 mL/kg (OR = 4.0; 95% CI = 1.6-10.1; P = .004) were the main determinants of CPAP application. In the CPAP group, five patients (8.4%) needed reintubation. Pediatric liver recipients with lower weight, higher need of inotropes/vasopressors, higher positive fluid balance after surgery, and lower PaO2 /FiO2 before extubation were at higher odds of developing ARF needing CPAP application.
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Affiliation(s)
- F Chiusolo
- Department of Anesthesia and Critical Care, ARCO, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - V Fanelli
- Department of Anesthesia and Critical Care, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - M L Ciofi Degli Atti
- Department of Epidemiology and Statistical Analysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - G Conti
- Department of Pediatric ICU, Intensive Care and Anesthesia, Catholic University of Rome, Rome, Italy
| | - F Tortora
- Department of Anesthesia and Critical Care, ARCO, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - R Pariante
- Department of Anesthesia and Critical Care, ARCO, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - L Ravà
- Department of Epidemiology and Statistical Analysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - C Grimaldi
- Department of Pediatric Surgery and Transplantation, Bambino Gesù Children's Hospital, IRRCS, Rome, Italy
| | | | - S Picardo
- Department of Anesthesia and Critical Care, ARCO, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Al-Abdwani R, Williams CB, Dunn C, Macartney J, Wollny K, Frndova H, Chin N, Stephens D, Parshuram CS. Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: An 11year experience. J Crit Care 2017; 44:368-375. [PMID: 29289914 DOI: 10.1016/j.jcrc.2017.12.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 11/06/2017] [Accepted: 12/22/2017] [Indexed: 12/27/2022]
Abstract
PURPOSE Unplanned extubation represents loss of control in the ICU, is associated with harm and is used as a measure of quality of care. We evaluated the rates and consequences of unplanned extubation. MATERIALS AND METHODS Eligible patients were intubated, <18years, and in ICU. Patient, care-related and environmental characteristics were compared in patients who did and did not receive positive pressure ventilation in the 24h after events. Rates are expressed per 100 intubation-days. RESULTS The 11,310 eligible patient-admissions identified were intubated for 75,519days; 410 (3.39%) patients had 458 unplanned extubation events (0.61 events/100 intubation-days). Annual rates of unplanned extubation reduced from 0.98 in 2004 to 0.37 in 2014. Consequences occurred in 245 (53.5%) events and included cardiac arrest in 9 (2%), bradycardia 52 (11%), and stridor 63 (14%). Positive pressure was provided after 263 (57%) events, and was independently associated with pre-event sedative and muscle relaxant drugs, non-use of restraints, respiratory reason for intubation and recent care by more nurses. CONCLUSION Unplanned extubation was associated with both significant and no morbidity. Modification of factors including more consistent nurse staffing, restraint use, and increased vigilance in patients with previous events may potentially reduce rates and adverse consequences of unplanned extubation.
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Affiliation(s)
- R Al-Abdwani
- Centre for Safety Research, Department of Critical Care Medicine, Hospital for Sick Children, Canada
| | - C B Williams
- Centre for Safety Research, Department of Critical Care Medicine, Hospital for Sick Children, Canada
| | - C Dunn
- Critical Care Program, Hospital for Sick Children, Canada
| | - J Macartney
- Critical Care Program, Hospital for Sick Children, Canada
| | - K Wollny
- Critical Care Program, Hospital for Sick Children, Canada
| | - H Frndova
- Centre for Safety Research, Critical Care Program, Hospital for Sick Children, Canada
| | - N Chin
- Critical Care Program, Informatics, Hospital for Sick Children, Canada
| | - D Stephens
- Child Health and Evaluation Sciences Program, The Research Institute, Hospital for Sick Children, Canada
| | - C S Parshuram
- Department of Critical Care Medicine, Department of Paediatrics, Child Health and Evaluation Sciences Program, The Research Institute, Centre for Safety Research Hospital for Sick Children, Canada; Department of Pediatrics, Interdepartmental Division of Critical Care Medicine, Department of Health Policy Management and Evaluation, University of Toronto, Canada.
