Clinical Challenges in Pediatric Ventilation Liberation: A Meta-Narrative Review

Jefta van Dijk, Robert G T Blokpoel, Samer Abu-Sultaneh, Christopher J L Newth, Robinder G Khemani, Martin C J Kneyber, Jefta van Dijk, Robert G T Blokpoel, Samer Abu-Sultaneh, Christopher J L Newth, Robinder G Khemani, Martin C J Kneyber

Abstract

Objectives: To map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards.

Data sources: CINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register.

Study selection: Abstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed.

Data extraction: None.

Data synthesis: Weaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient's respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation.

Conclusions: Current literature suggests using a structured approach that includes a daily assessment of patient's readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.

Trial registration: ClinicalTrials.gov NCT03266016.

Conflict of interest statement

Dr. Newth received funding from Philips Research North America. Dr. Khemani’s institution received funding from the National Heart, Lung, and Blood Institute (1RO11HL134666-01); he received funding from OrangeMed/Nihon Kohden; he received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

Figures

Figure 1.
Figure 1.
Knowns and unknowns in pediatric ventilation liberation. This figure graphically summarizes the disease trajectory of mechanically ventilated children. At some point, when their underlying disorder is resolving, patients meet predefined criteria for them to be assessed with a spontaneous breathing test (SBT), and if they pass this test according to specific criteria, they can be assessed for extubation readiness (extubation readiness testing [ERT]). Such as test takes other factors into account, including level of sedation, neurologic status, and other factors that might be predictive for failed extubation. Patients can then be extubated to postextubation nonrespiratory support (NRS) or no support. Most patients most likely do not need a weaning strategy, except for those who fail the SBT. In these patients, a certain weaning strategy might be indicated before they undergo another SBT. However, there are more unknowns than knowns when it comes to pediatric ventilation liberation, as outlined in the table. PS = pressure support.

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