Implementing the Pediatric Ventilator Liberation Guidelines Using the Most Current Evidence

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.

Keywords: airway extubation; airway obstruction; artificial respiration; clinical pathways; mechanical ventilation; noninvasive ventilation; pediatric ICUs; pediatrics.

Fig. 1.

Conceptualization of the ventilator liberation process according to guideline recommendations starting with intubation through recognition of weaning readiness (diagnostic triggering), deployment of the extubation readiness test bundle, and concluding with ventilator/respiratory support liberation. ERT = extubation readiness test; ETT = endotracheal tube; UAO = upper-airway obstruction; SBT = spontaneous breathing trial; PS = pressure support; P_Imax = maximal inspiratory pressure; HFNC = high-flow nasal cannula; BPAP = bi-level positive airway pressure.