A Respiratory Therapist-Driven Pathway Improves Timeliness of Extubation Readiness Assessment in a Single PICU

Framework for Research Gaps in Pediatric Ventilator Liberation

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.

Tests and Indices Predicting Extubation Failure in Children: A Systematic Review and Meta-analysis

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.

Pediatric ventilation liberation: evaluating the role of endotracheal secretions in an extubation readiness bundle

BACKGROUND

An evidence gap exists regarding the role of endotracheal secretions in pediatric extubation decisions. This study aims to evaluate whether endotracheal secretion burden independently correlates with pediatric extubation failure.

METHODS

This is a single-center, prospective cohort study of children aged <19 years requiring intubation. Nurses (RN) and respiratory therapists (RT) independently used a novel secretion assessment score focusing on secretion volume, character, and trend. We hypothesized that the RN and RT secretion scores would not correlate with extubation outcome and inter-rater reliability would be poor.

RESULTS

RN secretion character sub-score (OR 3.3, 95% CI 1.1-11.1, p = 0.048) was independently associated with extubation failure. RN and RT inter-rater reliability was poor (correlation 0.385, 95% CI 0.339-0.429, p < 0.001). A failure prediction model incorporating the RN secretion character sub-score as well as indication for mechanical ventilation and spontaneous breathing trial result demonstrated an area under the receiver operating curve of 0.817 (95% CI 0.730-0.904, p < 0.001).

CONCLUSIONS

In the general pediatric population, the RN assessment of endotracheal secretion character was independently associated with extubation failure. A model incorporating indication for mechanical ventilation, spontaneous breathing result, and RN assessment of endotracheal secretion character demonstrated reasonable accuracy in predicting failure in those clinically selected for extubation.

IMPACT

Development of comprehensive and sensitive extubation readiness bundles are key to balancing the competing risks of prolonged invasive mechanical ventilation duration and extubation failure. Evidence for clinical factors linked to extubation outcomes in children are limited. Endotracheal secretion burden is a common factor considered but has not been studied. This study supports a role for endotracheal secretion burden, as assessed by the bedside nurse, in extubation readiness bundles. Inter-rater reliability with respiratory therapists was poor. A model incorporating other key factors showed good discrimination for extubation outcome and sets the stage for prospective evaluation in the general population and diagnosis-specific subgroups.

A 30-Minute Spontaneous Breathing Trial Misses Many Children Who Go On to Fail a 120-Minute Spontaneous Breathing Trial

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.

Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document

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.

Pediatric Ventilation Liberation: A Survey of International Practice Among 555 Pediatric Intensivists

Pediatric ventilation liberation has limited evidence, likely resulting in wide practice variation. To inform future work, practice patterns must first be described.

Ventilation Liberation Practices Among 380 International PICUs

1) Characterize the prevalence of ventilator liberation protocol use in international PICUs, 2) identify the most commonly used protocol elements, and 3) estimate an international extubation failure rate and use of postextubation noninvasive respiratory support modes.

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

Objective Objective tools such as spontaneous breathing trials (SBT) aim to identify patients ready for extubation and shorten the length of mechanical ventilation (MV). Despite passing an SBT, patients sometimes are not extubated based on clinicians' subjective impressions. In this article, we explored the factors that influence the decision to extubate among pediatric intensivists and their association with objective criteria.

Design This is a single-center prospective observational study.

Setting This study was conducted in an academic, multidisciplinary 20-bed pediatric intensive care unit (PICU).

Patients The study group involves mechanically ventilated, orally intubated patients admitted to the PICU from January 1 to June 30, 2019.

Measurements and Main Results Objective clinical data were collected for 650 MV days. Attending surveys about extubation readiness were completed for 419 (64.5%) MV days and 63 extubation events. Extubation occurred on 42% of days after passing an SBT. The primary reasons patients who passed an SBT were not extubated on days were unresolved lung pathology (66.6%) and fluid overload (37.6%). On days without extubation, there was no association between a specific reason for not extubating and SBT result (p > 0.05).

Conclusions In this single-center study, the decision to extubate was not strongly associated with passing an SBT, indicating that clinician impressions, namely unresolved lung pathology and fluid overload, outweighed objective measures for determining extubation readiness. To mitigate morbidities and costs associated with unnecessarily prolonged intubations, a better-defined extubation readiness process is needed to guide the decision to extubate in the pediatric population.

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

OBJECTIVES

There is limited evidence on the impact of protocolized ventilator weaning in pediatric acute respiratory distress syndrome, despite utilization in clinical trials and clinical care. We aimed to determine whether protocolized ventilator weaning shortens mechanical ventilation duration and PICU length of stay in pediatric acute respiratory distress syndrome survivors.

DESIGN

Secondary analysis of a prospective pediatric acute respiratory distress syndrome (Berlin definition) cohort from July 2011 to June 2019 analyzed using interrupted time series analysis pre- and postimplementations of a ventilator-weaning pathway. We compared duration of invasive ventilation and PICU length of stay in survivors before and after implementation of a ventilator-weaning pathway. We excluded PICU nonsurvivors and subjects with greater than 100 ventilator days.

SETTING

Large academic tertiary-care PICU.

PATIENTS

Children with acute respiratory distress syndrome who survived to PICU discharge with less than or equal to 100 days of invasive mechanical ventilation.

INTERVENTIONS

Implementation of a ventilator-weaning pathway on May 2016.

MEASUREMENTS AND MAIN RESULTS

Of 723 children with acute respiratory distress syndrome, 132 subjects died and six subjects with ventilation greater than 100 days were excluded. Of the remaining 585 subjects, 375 subjects had acute respiratory distress syndrome prior to pathway intervention and 210 after. Patients in the preintervention epoch were younger, more likely to have infectious acute respiratory distress syndrome, and had increased use of alternative ventilator modes. Pathway adoption was rapid and sustained. Controlling for temporality, pathway implementation was associated with a decrease of a median 3.6 ventilator days (95% CI, -5.4 to -1.7; p < 0.001). There was no change in the reintubation rates. Results were robust to multiple sensitivity analyses adjusting for confounders.

CONCLUSIONS

Ventilator-weaning pathway implementation shortened invasive ventilation duration in pediatric acute respiratory distress syndrome survivors with no change in reintubation. The effect size of this intervention was comparable with those targeted in acute respiratory distress syndrome trials.

Progression of Respiratory Support Following Pediatric Extubation

OBJECTIVES

High-flow nasal cannula and noninvasive positive pressure ventilation have become ubiquitous in contemporary PICUs. Practice patterns associated with the use of these modalities have not been well described. In this study, we aimed to describe the use of high-flow nasal cannula and noninvasive positive pressure ventilation in children after extubation and analyze the progression of usage in association with patient factors. Our secondary aim was to describe interventions used for postextubation stridor.

DESIGN

Single-center retrospective cohort study.

SETTING

A 36-bed quaternary medical-surgical PICU.

PATIENTS

Mechanically ventilated pediatric patients admitted between April 2017 and March 2018. Exclusions were patients in the cardiac ICU, patients requiring a tracheostomy or chronic ventilatory support, and patients with limited resuscitation status.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data regarding respiratory modality use was collected for the first 72 hours after extubation. There were 427 patients included in the analysis; 51 patients (11.9%) were extubated to room air, 221 (51.8%) to nasal cannula, 132 (30.9%) to high-flow nasal cannula, and 23 (5.4%) to noninvasive positive pressure ventilation. By 72 hours, 314 patients (73.5%) were on room air, 52 (12.2%) on nasal cannula, 29 (6.8%) on high-flow nasal cannula, eight (1.9%) on noninvasive positive pressure ventilation, and 24 (5.6%) were reintubated. High-flow nasal cannula was the most used respiratory modality for postextubation stridor. Multivariate analysis demonstrated that longer duration of invasive mechanical ventilation increased the odds of initial high-flow nasal cannula and noninvasive positive pressure ventilation use, and a diagnosis of cerebral palsy increased the odds of escalating from high-flow nasal cannula to noninvasive positive pressure ventilation in the first 24 hours post extubation.

CONCLUSIONS

High-flow nasal cannula is commonly used immediately after pediatric extubation and the development of postextubation stridor; however, its usage sharply declines over the following 72 hours. Larger multicenter trials are needed to identify high-risk patients for extubation failure that might benefit the most from prophylactic use of high-flow nasal cannula and noninvasive positive pressure ventilation after extubation.