Accuracy of an Extubation Readiness Test in Predicting Successful Extubation in Children With Acute Respiratory Failure From Lower Respiratory Tract Disease*

Abstract

OBJECTIVE Identifying children ready for extubation is desirable to minimize morbidity and mortality associated with prolonged mechanical ventilation and extubation failure. We determined the accuracy of an extubation readiness test (RESTORE ERT) in predicting successful extubation in children with acute respiratory failure from lower respiratory tract disease. DESIGN Secondary analysis of data from the RESTORE clinical trial, a pediatric multicenter cluster randomized trial of sedation. SETTING 17 pediatric intensive care units in the intervention arm. PATIENTS Children 2 weeks to 17 years receiving invasive mechanical ventilation for lower respiratory tract disease. INTERVENTION ERT in which spontaneously breathing children with oxygenation index ≤6 were placed on FiO2 of 0.50, positive end expiratory pressure of 5 cm H2O, and pressure support. MEASUREMENTS AND MAIN RESULTS Of 1,042 children, 444 (43%) passed their first ERT. Of these, 295 (66%) were extubated within 10 hours of starting the ERT, including 272 who were successfully extubated, for a positive predictive value of 92%. Among 861 children who were extubated for the first time within 10 hours of performing an ERT, 788 passed their ERT and 736 were successfully extubated for a positive predictive value of 93%. The median time of day for extubation with an ERT was 12:15H compared with 14:54H for extubation without an ERT within 10 hours (p<0.001). CONCLUSIONS In children with acute respiratory failure from lower respiratory tract disease, an ERT, as described, should be considered at least daily if the oxygenation index is ≤6. If the child passes the ERT, there is a high likelihood of successful extubation.

Challenges With Implementation of a Respiratory Therapist–Driven Protocol of Spontaneous Breathing Trials in the Pediatric ICU

“…These studies used similar screening criteria, but a recent secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial used a simplified nursingdriven protocol to screen for spontaneous breathing and an oxygenation index or oxygenation saturation index of Յ 6. 9 While these studies are useful and do suggest that protocols using extubation readiness testing or weaning reduce the duration of mechanical ventilation, 9,10 there is a lack of consensus on the best approach. More studies evaluating RT-driven protocols to provide early identification of pediatric patients eligible for ventilator liberation are necessary.…”

“…The odds of being placed on any form of noninvasive respiratory support at 1 h postextubation were higher in the intervention group ( 9.27], P ϭ .14) ( Table 3). Table 4 summarizes adherence to the protocol.…”

“…11,16 While controversial, when compared to previous studies performed on this topic, adjustment of pressure support by ETT size was the most utilized. [9][10][11] …”

“…This process consisted of multiple drafts and revisions and incorporated various clinical parameters and screening criteria based on an extensive literature review of adult and pediatric ventilator weaning strategies. 6,7,[9][10][11]14,15 We ensured that the RT would have the ability to objectively measure a patient's clinical stability, oxygenation, ventilation, and mental status prior to initiation of an SBT. The pediatric sedation score of the patient was taken into account; if the score was noted to be Ͼ3, the patient was not consistently breathing above the ventilator and thus was deemed not appropriate for SBT.…”

“…8 This is especially important because it was recently suggested that pediatric patients who pass a daily extubation readiness screening have a higher likelihood of successful extubation. 9 Most studies on pediatric ventilator weaning compare protocol versus usual care with the physician primarily performing the screening. 1,[10][11][12] While the largest study to date showed a significant decrease in duration of mechanical ventilation, the study also implies that pediatric critical care physicians continue to take an active role in assessing recovering patients and determining readiness to wean.…”