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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 filled 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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Napolitano N, Loberger J, Romer A. Successful Extubation of Children With Congenital Heart Disease Requires a Specialized Approach. Respir Care 2024; 69:521-523. [PMID: 38538024 PMCID: PMC11108108 DOI: 10.4187/respcare.11949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Affiliation(s)
- Natalie Napolitano
- Respiratory Therapy DepartmentChildren's Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Jeremy Loberger
- Division of Pediatric Critical Care MedicineUniversity of Alabama Medical CenterBirmingham, Alabama
| | - Amy Romer
- Division of Pediatric Critical Care MedicineChildren's Hospital of PhiladelphiaPhiladelphia, Pennsylvania
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Mortamet G, Milési C, Baudin F, Yalindag N, Kneyber M, Pons-Odena M. Weaning from noninvasive respiratory support in children in acute settings: Expert consensus statement using modified Delphi methodology. Pediatr Pulmonol 2024; 59:348-354. [PMID: 37942833 DOI: 10.1002/ppul.26753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/29/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE To reach a consensus on the definition and modalities of weaning from noninvasive ventilation in acute settings. DESIGN A modified Delphi survey using closed and open-ended questions. SETTING Three rounds of consensus determination were sent via electronic mail survey to 33 experts. The survey questionnaire had four sections: definition of weaning, definition of weaning failure, criteria to initiate weaning, and modalities of weaning. Questions where agreement had been reached on round 1 were no longer part of the survey in rounds 2 and 3. SUBJECTS Twenty-five international experts from 10 countries. MEASUREMENT AND MAIN RESULTS Overall, this survey generated positive consensus from experts for 19/35 statements (9 with strong agreement and 10 with weak agreement) about weaning from noninvasive respiratory support. No negative consensus could be identified. CONCLUSION The clinical practice statements issued address important aspects of definition of weaning, definition of weaning failure, criteria to initiate weaning, and modalities of weaning in acute settings.
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Affiliation(s)
- Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Christophe Milési
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Florent Baudin
- Pediatric Intensive Care Unit, Women Mother Children Hospital, Bron, France
| | - Nilufer Yalindag
- Pediatric Intensive Care Unit, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Martin Kneyber
- Department of Pediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Critical Care, Anaesthesiology, Peri-operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Marti Pons-Odena
- Immune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
- Pediatric Intensive Care and Intermediate Care Department, Sant Joan de Déu University Hospital, Esplugues de Llobregat, Spain
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Rogerson CM, Abu-Sultaneh S, Loberger JM, Ross P, Khemani RG, Sanchez-Pinto LN. Predicting Duration of Invasive Mechanical Ventilation in the Pediatric ICU. Respir Care 2023; 68:1623-1630. [PMID: 37137712 PMCID: PMC10676255 DOI: 10.4187/respcare.11015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/02/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Timely ventilator liberation can prevent morbidities associated with invasive mechanical ventilation in the pediatric ICU (PICU). There currently exists no standard benchmark for duration of invasive mechanical ventilation in the PICU. This study sought to develop and validate a multi-center prediction model of invasive mechanical ventilation duration to determine a standardized duration of invasive mechanical ventilation ratio. METHODS This was a retrospective cohort study using registry data from 157 institutions in the Virtual Pediatric Systems database. The study population included encounters in the PICU between 2012-2021 involving endotracheal intubation and invasive mechanical ventilation in the first day of PICU admission who received invasive mechanical ventilation for > 24 h. Subjects were stratified into a training cohort (2012-2017) and 2 validation cohorts (2018-2019/2020-2021). Four models to predict the duration of invasive mechanical ventilation were trained using data from the first 24 h, validated, and compared. RESULTS The study included 112,353 unique encounters. All models had observed-to-expected (O/E) ratios close to one but low mean squared error and R2 values. The random forest model was the best performing model and achieved an O/E ratio of 1.043 (95% CI 1.030-1.056) and 1.004 (95% CI 0.990-1.019) in the validation cohorts and 1.009 (95% CI 1.004-1.016) in the full cohort. There was a high degree of institutional variation, with single-unit O/E ratios ranging between 0.49-1.91. When stratified by time period, there were observable changes in O/E ratios at the individual PICU level over time. CONCLUSIONS We derived and validated a model to predict the duration of invasive mechanical ventilation that performed well in aggregated predictions at the PICU and the cohort level. This model could be beneficial in quality improvement and institutional benchmarking initiatives for use at the PICU level and for tracking of performance over time.
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Affiliation(s)
- Colin M Rogerson
- Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana.
