Practice Guideline

. 2024 Nov;166(5):1056-1070.

doi: 10.1016/j.chest.2024.05.012. Epub 2024 Jun 7.

Framework for Research Gaps in Pediatric Ventilator Liberation

Collaborators, Affiliations

Collaborators

Samer Abu-Sultaneh¹⁰, Arun Kumar Baranwal¹¹, Bronagh Blackwood¹², Hannah J Craven¹³, Martha A Q Curley¹⁴, Guillaume Emeriaud⁷, Sandrine Essouri⁷, Analía Fernández³, Jose Roberto Fioretto¹⁵, Michael Gaies¹⁶, Sebastián González-Dambrauskas¹⁷, Silvia M M Hartmann¹⁸, Justin Christian Hotz¹⁹, Narayan Prabhu Iyer²⁰, Philippe Jouvet⁷, Martin C J Kneyber⁵, Steven Kwasi Korang²¹, Yolanda M López-Fernández⁶, Christopher W Mastropietro¹⁰, Natalie Napolitano²², Christopher J L Newth⁹, Gerrard F Rafferty²³, Padmanabhan Ramnarayan⁸, Louise Rose²⁴, Alexandre T Rotta²⁵, Lyvonne N Tume⁴, David K Werho²⁶, Elizabeth C Whipple¹³, Judith Ju Ming Wong²⁷, Robinder G Khemani²⁸

Affiliations

¹ Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health and 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 Division of Critical Care Medicine, Hospital General de Agudos "C. Durand," Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
⁴ Edge Hill University Health Research Institute, Ormskirk, England.
⁵ Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
⁶ Pediatric Critical Care Division, Department of Pediatrics, Cruces University Hospital, BioBizkaia Health Research Institute, Bizkaia, Spain.
⁷ Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada.
⁸ Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England.
⁹ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA.
¹⁰ Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine Indianapolis, IN.
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.
¹³ Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN.
¹⁴ Family and Community Health, University of Pennsylvania School of Nursing, and Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA.
¹⁵ Department of Pediatrics, Pediatric Critical Care Division, Botucatu Medical School-UNESP-São Paulo State University, Botucatu, São Paulo, Brazil.
¹⁶ Division of Pediatric Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, OH.
¹⁷ Red Colaborativa Pediátrica de Latinoamérica [LARed Network] and Departamento de Pediatría Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell (UCIN-CHPR), Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.
¹⁸ Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA.
¹⁹ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA.
²⁰ Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA.
²¹ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA, and Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
²² Children's Hospital of Philadelphia, Philadelphia, PA.
²³ Centre for Human and Applied Physiological Sciences [CHAPS], Faculty of Life Sciences & Medicine, King's College London, London, England.
²⁴ Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England.
²⁵ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC.
²⁶ Division of Pediatric Cardiology, Cardiothoracic Intensive Care, UC San Diego, Rady Children's Hospital, San Diego, CA.
²⁷ KK Women's and Children's Hospital, Singapore, Republic of Singapore.
²⁸ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California and Keck School of Medicine, Los Angeles, CA.

PMID: 38852880
PMCID: PMC11562655 (available on 2025-11-01)
DOI: 10.1016/j.chest.2024.05.012

Practice Guideline

Framework for Research Gaps in Pediatric Ventilator Liberation

Samer Abu-Sultaneh et al. Chest. 2024 Nov.

. 2024 Nov;166(5):1056-1070.

doi: 10.1016/j.chest.2024.05.012. Epub 2024 Jun 7.

