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van der Heijden JEM, de Hoop-Sommen M, Hoevenaars N, Freriksen JJM, Joosten K, Greupink R, de Wildt SN. Getting the dose right using physiologically-based pharmacokinetic modeling: dexamethasone to prevent post-extubation stridor in children as proof of concept. Front Pediatr 2024; 12:1416440. [PMID: 39035463 PMCID: PMC11257885 DOI: 10.3389/fped.2024.1416440] [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: 04/12/2024] [Accepted: 06/11/2024] [Indexed: 07/23/2024] Open
Abstract
Introduction Critically ill patients show large variability in drug disposition due to e.g., age, size, disease and treatment modalities. Physiologically-based pharmacokinetic (PBPK) models can be used to design individualized dosing regimens taking this into account. Dexamethasone, prescribed for the prevention post-extubation stridor (PES), is metabolized by the drug metabolizing enzyme CYP3A. As CYP3A4 undergoes major changes during childhood, we aimed to develop age-appropriate dosing recommendations for children of dexamethasone for PES, as proof of concept for PBPK modeling to individualize dosing for critically ill patients. Methods All simulations were conducted in Simcyp™ v21 (a population-based PBPK modeling platform), using an available dexamethasone compound model and pediatric population model in which CYP3A4 ontogeny is incorporated. Published pharmacokinetic (PK) data was used for model verification. Evidence for the dose to prevent post-extubation stridor was strongest for 2-6 year old children, hence simulated drug concentrations resulting from this dose from this age group were targeted when simulating age-appropriate doses for the whole pediatric age range. Results Dexamethasone plasma concentrations upon single and multiple intravenous administration were predicted adequately across the pediatric age range. Exposure-matched predictions of dexamethasone PK indicated that doses (in mg/kg) for the 2-6 years olds can be applied in 3 month-2 year old children, whereas lower doses are needed in children of other age groups (60% lower for 0-2 weeks, 40% lower for 2-4 weeks, 20% lower for 1-3 months, 20% lower for 6-12 year olds, 40% lower for 12-18 years olds). Discussion We show that PBPK modeling is a valuable tool that can be used to develop model-informed recommendations using dexamethasone to prevent PES in children. Based on exposure matching, the dose of dexamethasone should be reduced compared to commonly used doses, in infants <3 months and children ≥6 years, reflecting age-related variation in drug disposition. PBPK modeling is an promising tool to optimize dosing of critically ill patients.
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Affiliation(s)
- Joyce E. M. van der Heijden
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marika de Hoop-Sommen
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noa Hoevenaars
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jolien J. M. Freriksen
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Koen Joosten
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Rick Greupink
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia N. de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
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Loberger JM, Steffen K, Khemani RG, Nishisaki A, Abu-Sultaneh S. Implementing the Pediatric Ventilator Liberation Guidelines Using the Most Current Evidence. Respir Care 2024; 69:869-880. [PMID: 38346842 DOI: 10.4187/respcare.11708] [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: 04/18/2024]
Abstract
Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation varies widely. As a first step to minimizing that variation, the first evidence-based pediatric ventilator liberation guidelines were published in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay before clinical guidelines reach widespread clinical practice. As such, it is important to consider barriers and facilitators using a systematic approach during implementation planning and design. In this narrative review, we will (1) summarize guideline recommendations, (2) discuss recent evidence and identify practice gaps relating to those recommendations, and (3) hypothesize about potential barriers and facilitators to their implementation in clinical practice.