| | - Samer Abu-Sultaneh
- Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Jeremy M Loberger
- University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Patrick Ross
- University of Southern California Keck School of Medicine and Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, California
| | - Robinder G Khemani
- University of Southern California Keck School of Medicine and Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, California
| | - L Nelson Sanchez-Pinto
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Miller AG, Kumar KR, Adagarla BS, Haynes KE, Watts RM, Muddiman JL, Heath TS, Allareddy V, Rotta AT. Noninvasive Ventilation or CPAP for Postextubation Support in Small Infants. Respir Care 2023; 69:respcare.11194. [PMID: 37491072 PMCID: PMC10753612 DOI: 10.4187/respcare.11194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Infants with a high risk of extubation failure are often treated with noninvasive ventilation (NIV) or CPAP, but data on the role of these support modalities following extubation are sparse. This report describes our experience using NIV or CPAP to support infants following extubation in our pediatric ICUs (PICUs). METHODS We performed a retrospective study of children < 10 kg receiving postextubation NIV or CPAP in our PICUs. Data on demographics, medical history, type of support, vital signs, pulse oximetry, near-infrared spectroscopy (NIRS), gas exchange, support settings, and re-intubation were extracted from the electronic medical record. Support was classified as prophylactic if planned before extubation and rescue if initiated within 24 h of extubation. We compared successfully extubated and re-intubated subjects using chi-square test for categorical variables and Mann-Whitney test for continuous variables. RESULTS We studied 51 subjects, median age 44 (interquartile range 0.5-242) d and weight 3.7 (3-4.9) kg. There were no demographic differences between groups, except those re-intubated were more likely to have had cardiac surgery prior to admission (0% vs 14%, P = .040). NIV was used in 31 (61%) and CPAP in 20 (39%) subjects. Prophylactic support was initiated in 25 subjects (49%), whereas rescue support was needed in 26 subjects (51%). Twenty-two subjects (43%) required re-intubation. Re-intubation rate was higher for rescue support (58% vs 28%, P = .032). Subjects with a pH < 7.35 (4.3% vs 42.0%, P = .003) and lower somatic NIRS (39 [24-56] vs 62 [46-72], P = .02) were more likely to be re-intubated. The inspiratory positive airway pressure, expiratory positive airway pressure, and FIO2 were higher in subjects who required re-intubation. CONCLUSIONS NIV or CPAP use was associated with a re-intubation rate of 43% in a heterogeneous sample of high-risk infants. Acidosis, cardiac surgery, higher FIO2 , lower somatic NIRS, higher support settings, and application of rescue support were associated with the need for re-intubation.
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Affiliation(s)
- Andrew G Miller
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Karan R Kumar
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Bhargav S Adagarla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Kaitlyn E Haynes
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Rachel M Watts
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Jeanette L Muddiman
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Travis S Heath
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina
| | - Veerajalandhar Allareddy
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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Havan M, Uçmak H, Kendirli T. Pediatric Ventilator Liberation Guideline: Should the T-Piece and Automatic Tube Compensation Be Ignored in the Spontaneous Breathing Trial? Am J Respir Crit Care Med 2023; 207:1404-1405. [PMID: 36930960 PMCID: PMC10595460 DOI: 10.1164/rccm.202302-0300le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Affiliation(s)
- Merve Havan
- Division of Pediatric Critical Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hacer Uçmak
- Division of Pediatric Critical Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tanıl Kendirli
- Division of Pediatric Critical Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
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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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Loberger JM, Watson CR, Clingan EM, Petrusnek SD, Aban IB, Prabhakaran P. Pediatric Ventilator Liberation: One-Hour Versus Two-Hour Spontaneous Breathing Trials in a Single Center. Respir Care 2023; 68:649-657. [PMID: 37015811 PMCID: PMC10171336 DOI: 10.4187/respcare.10652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND The optimal spontaneous breathing trial (SBT) duration is not known for children who are critically ill. The study objective was to evaluate extubation outcomes between cohorts exposed to a 1- or 2-h SBT. METHODS This was a retrospective cohort study of a quality improvement project database in a 24-bed pediatric ICU. The intervention was a respiratory therapist-driven SBT clinical pathway across 2 improvement cycles by using a 2- or 1-h SBT. The primary outcomes were extubation failure and rescue noninvasive ventilation in the first 48 h. Secondary outcomes included SBT results and process measures. RESULTS There were 218 and 305 encounters in the 2- and 1-h cohorts, respectively. Extubation failure (7.3 vs 8.5%; P = .62) and rescue noninvasive ventilation rates (9.3 vs 8.2%; P = .68) were similar. In logistic regression models, SBT duration was not independently associated with either primary outcome. Extubation after 1-h SBT failure was associated with significantly higher odds of rescue noninvasive ventilation exposure (odds ratio 3.94, 95% CI 1.3-11.9; P = .02). SBT results were not associated with odds of extubation failure. There were 1,072 (2 h) and 1,333 (1 h) SBTs performed. The 1-h SBT pass rate was significantly higher versus the 2-h SBT (71.4 vs 51.1%; P < .001). Among all failed SBTs, the top 3 reported failure modes were tidal volume ≤ 5 mL/kg (23.6%), breathing frequency increase > 30% (21%), and oxygen saturation < 92% (17.3%). When considering all failed SBTs, 75.5% of failures occurred before 45 min. CONCLUSIONS A 1-h SBT may be a viable alternative to a 2-h version for the average child who is critically ill. Further, a 1-h SBT may better balance extubation outcomes and duration of invasive ventilation for the general pediatric ICU population.
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Affiliation(s)
- Jeremy M Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Caleb R Watson
- Department of Respiratory Therapy, Children's of Alabama, Birmingham, Alabama
| | - Emily M Clingan
- Department of Respiratory Therapy, Children's of Alabama, Birmingham, Alabama
| | - Sarah D Petrusnek
- Department of Nursing Services, Children's of Alabama, Birmingham, Alabama
| | - Inmaculada B Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Priya Prabhakaran
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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Wakeham MK. The Ideal Extubation Readiness Testing for the Pediatric Patient: Is There One? Respir Care 2023; 68:440-441. [PMID: 36828580 PMCID: PMC10027147 DOI: 10.4187/respcare.10892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Affiliation(s)
- Martin K Wakeham
- Pediatric Division of Critical CareMedical College of Wisconsin/Children's WisconsinMilwaukee, Wisconsin
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