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Koyama Y, Yoshida T, Uchiyama A, Fujino Y. Monitoring diaphragm function in a patient with myasthenia gravis: electrical activity of the diaphragm vs. maximal inspiratory pressure. J Intensive Care 2017; 5:66. [PMID: 29209502 PMCID: PMC5704593 DOI: 10.1186/s40560-017-0262-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 11/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background Maximal inspiratory pressure (MIP) is used to assess respiratory muscle strength of patients with myasthenia gravis (MG) requiring ventilatory support. Electrical activity of the diaphragm (E-di) has been used to guide weaning. Case presentation The MIP and tidal volume/ΔE-di (the patient-to-ventilator breath contribution) were monitored in a 12-year-old girl with MG requiring ventilator support. The same ventilatory settings were maintained until extubation. During weaning, MIP increased slightly, but varied unpredictably. Tidal volume/ΔE-di decreased at a constant rate as muscle strength recovered. Conclusion In this patient with muscle weakness, E-di was a reliable tool to monitor weaning from mechanical ventilation.
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Affiliation(s)
- Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871 Japan.,Physiology and Experimental Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, ON M5G 0A4 Canada
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871 Japan
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An Interprofessional Quality Improvement Initiative to Standardize Pediatric Extubation Readiness Assessment. Pediatr Crit Care Med 2017; 18:e463-e471. [PMID: 28737600 DOI: 10.1097/pcc.0000000000001285] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Establishing protocols to wean mechanical ventilation and assess readiness for extubation, with the goal of minimizing morbidity associated with extubation failure and prolonged mechanical ventilation, have become increasingly important in contemporary PICUs. The aim of this quality improvement initiative is to establish a respiratory therapist-led daily spontaneous breathing trial protocol to standardize extubation readiness assessment and documentation in our PICU. DESIGN A quality improvement project. SETTING Single center, tertiary care Children's Hospital PICU. PATIENTS All intubated patients admitted to PICU requiring conventional mechanical ventilation between February 2013 and January 2016. INTERVENTIONS A working group of pediatric intensivists, respiratory therapists, nurses, and information technology specialists established the protocol, standardized documentation via the electronic medical record, and planned education. Daily spontaneous breathing trial protocol implementation began in February 2015. All patients on mechanical ventilation were screened daily at approximately 4 AM by a respiratory therapist to determine daily spontaneous breathing trial eligibility. If all screening criteria were met, patients were placed on continuous positive airway pressure of 5 cm H2O with pressure support of 8 cm H2O for up to 2 hours. If tolerated, patients would be extubated to supplemental oxygen delivered via nasal cannula in the morning, after intensivist approval. Daily audits were done to assess screening compliance and accuracy of documentation. MEASUREMENTS AND MAIN RESULTS We analyzed data from 398 mechanically ventilated patients during daily spontaneous breathing trial period (February 2015-January 2016), compared with 833 patients from the pre-daily spontaneous breathing trial period (February 2013-January 2015). During the daily spontaneous breathing trial period, daily screening occurred in 92% of patients. Extubation failure decreased from 7.8% in the pre-daily spontaneous breathing trial period to 4.5% in daily spontaneous breathing trial period. The use of high-flow nasal cannula slightly increased during the project, while there was no change in duration of mechanical ventilation or the use of noninvasive ventilation. CONCLUSIONS An interprofessionally developed respiratory therapist-led extubation readiness protocol can be successfully implemented in a busy tertiary care PICU without adverse events.
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Newth CJL, Khemani RG, Jouvet PA, Sward KA. Mechanical Ventilation and Decision Support in Pediatric Intensive Care. Pediatr Clin North Am 2017; 64:1057-1070. [PMID: 28941535 DOI: 10.1016/j.pcl.2017.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Respiratory support is required in most children in the pediatric intensive care unit. Decision-support tools (paper or electronic) have been shown to improve the quality of medical care, reduce errors, and improve outcomes. Computers can assist clinicians by standardizing descriptors and procedures, consistently performing calculations, incorporating complex rules with patient data, and capturing relevant data. This article discusses computer decision-support tools to assist clinicians in making flexible but consistent, evidence-based decisions for equivalent patient states.
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Affiliation(s)
- Christopher John L Newth
- Anesthesiology and Critical Care Medicine, University of Southern California, Children's Hospital Los Angeles, MS #12, PICU Administration, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
| | - Robinder G Khemani
- Anesthesiology and Critical Care Medicine, University of Southern California, Children's Hospital Los Angeles, MS #12, PICU Administration, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Philippe A Jouvet
- CHU Sainte-Justine, 3175 Chemin de Côte Sainte Catherine, Montreal, Québec H3T 1C5, Canada
| | - Katherine A Sward
- University of Utah College of Nursing, 10 S 2000 East, Salt Lake City, UT 84112
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Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med 2017; 43:1764-1780. [PMID: 28936698 PMCID: PMC5717127 DOI: 10.1007/s00134-017-4920-z] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022]
Abstract
Purpose Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children. Methods The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms. Results The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement. Conclusions These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research. Electronic supplementary material The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.