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Affiliation(s)
- Jeremy M Loberger
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Katherine Steffen
- Steffen is affiliated with Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University, Palo Alto, California
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, Los Angeles, California
| | - Akira Nishisaki
- Nishisaki is affiliated with Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samer Abu-Sultaneh
- Abu-Sultaneh is affiliated with Department of Pediatrics, Division of Pediatric Critical Care Medicine, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
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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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Al-Sofyani KA. Predictors and outcomes of extubation failures in a pediatric intensive care unit: A retrospective study. J Taibah Univ Med Sci 2024; 19:516-523. [PMID: 39026556 PMCID: PMC11255959 DOI: 10.1016/j.jtumed.2024.03.005] [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: 11/05/2023] [Revised: 01/22/2024] [Accepted: 03/12/2024] [Indexed: 07/20/2024] Open
Abstract
Objectives This study was aimed at determining the extubation failure (EF) rate in a pediatric intensive care unit (PICU), and assessing the etiology, associated risk factors, and outcomes. Methods We conducted a retrospective study on 335 pediatric patients admitted to King Abdulaziz University Hospital between 2018 and 2020, ranging in age from 1 month to 14 years, who required invasive mechanical ventilation (MV) for >24 h. Extubation readiness was determined by the attending pediatric intensive care physician, according to the patients' clinical status and extubation readiness criteria. Results In the cohort of 335 patients, 42 experienced issues during extubation (failure rate, 12.5%). Cardiovascular disease (42.9%) was the main primary admission condition in patients with EF. Younger age (median, interquartile range [IQR]: 4, 1.38-36 months) was strongly associated with EF compared with successful extubation (median, IQR: 12, 2-48; p = 0.036), and with a high predicted mortality rate (10.9%; p < 0.001) and Pediatric Risk of Mortality III (PRISM) score (13; p < 0.001). Furthermore, prolonged ICU stay (25.5 days; p < 0.001) and longer MV requirements (4 days; p < 0.001) before extubation in patients with EF were associated with a high mortality rate (∼12%; p < 0.001). Interestingly, dexamethasone administration before extubation significantly alleviated EF risk (28.3%; p < 0.001). Conclusion A higher EF rate in younger patients may potentially be associated with longer ICU stays, prolonged MV requirements before extubation, and the primary diagnostic condition. Dexamethasone effectively alleviated EF incidence. Further research with a rigorous evidence-based study design is necessary to substantiate the factors identified as predictors of EF and to develop strategies to avoid EF.
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Affiliation(s)
- Khouloud A. Al-Sofyani
- Department of Pediatric, Pediatric Critical Care Unit, Faculty of Medicine, King Abdulaziz University, Jeddah, KSA
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Burton L, Loberger J, Baker M, Prabhakaran P, Bhargava V. Pre-Extubation Ultrasound Measurement of In Situ Cuffed Endotracheal Tube Laryngeal Air Column Width Difference: Single-Center Pilot Study of Relationship With Post-Extubation Stridor in Subjects Younger Than 5 Years Old. Pediatr Crit Care Med 2024; 25:222-230. [PMID: 37846938 DOI: 10.1097/pcc.0000000000003377] [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] [Indexed: 10/18/2023]
Abstract
OBJECTIVES Post-extubation stridor (PES) is difficult to predict before extubation. We therefore evaluated the potential diagnostic performance of pre-extubation laryngeal air column width difference (LACWD) measurement, as assessed by intensivist-performed point-of-care laryngeal ultrasound, in relation to clinically important PES. DESIGN Prospective observational cohort study. SETTING Single quaternary care PICU (July 19, 2021, to October 31, 2022). PATIENTS Included subjects were younger than 5 years old, intubated with a cuffed endotracheal tube, requiring invasive mechanical ventilation for greater than 24 hours, and nearing extubation. Subjects at high risk for supraglottic airway obstruction were excluded. INTERVENTIONS Laryngeal ultrasound with measurement of laryngeal air column width with the endotracheal tube cuff inflated and deflated. Clinically important PES was defined as a high-pitched inspiratory respiratory noise suspected to be from a subglottic focus necessitating received medical intervention or reintubation. MEASUREMENTS AND MAIN RESULTS Among 53 enrolled subjects, 18 of 53 (34%) experienced PES and three of 53 (6%) were reintubated because of severe subglottic upper airway obstruction. Median LACWD was significantly lower in the stridor group compared with the nonstridor group (∆ 0.41 mm; 95% CI, 0.37-0.48; p < 0.001). The area under the receiver operating characteristic curve for LACWD as a diagnosis of PES was 0.94 (95% CI, 0.89-1.00; p < 0.001). The LACWD cutoff for PES was less than or equal to 0.47 mm, which yielded a diagnostic sensitivity of 91.4% and specificity of 88.9%. In this population, the pre-to-post-test change in probability of PES for LACWD less than or equal to 0.47 mm is 0.34 to 0.81. CONCLUSIONS Pre-extubation LACWD is a novel, noninvasive assessment that can be performed and interpreted by the intensivist at the bedside. There is, however, diagnostic uncertainty in the use of this measurement for identifying those at-risk of PES and larger validation studies are needed.
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Affiliation(s)
- Luke Burton
- Department of Pediatrics, Division of Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Jeremy Loberger
- Department of Pediatrics, Division of Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Mark Baker
- Department of Pediatrics, Division of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Priya Prabhakaran
- Department of Pediatrics, Division of Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Vidit Bhargava
- Department of Pediatrics, Division of Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
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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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Wilson KC. Clinical Practice Guideline Methodology: An Evolving Science. Am J Respir Crit Care Med 2023; 207:1-2. [PMID: 36067508 PMCID: PMC9952859 DOI: 10.1164/rccm.202209-1646ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Kevin C. Wilson
- Department of MedicineBoston University School of MedicineBoston, Massachusetts
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