Weaning Children from Mechanical ventilation: A Prospective Randomized Trial of Protocol-Directed versus Physician-Directed Weaning

Abstract

Objective

Compare outcomes between physician-directed and protocol-directed weaning from mechanical ventilation in pediatric patients.

Design

Prospective-randomized.

Setting

Pediatric and cardiac intensive care units in a 307-bed tertiary referral hospital for children.

Interventions

The control group (physician-directed) was weaned according to individual physician order for reduc-tion in minute ventilation, positive end-expiratory pressure, and ordered oxygen saturation parameters for reduction in fraction of inspired oxygen (F10). The study group (protocol-directed) was weaned according to a predetermined algorithm developed for the purpose of this investigation.

Methods

The study enrolled 223 patients (116 physician-directed, 107 protocol-directed). All patients were mon-itored for hemodynamics, ventilator parameters, arterial blood gas values when available, oxygen saturation, weaning time, pre-weaning time, extubation time, and time on Fro, ≥ 0.40. We also moni-tored the incidence of reintubation, subglottic stenosis, tracheitis, and pneumonia. The protocol-directed group had additional measurements of actual versus predicted minute volume, comparisons of respi-ratory rate (actual versus predicted for age), and presence of spontaneous breathing effort for 10 consecutive minutes. Data analysis was done according to intent to treat.

Results

There was no significant difference in 12-hour and 24-hour pediatric risk of mortality (PRISM III) scores between groups. The protocol-directed group overall had shorter total ventilation time, weaning time, pre-weaning time, time to extubation, and time on F10, > 0.40, although after stratification for respiratory diagnosis, only the difference in weaning time remained significant. There was no difference in the incidence of reintubation, new-onset tracheitis, subglottic stenosis, or pneumonia.

Conclusions

Protocol-directed weaning resulted in a shorter weaning time than physician-directed weaning in these pediatric patients.