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Mohr R, Thomas J, Cannizzaro V, Weiss M, Schmidt AR. Impact of endotracheal tube shortening on work of breathing in neonatal and pediatric in vitro lung models. Paediatr Anaesth 2017; 27:942-948. [PMID: 28653420 DOI: 10.1111/pan.13183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Work of breathing accounts for a significant proportion of total oxygen consumption in neonates and infants. Endotracheal tube inner diameter and length significantly affect airflow resistance and thus work of breathing. While endotracheal tube shortening reduces endotracheal tube resistance, the impact on work of breathing in mechanically ventilated neonates and infants remains unknown. AIM The objective of this in vitro study was to quantify the effect of endotracheal tube shortening on work of breathing in simulated pediatric lung settings. We hypothesized that endotracheal tube shortening significantly reduces work of breathing. METHODS We used the Active-Servo-Lung 5000 to simulate different clinical scenarios in mechanically ventilated infants and neonates under spontaneous breathing with and without pressure support. Endotracheal tube size, lung resistance, and compliance, as well as respiratory settings such as respiratory rate and tidal volume were weight and age adapted for each lung model. Work of breathing was measured before and after maximal endotracheal tube shortening and the reduction of the daily energy demand calculated. RESULTS Tube shortening with and without pressure support decreased work of breathing to a maximum of 10.1% and 8.1%, respectively. As a result, the calculated reduction of total daily energy demand by endotracheal tube shortening was between 0.002% and 0.02%. CONCLUSION In this in vitro lung model, endotracheal tube shortening had minimal effects on work of breathing. Moreover, the calculated percentage reduction of the total daily energy demand after endotracheal tube shortening was minimal.
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Affiliation(s)
- Rebecca Mohr
- Department of Anaesthesia, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Jörg Thomas
- Department of Anaesthesia, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Vincenzo Cannizzaro
- Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland.,Department of Intensive Care Medicine and Neonatology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anaesthesia, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Alexander R Schmidt
- Department of Anaesthesia, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland.,Department of Intensive Care Medicine and Neonatology, University Children's Hospital of Zurich, Zurich, Switzerland
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Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength. Crit Care Med 2017; 45:e798-e805. [PMID: 28437378 DOI: 10.1097/ccm.0000000000002433] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Respiratory muscle weakness frequently develops during mechanical ventilation, although in children there are limited data about its prevalence and whether it is associated with extubation outcomes. We sought to identify risk factors for pediatric extubation failure, with specific attention to respiratory muscle strength. DESIGN Secondary analysis of prospectively collected data. SETTING Tertiary care PICU. PATIENTS Four hundred nine mechanically ventilated children. INTERVENTIONS Respiratory measurements using esophageal manometry and respiratory inductance plethysmography were made preextubation during airway occlusion and on continuous positive airway pressure of 5 and pressure support of 10 above positive end-expiratory pressure 5 cm H2O, as well as 5 and 60 minutes postextubation. MEASUREMENTS AND MAIN RESULTS Thirty-four patients (8.3%) were reintubated within 48 hours of extubation. Reintubation risk factors included lower maximum airway pressure during airway occlusion (aPiMax) preextubation, longer length of ventilation, postextubation upper airway obstruction, high respiratory effort postextubation (pressure rate product, pressure time product, tension time index), and high postextubation phase angle. Nearly 35% of children had diminished respiratory muscle strength (aPiMax ≤ 30 cm H2O) at the time of extubation, and were nearly three times more likely to be reintubated than those with preserved strength (aPiMax > 30 cm H2O; 14% vs 5.5%; p = 0.006). Reintubation rates exceeded 20% when children with low aPiMax had moderately elevated effort after extubation (pressure rate product > 500), whereas children with preserved aPiMax had reintubation rates greater than 20% only when postextubation effort was very high (pressure rate product > 1,000). When children developed postextubation upper airway obstruction, reintubation rates were 47.4% for those with low aPiMax compared to 15.4% for those with preserved aPiMax (p = 0.02). Multivariable risk factors for reintubation included acute neurologic disease, lower aPiMax, postextubation upper airway obstruction, higher preextubation positive end-expiratory pressure, higher postextubation pressure rate product, and lower height. CONCLUSIONS Neuromuscular weakness at the time of extubation was common in children and was independently associated with reintubation, particularly when postextubation effort was high.
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