There is currently no standardized way to determine suitability for extubation of pediatric ICU (PICU) patients, potentially resulting in prolonged duration of mechanical ventilation. We aimed to design and implement a protocol for screening all intubated PICU patients for extubation readiness.
METHODS:
We adopted the quality improvement (QI) Model for Improvement with Plan-Do-Study-Act (PDSA) cycles to achieve this aim. This QI project was conducted over 11 months in a multidisciplinary PICU. Outcome measures included the (1) development of a standardized extubation readiness test (ERT) that was acceptable and safe; (2) performance of ERT on > 80% of all mechanically ventilated subjects; and (3) maintenance or reduction in mechanical ventilation duration, extubation failure (non-elective re-intubation within 48 h of extubation), and need for rescue noninvasive ventilation (NIV). Balancing measures were to ensure (1) no compromise of the subject's clinical status; and (2) acceptability of the ERT workflow by medical, nursing, and respiratory therapist (RT) teams.
RESULTS:
Four PDSA cycles were necessary to achieve the aims of this study. During the QI period, 438 subjects were admitted to the PICU. The ERT was championed by the RTs who conducted the test during office hours. ERT performance increased from 0% (baseline) to 90% (fourth PDSA cycle). Extubation failure rate after implementing ERT was reduced compared to baseline (4/31 [12.9%] vs 3/127 [2.4%], P = .01), whereas need for rescue NIV (3/31 [9.7%] vs 10/127 [7.9%], P = .74) and duration of mechanical ventilation (2 [1–7] d vs 1 [1–3] d, P = .09) were unchanged. PICU length of stay was reduced after implementing ERT (5 [3–10] d vs 3 [1–6] d, P = .01). No subject was destabilized as a result of ERT, and PICU staff found the workflow acceptable.
CONCLUSIONS:
An acceptable and safe ERT protocol was implemented and found to improve outcomes in PICU subjects on mechanical ventilation.
StollerJK. The rationale for therapist-driven protocols. Respir Care Clin N Am, 1996; 2(1):1–14.
2.
StollerJK, SkibinskiCI, GilesDK, KesterEL, HaneyDJ. Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service: results of a prospective observational study. Chest, 1996; 110(2):422–429.
3.
FordRM, Phillips-ClarJE, BurnsDM. Implementing therapist-driven protocols. Respir Care Clin N Am, 1996; 2(1):51–76.
4.
KollefMH, ShapiroSD, ClinkscaleD, CracchioloL, ClaytonD, WilnerR, HossinL. The effect of respiratory therapist–initiated treatment protocols on patient outcomes and resource utilization. Chest, 2000; 117(2):467–475.
5.
ColiceG, CarnathanB, SungJ, ParamoreLC. A respiratory therapist–directed protocol for managing inpatients with asthma and COPD incorporating a long-acting bronchodilator. J Asthma, 2005; 42(1):29–34.
6.
ChristmanSL, VolskoTA. Evaluation of an oxygen protocol in long-term care. Respir Care, 2006; 51(12):1424–1431.
7.
KallamA, MeyerinkK, ModrykamienAM. Physician-ordered aerosol therapy versus respiratory therapist–driven aerosol protocol: the effect on resource utilization. Respir Care, 2013; 58(3):431–437.
8.
MacIntyreNR, CookDJ, ElyEWJr, EpsteinSK, FinkJB, HeffnerJE, et al. American College of Chest Physicians, American Association for Respiratory Care, American College of Critical Care Medicine. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physician, the American Association for Respiratory Care, and the American College of Critical Care Medicine. Respir Care, 2002; 47(1):69–90.
9.
BlackwoodB, AlderdiceF, BurnsK, CardwellC, LaveryG, O'HalloranP. Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis. BMJ, 2011; 342(jan13 2):c7237–c7237.
10.
GirardTD, AlhazzaniW, KressJP, OuelletteDR, SchmidtGA, TruwitJD, et al. ATS/CHEST Ad Hoc Committee on Liberation from Mechanical Ventilation in Adults. An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med, 2017; 195(1):120–133.
