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

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Abstract

Rationale

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.

Methods

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.

Conclusions

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

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Author and article information

Contributors

Robinder G. Khemani:

ORCID: https://orcid.org/0000-0002-5815-0314

On behalf of : on behalf of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

Journal

Journal ID (nlm-ta): Am J Respir Crit Care Med

Journal ID (iso-abbrev): Am J Respir Crit Care Med

Journal ID (publisher-id): ajrccm

Title: American Journal of Respiratory and Critical Care Medicine

Publisher: American Thoracic Society

ISSN (Print): 1073-449X

ISSN (Electronic): 1535-4970

Publication date (Electronic, pub): 15 August 2022

Publication date Collection: 1 January 2023

Publication date PMC-release: 1 January 2024

Volume: 207

Issue: 1

Pages: 17-28

Affiliations

[ 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 .