Collaborators

Samer Abu-Sultaneh¹⁰, Arun Kumar Baranwal¹¹, Bronagh Blackwood¹², Hannah J Craven¹³, Martha A Q Curley¹⁴, Guillaume Emeriaud⁷, Sandrine Essouri⁷, Analía Fernández³, Jose Roberto Fioretto¹⁵, Michael Gaies¹⁶, Sebastián González-Dambrauskas¹⁷, Silvia M M Hartmann¹⁸, Justin Christian Hotz¹⁹, Narayan Prabhu Iyer²⁰, Philippe Jouvet⁷, Martin C J Kneyber⁵, Steven Kwasi Korang²¹, Yolanda M López-Fernández⁶, Christopher W Mastropietro¹⁰, Natalie Napolitano²², Christopher J L Newth⁹, Gerrard F Rafferty²³, Padmanabhan Ramnarayan⁸, Louise Rose²⁴, Alexandre T Rotta²⁵, Lyvonne N Tume⁴, David K Werho²⁶, Elizabeth C Whipple¹³, Judith Ju Ming Wong²⁷, Robinder G Khemani²⁸

Affiliations

¹ Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health and 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 Division of Critical Care Medicine, Hospital General de Agudos "C. Durand," Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
⁴ Edge Hill University Health Research Institute, Ormskirk, England.
⁵ Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
⁶ Pediatric Critical Care Division, Department of Pediatrics, Cruces University Hospital, BioBizkaia Health Research Institute, Bizkaia, Spain.
⁷ Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada.
⁸ Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England.
⁹ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA.
¹⁰ Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine Indianapolis, IN.
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.
¹³ Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN.
¹⁴ Family and Community Health, University of Pennsylvania School of Nursing, and Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA.
¹⁵ Department of Pediatrics, Pediatric Critical Care Division, Botucatu Medical School-UNESP-São Paulo State University, Botucatu, São Paulo, Brazil.
¹⁶ Division of Pediatric Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, OH.
¹⁷ Red Colaborativa Pediátrica de Latinoamérica [LARed Network] and Departamento de Pediatría Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell (UCIN-CHPR), Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.
¹⁸ Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA.
¹⁹ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA.
²⁰ Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA.
²¹ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, CA, and Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
²² Children's Hospital of Philadelphia, Philadelphia, PA.
²³ Centre for Human and Applied Physiological Sciences [CHAPS], Faculty of Life Sciences & Medicine, King's College London, London, England.
²⁴ Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England.
²⁵ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC.
²⁶ Division of Pediatric Cardiology, Cardiothoracic Intensive Care, UC San Diego, Rady Children's Hospital, San Diego, CA.
²⁷ KK Women's and Children's Hospital, Singapore, Republic of Singapore.
²⁸ Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California and Keck School of Medicine, Los Angeles, CA.

PMID: 38852880
PMCID: PMC11562655 (available on 2025-11-01)
DOI: 10.1016/j.chest.2024.05.012

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.

Keywords: airway extubation; clinical protocols; mechanical ventilators; pediatric ICUs; ventilator weaning.

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Conflict of interest statement

Financial/Nonfinancial Disclosures None declared.

References

1. Abu-Sultaneh S., Iyer N.P., Fernandez A., et al. Executive summary: international clinical practice guidelines for pediatric ventilator liberation, a Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network document. Am J Respir Crit Care Med. 2023;207(1):17–28. - PMC - PubMed
1. Iyer N.P., Lopez-Fernandez Y.M., Gonzalez-Dambrauskas S., et al. A network meta-analysis of dexamethasone for preventing postextubation upper airway obstruction in children. Ann Am Thorac Soc. 2023;20(1):118–130. - PMC - PubMed
1. Abu-Sultaneh S., Iyer N.P., Fernandez A., et al. Operational definitions related to pediatric ventilator liberation. Chest. 2023;163(5):1130–1143. - PMC - PubMed
1. Iyer N.P., Rotta A.T., Essouri S., et al. Association of extubation failure rates with high-flow nasal cannula, continuous positive airway pressure, and bilevel positive airway pressure vs conventional oxygen therapy in infants and young children: a systematic review and network meta-analysis. JAMA Pediatr. 2023;177(8):774–781. - PMC - PubMed
1. Boles J.M., Bion J., Connors A., et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033–1056. - PubMed

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Framework for Research Gaps in Pediatric Ventilator Liberation

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Framework for Research Gaps in Pediatric Ventilator Liberation

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Conflict of interest statement

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