Ventilation Liberation Practices Among 380 International PICUs

Abstract

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.

Design: International cross-sectional study.

Subjects: Nontrainee pediatric medical and cardiac critical care physicians.

Setting: Electronic survey.

Intervention: None.

Measurements and main results: Responses represented 380 unique PICUs from 47 different countries. Protocols for Spontaneous Breathing Trial (SBT) practice (50%) and endotracheal tube cuff management (55.8%) were the only protocols used by greater than or equal to 50% of PICUs. Among PICUs screening for SBT eligibility, physicians were most commonly screened (62.7%) with daily frequency (64.2%). Among those with an SBT practice protocol, SBTs were most commonly performed by respiratory therapists/physiotherapists (49.2%) and least commonly by nurses (4.9%). Postextubation respiratory support protocols were not prevalent (28.7%). International practice variation was significant for most practices surveyed. The estimated median international extubation failure was 5% (interquartile range, 2.3-10%). A majority of respondents self-reported use of planned high-flow nasal cannula in less than or equal to 50% (84.2%) and planned noninvasive ventilation in less than or equal to 20% of extubations (81.6%).

Conclusions: Variability in international pediatric ventilation liberation practice is high, and prevalence of protocol implementation is generally low. There is a need to better understand elements that drive clinical outcomes and opportunity to work on standardizing pediatric ventilation liberation practices worldwide.

Keywords: clinical pathway; extubation; mechanical ventilation; pediatric intensive care unit; pediatrics; respiratory therapy.

Figure 1.

CONSORT diagram, describing survey responses and exclusions leading to final cohort of unique ICU responses. ¹High-risk duplicate response status was determined by comparing duplicate responses to all of the following: hospital name, hospital city, hospital country, length of clinical practice, percent clinical time, PICU type, and division chief/medical director status. For high-risk duplicate responses, the response with the fewest questions answered was excluded. Where both responses had the same number of questions answered, the second response was excluded. ²Where multiple responses existed from the same ICU, first preference was given to division chief/medical director responses. Where none existed, the response with the most questions answered was included. CONSORT = Consolidated Standards of Reporting Trials.

Figure 2.

Self-reported use of other (non-ERT) ICU liberation protocols. A, Other ICU liberation protocols for children requiring invasive mechanical ventilation. B, Cumulative concurrent ICU liberation protocols used in each ICU (Spontaneous Breathing Trial/extubation readiness test protocols excluded).

Figure 3.

ICU and ventilation liberation-relevant protocol prevalence stratified by region (if regional differences were statistically significant, the p value is reported). ETT = endotracheal tube, SBT = Spontaneous Breathing Trial, UAO = upper airway obstruction.