Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2025 Apr 1;26(4):e423-e431.
doi: 10.1097/PCC.0000000000003685. Epub 2025 Jan 23.

Sedation and Ventilator Weaning Bundle and Time to Extubation in Infants With Bronchiolitis: Secondary Analysis of the Sedation AND Weaning in Children (SANDWICH) Trial

Rebecca B Mitting  1   2 , Cliona McDowell  3 , Bronagh Blackwood  3 , Samiran Ray  4   5
Affiliations
Randomized Controlled Trial

Sedation and Ventilator Weaning Bundle and Time to Extubation in Infants With Bronchiolitis: Secondary Analysis of the Sedation AND Weaning in Children (SANDWICH) Trial

Rebecca B Mitting et al. Pediatr Crit Care Med. .

Abstract

Objective: The Sedation and Weaning in Children (SANDWICH) trial of a sedation weaning and ventilator liberation bundle had a primary outcome of time to successful extubation, and showed significant but small difference. We explored the impact of the intervention on infants with bronchiolitis.

Design: Post hoc subgroup analysis of a cluster-randomized trial, 2018 to 2019 (ISRCTN16998143).

Patients: Surviving patients with bronchiolitis under 1 year of age in the SANDWICH trial ( n = 784).

Interventions: Nil.

Measurements and main results: Time to successful extubation, and rates of unplanned and failed extubation were compared in patients exposed and not exposed to the intervention. To explore a site-level effect, we tested the correlation between the rate of unplanned and failed extubation at each trial site with the median time to successful extubation at that site. Of 784 patients (48%), 376 were exposed to the intervention. Median (interquartile range [IQR]) time to successful extubation was 69.6 (IQR 50.4-110.4) hours in patients exposed to the intervention and 86.4 (IQR 60-124.8) hours in non-exposed. Exposure to the SANDWICH intervention was associated with a 13% (95% CI, 1%-26%) reduction in time to extubation following adjustment for confounders. Thirty (3.8%) patients experienced unplanned extubation and 112 (14%) failed extubation. Patients who experienced failed extubation had an increased time to successful extubation, which remained significant after adjustment for confounders. At the site level, there was a negative correlation between failed extubation rate and median time to successful extubation (Spearman rho -0.53 [95% CI, -0.8 to -0.08], p = 0.02).

Conclusions: In a secondary analysis of the SANDWICH trial, the subgroup of bronchiolitis patients showed that exposure to the intervention was associated with a clinically significant reduction in time to successful extubation. Although failed extubation was associated with increased duration of ventilation in an individual, sites with higher rates of failed extubation had a lower median duration of ventilation.

Keywords: accidental extubation; bronchiolitis; failed extubation; sedation; ventilation; weaning.

PubMed Disclaimer

Conflict of interest statement

Dr. Blackwood’s institution received funding from the National Institutes of Health. Dr. Ray’s institution received funding from the National Institute of Health Research (NIHR) Great Ormond Street Hospital Biomedical Research Centre, the U.K. NIHR, the Engineering and Physical Sciences Research Council, and La Roche Ltd. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Consolidated Standards of Reporting Trials diagram for inclusion into the post hoc analysis. SANDWICH = Secondary Analysis of the Sedation and Weaning in Children.
Figure 2.
Figure 2.
Frequency of reintubation at a site in comparison with median time to extubation at that site. The number next to the point reflects the volume of cases at the site (sites with < 5 patients not included).
See this image and copyright information in PMC

References

    1. Blackwood B, Tume LN, Morris KP, et al. ; SANDWICH Collaborators: Effect of a sedation and ventilator liberation protocol vs usual care on duration of invasive IMV in pediatric intensive care units: A randomized clinical trial. JAMA. 2021; 326:401–410 - PMC - PubMed
    1. Miranda M, Ray S, Boot E, et al. : Variation in early pediatric intensive care management strategies and duration of invasive IMV for acute viral bronchiolitis in the United Kingdom: A retrospective multicenter cohort study. Pediatr Crit Care Med. 2023; 24:1010–1021 - PubMed
    1. Gill PJ, Thavam T, Anwar MR, et al. ; Ontario Pediatric Hospital Care Study Group (OPHCSG) and the Canadian Paediatric Inpatient Research Network (PIRN): Prevalence, cost, and variation in cost of pediatric hospitalizations in Ontario, Canada. JAMA Netw Open. 2022; 5:e2147447. - PMC - PubMed
    1. De Luca D, Pezza L, Vivalda L, et al. : Critical care of severe bronchiolitis during shortage of ICU resources. EClin Med. 2024; 69:102450 - PMC - PubMed
    1. Bechini A, Salvati C, Bonito B, et al. : Costs and healthcare utilisation due to respiratory syncytial virus disease in paediatric patients in Italy: A systematic review. Public Health. 2024; 227:103–111 - PubMed

Publication types

Substances

LinkOut - more resources