Practice Guideline

. 2023 May;163(5):1130-1143.

doi: 10.1016/j.chest.2022.12.010. Epub 2022 Dec 20.

Operational Definitions Related to Pediatric Ventilator Liberation

Samer Abu-Sultaneh¹, Narayan Prabhu Iyer², Analía Fernández³, Michael Gaies⁴, Sebastián González-Dambrauskas⁵, Justin Christian Hotz⁶, Martin C J Kneyber⁷, Yolanda M López-Fernández⁸, Alexandre T Rotta⁹, David K Werho¹⁰, Arun Kumar Baranwal¹¹, Bronagh Blackwood¹², Hannah J Craven¹³, Martha A Q Curley¹⁴, Sandrine Essouri¹⁵, Jose Roberto Fioretto¹⁶, Silvia M M Hartmann¹⁷, Philippe Jouvet¹⁵, Steven Kwasi Korang¹⁸, Gerrard F Rafferty¹⁹, Padmanabhan Ramnarayan²⁰, Louise Rose²¹, Lyvonne N Tume²², Elizabeth C Whipple¹³, Judith Ju Ming Wong²³, Guillaume Emeriaud¹⁵, Christopher W Mastropietro²⁴, Natalie Napolitano²⁵, Christopher J L Newth²⁶, Robinder G Khemani²⁶; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

Affiliations

¹ Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN. Electronic address: sultaneh@iu.edu.
² 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.
³ Pediatric Critical Care Unit, Hospital General de Agudos "C. Durand" Ciudad Autónoma de Buenos Aires, Argentina.
⁴ Department of Pediatrics, Division of Pediatric Cardiology, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, OH.
⁵ Red Colaborativa Pediátrica de Latinoamérica (LARed Network) and Departamento de Pediatría Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.
⁶ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA.
⁷ Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
⁸ Department of Pediatrics, Pediatric Critical Care Division, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain.
⁹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC.
¹⁰ Division of Pediatric Cardiology, Cardiothoracic Intensive Care, UC San Diego, Rady Children's Hospital, San Diego, CA.
¹¹ Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
¹² Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom.
¹³ Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN.
¹⁴ Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA; Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA.
¹⁵ Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada.
¹⁶ Department of Pediatrics, Pediatric Critical Care Division, Botucatu Medical School-UNESP-São Paulo State University, Botucatu, SP, Brazil.
¹⁷ Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA.
¹⁸ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA; Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
¹⁹ Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences & Medicine, King's College London, London, England.
²⁰ Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England.
²¹ Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England.
²² Edge Hill University Health Research Institute, Ormskirk, England.
²³ KK Women's and Children's Hospital, Singapore.
²⁴ Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN.
²⁵ Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA.
²⁶ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA; Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA.

PMID: 36563873
PMCID: PMC10206507
DOI: 10.1016/j.chest.2022.12.010

Practice Guideline

Operational Definitions Related to Pediatric Ventilator Liberation

Samer Abu-Sultaneh et al. Chest. 2023 May.

. 2023 May;163(5):1130-1143.

doi: 10.1016/j.chest.2022.12.010. Epub 2022 Dec 20.

Authors

Affiliations

¹ Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN. Electronic address: sultaneh@iu.edu.
² 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.
³ Pediatric Critical Care Unit, Hospital General de Agudos "C. Durand" Ciudad Autónoma de Buenos Aires, Argentina.
⁴ Department of Pediatrics, Division of Pediatric Cardiology, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, OH.
⁵ Red Colaborativa Pediátrica de Latinoamérica (LARed Network) and Departamento de Pediatría Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.
⁶ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA.
⁷ Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
⁸ Department of Pediatrics, Pediatric Critical Care Division, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain.
⁹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC.
¹⁰ Division of Pediatric Cardiology, Cardiothoracic Intensive Care, UC San Diego, Rady Children's Hospital, San Diego, CA.
¹¹ Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
¹² Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom.
¹³ Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN.
¹⁴ Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA; Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA.
¹⁵ Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada.
¹⁶ Department of Pediatrics, Pediatric Critical Care Division, Botucatu Medical School-UNESP-São Paulo State University, Botucatu, SP, Brazil.
¹⁷ Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA.
¹⁸ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA; Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
¹⁹ Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences & Medicine, King's College London, London, England.
²⁰ Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England.
²¹ Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England.
²² Edge Hill University Health Research Institute, Ormskirk, England.
²³ KK Women's and Children's Hospital, Singapore.
²⁴ Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN.
²⁵ Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA.
²⁶ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA; Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA.

PMID: 36563873
PMCID: PMC10206507
DOI: 10.1016/j.chest.2022.12.010

Abstract

Background: Common, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices.

Research question: Can we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches?

Study design and methods: A panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions.

Results: In eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support.

Interpretation: We propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.

Keywords: airway extubation; extubation failure; high-flow nasal cannula; mechanical ventilation; noninvasive ventilation; pediatric ICU; ventilator weaning.

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Figures

**Figure 1**
Conceptual framework of pediatric ventilator liberation operational definitions. HFNC = high-flow nasal cannula; MV = mechanical ventilation; NIV = noninvasive ventilation; NPV = negative pressure ventilation; NRS = noninvasive respiratory support; VFDs-28 = 28 ventilator-free days.

**Figure 3**
Reported extubation failure time frame (n = 38).

See this image and copyright information in PMC

References

1. Newth C.J., Venkataraman S., Willson D.F., et al. Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med. 2009;10(1):1–11. - PMC - PubMed
1. Fan E., Zakhary B., Amaral A., et al. Liberation from mechanical ventilation in critically ill adults. An Official ATS/ACCP Clinical Practice Guideline. Ann Am Thorac Soc. 2017;14(3):441–443. - PubMed
1. Abu-Sultaneh S., Mastropietro C.W. In: Pediatric Critical Care. Mastropietro C., Valentine K., editors. Springer; 2019. Weaning and extubation readiness assessment in pediatric patients; pp. 43–62.
1. Newth C.J., Hotz J.C., Khemani R.G. Ventilator liberation in the pediatric ICU. Respir Care. 2020;65(10):1601–1610. - PMC - PubMed
1. Loberger J.M., Campbell C.M., Colleti J., Jr., Borasino S., Abu-Sultaneh S., Khemani R.G. Ventilation liberation practices among 380 international PICUs. Crit Care Explor. 2022;4(6) - PMC - PubMed

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Operational Definitions Related to Pediatric Ventilator Liberation

Affiliations

Operational Definitions Related to Pediatric Ventilator Liberation

Authors

Affiliations

Abstract

Figures

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources