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

Abstract

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

Objectives: Describe international pediatric ventilation liberation practices and regional practice variation.

Design setting and participants: International cross-sectional electronic survey. Nontrainee pediatric medical and cardiac critical care physicians.

Main outcomes and measures: Practices focusing on spontaneous breathing trial (SBT) eligibility, SBT practice, non-SBT extubation readiness bundle elements, and post-extubation respiratory support.

Results: Five-hundred fifty-five responses representing 47 countries were analyzed. Most respondents reported weaning followed by an SBT (86.4%). The top SBT eligibility variables reported were positive end-expiratory pressure (95%), Fio₂ (93.4%), and peak inspiratory pressure (73.9%). Most reported use of standardized pressure support regardless of endotracheal tube size (40.4%) with +10 cm H₂O predominating (38.6%). SBT durations included less than or equal to 30 minutes (34.8%), 31 minutes to 1 hour (39.3%), and greater than 1 hours (26%). In assigning an SBT result, top variables were respiratory rate (94%), oxygen saturation (89.3%), and subjective work of breathing (79.8%). Most reported frequent consideration of endotracheal secretion burden (81.3%), standardized pain/sedation measurement (72.8%), fluid balance (83%), and the endotracheal air leak test as a part of extubation readiness bundles. Most reported using planned high flow nasal cannula in less than or equal to 50% of extubations (83.2%). Top subpopulations supported with planned HFNC were those with chronic lung disease (67.3%), exposed to invasive ventilation greater than 14 days (66.6%), and chronic critical illness (44.9%). Most reported using planned noninvasive ventilation (NIV) following less than or equal to 20% of extubations (79.9%). Top subpopulations supported with planned NIV were those with neuromuscular disease (72.8%), chronic lung disease (66.7%), and chronic NIV use for any reason (61.6%). Regional variation was high for most practices studied.

Conclusion and relevance: International pediatric ventilation liberation practices are heterogeneous. Future study is needed to address key evidence gaps. Many practice differences were associated with respondent region, which must be considered in international study design.

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

Figure 1.

Self-reported use of selected criteria for spontaneous trial eligibility: A, Frequency each variable was selected by respondents; B, specific cut-off values self-reported by respondents (note: threshold values are reported within each bar alongside percent responses. Only respondents that selected a given variable were asked to indicate a specific cut-off value. Respondents were not forced to provide a specific cut-off value). Total responses are reported below the column label for each variable.

Figure 2.

Self-reported use of selected criteria for spontaneous trial pass or fail: A, Frequency each variable was selected by respondents; B, specific cut-off values self-reported by respondents (note: threshold values are reported within each bar alongside percent responses. Only respondents that selected a given variable were asked to indicate a specific cut-off value. Respondents were not forced to provide a specific cut-off value). Total responses are reported below the column label for each variable. Etco₂ = end-tidal carbon dioxide (EtCO₂).

Figure 3.

Heat map depicting selected components of extubation readiness testing and responses regarding inclusion in personal practice. ^aIncluding only respondents who reported managing cuffed and uncuffed endotracheal tubes the same. ^bIncluding only respondents who reported different management based on endotracheal tube type. IQR = interquartile range.

Figure 4.

Self-reported practice patterns regarding subpopulations most likely to receive planned postextubation support with high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), or neither modality. Respondents were asked to select all subpopulations for which they are most likely to routinely support with HFNC or NIV separately. Where a single respondent did not select either for a given population, most likely extubation to room air or supplemental oxygen was presumed. Axis represents percentage selected by respondents.