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      Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document

      1 , 2 , , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 18 , 8 , 21 , 22 , 23 , 24 , 25 , 15 , 26 , 18 , 1 , 2 , 27 , 4 , 8 , 4 , 8
      American Journal of Respiratory and Critical Care Medicine
      American Thoracic Society
      airway extubation, clinical protocols, mechanical ventilators, pediatric intensive care units, ventilator weaning

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          Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients’ readiness for extubation.


          Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of ⩾80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations.

          Measurements and Main Results

          Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence.


          This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.

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          Most cited references88

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          RoB 2: a revised tool for assessing risk of bias in randomised trials

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            ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions

            Non-randomised studies of the effects of interventions are critical to many areas of healthcare evaluation, but their results may be biased. It is therefore important to understand and appraise their strengths and weaknesses. We developed ROBINS-I (“Risk Of Bias In Non-randomised Studies - of Interventions”), a new tool for evaluating risk of bias in estimates of the comparative effectiveness (harm or benefit) of interventions from studies that did not use randomisation to allocate units (individuals or clusters of individuals) to comparison groups. The tool will be particularly useful to those undertaking systematic reviews that include non-randomised studies.
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              GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables.

              This article is the first of a series providing guidance for use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of rating quality of evidence and grading strength of recommendations in systematic reviews, health technology assessments (HTAs), and clinical practice guidelines addressing alternative management options. The GRADE process begins with asking an explicit question, including specification of all important outcomes. After the evidence is collected and summarized, GRADE provides explicit criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations are characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of the alternative management options. GRADE suggests summarizing evidence in succinct, transparent, and informative summary of findings tables that show the quality of evidence and the magnitude of relative and absolute effects for each important outcome and/or as evidence profiles that provide, in addition, detailed information about the reason for the quality of evidence rating. Subsequent articles in this series will address GRADE's approach to formulating questions, assessing quality of evidence, and developing recommendations. Copyright © 2011 Elsevier Inc. All rights reserved.

                Author and article information

                On behalf of : on behalf of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
                Am J Respir Crit Care Med
                Am J Respir Crit Care Med
                American Journal of Respiratory and Critical Care Medicine
                American Thoracic Society
                15 August 2022
                1 January 2023
                1 January 2024
                : 207
                : 1
                : 17-28
                [ 1 ]Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana;
                [ 2 ]Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana;
                [ 3 ]Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California;
                [ 4 ]Keck School of Medicine, University of Southern California, Los Angeles, California;
                [ 5 ]Pediatric Critical Care Unit, Acute Care General Hospital “Carlos G. Durand,” Buenos Aires, Argentina;
                [ 6 ]Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio;
                [ 7 ]Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Facultad de Medicina, Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay;
                [ 8 ]Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California;
                [ 9 ]Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands;
                [ 10 ]Department of Pediatrics, Biocruces-Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain;
                [ 11 ]Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, North Carolina;
                [ 12 ]Division of Pediatric Cardiology, Cardiothoracic Intensive Care, Rady Children’s Hospital, University of California, San Diego, San Diego, California;
                [ 13 ]Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India;
                [ 14 ]Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom;
                [ 15 ]Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana;
                [ 16 ]Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania;
                [ 17 ]Research Institute, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;
                [ 18 ]Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada;
                [ 19 ]Pediatric Critical Care Division, Department of Pediatrics, Botucatu Medical School, Sao Paulo State University, Botucatu, Sao Paulo, Brazil;
                [ 20 ]Division of Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington;
                [ 21 ]Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;
                [ 22 ]Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences & Medicine, and
                [ 23 ]Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom;
                [ 24 ]Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London United Kingdom;
                [ 25 ]Edge Hill University Health Research Institute, Ormskirk, England;
                [ 26 ]KK Women’s and Children’s Hospital, Singapore, Singapore; and
                [ 27 ]Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
                Author notes
                Correspondence and requests for reprints should be addressed to Samer Abu-Sultaneh, M.D., F.A.A.P., F.C.C.M., Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Riley Phase 2 Room 4900, Indianapolis, IN 46202-5225. E-mail: sultaneh@ 123456iu.edu .
                Author information
                Copyright © 2023 by the American Thoracic Society

                This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0. For commercial usage and reprints, please e-mail Diane Gern ( dgern@ 123456thoracic.org ).

                : 25 April 2022
                : 12 August 2022
                Page count
                Figures: 2, Tables: 5, References: 91, Pages: 12
                Funded by: Eunice Kennedy Shriver National Institute of Child Health and Human Development, doi 10.13039/100009633;
                Funded by: National Heart, Lung, and Blood Institute, doi 10.13039/100009633;
                Award ID: R13HD102137
                Funded by: Department of Pediatrics at the Indiana University, doi 10.13039/100009633;
                Funded by: School of Medicine
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                airway extubation,clinical protocols,mechanical ventilators,pediatric intensive care units,ventilator weaning


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