11.
KhemaniRG, MarkovitzBP, CurleyMA. Characteristics of children intubated and mechanically ventilated in 16 PICUs. Chest, 2009; 136(3):765–771.
12.
FariasJA, FrutosF, EstebanA, FloresJC, RettaA, BaltodanoA, et al. What is the daily practice of mechanical ventilation in pediatric intensive care units? A multi-center study. Intensive Care Med, 2004; 30(5):918–925.
13.
WolflerA, CalderiniE, OttonelloG, ContiG, BaronciniS, SantuzP, et al. Daily practice of mechanical ventilation in Italian pediatric intensive care units: a prospective survey. Pediatr Crit Care Med, 2011; 12(2):141–146.
14.
MeligyBS, KamalS, El SherbiniSA. Mechanical ventilation practice in Egyptian pediatric intensive care units. Electron Physician, 2017; 9(5):4370–4377.
15.
KlugmanD, MeltonK, MaynordPON, DawsonA, MadhavanG, MontgomeryVL, et al. Assessment of an unplanned extubation bundle to reduce unplanned extubations in critically ill neonates, infants, and children. JAMA Pediatr, 2020; 174(6):e200268.
16.
FitzgeraldRK, DavisAT, HansonSJ. National Association of Children's Hospital and Related Institution PICU Focus Group Investigators. Multi-center analysis of the factors associated with unplanned extubation in the PICU. Pediatr Crit Care Med, 2015; 16(7):e217–e223.
17.
da SilvaPSL, FonsecaMCM. Incidence and risk factors for cardiovascular collapse after unplanned extubations in the pediatric ICU. Respir Care, 2017; 62(7):896–903.
18.
da SilvaPSL, FonsecaMCM. Factors associated with unplanned extubation in children: a case-control study. J Intensive Care Med, 2020; 35(1):74–81.
19.
KlugmanD, BergerJT, SpaederMC, WrightA, PastorW, StockwellDC. Acute harm: unplanned extubations and cardiopulmonary resuscitation in children and neonates. Intensive Care Med, 2013; 39(7):1333–1334.
20.
RoddyDJ, SpaederMC, PastorW, StockwellDC, KlugmanD. Unplanned extubations in children: impact on hospital cost and length of stay. Pediatr Crit Care Med, 2015; 16(6):572–575.
21.
TekgüçH, CanFK, ŞikG, DemirkolD, ÖzelD, YamanA, et al. Daily practice of mechanical ventilation and weaning in Turkish PICUs: a multi-center prospective survey. Pediatr Crit Care Med, 2020; 21(5):e253–e258.
22.
SchultzT, LinR, WatzmanH, DurningS, HalesR, WoodsonA, et al. Weaning children from mechanical ventilation: a prospective randomized trial of protocol-directed versus physician-directed weaning. Respir Care, 2001; 46(8):772–782.
23.
RestrepoRD, FortenberryJD, SpainhourC, StockwellJ, GoodfellowLT. Protocol-drive ventilator management in children: comparison to nonprotocol care. J Intensive Care Med, 2004; 19(5):274–284.
24.
ForondaFK, TrosterEJ, FariasJA, BarbasCS, FerraroAA, FariaLS, et al. The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial. Crit Care Med, 2011; 39(11):2526–2533.
25.
BlackwoodB, TumeLN, MorrisKP, ClarkeM, McDowellC, HemmingK, et al. SANDWICH Collaborators. Effect of a sedation and ventilator liberation protocol vs usual care on duration of invasive mechanical ventilation in pediatric intensive care units: a randomized clinical trial. JAMA, 2021; 326(5):401–410.
26.
LobergerJM, JonesRM, PrabhakaranP. A respiratory therapist–driven pathway improves timeliness of extubation readiness assessment in a single PICU. Pediatr Crit Care Med, 2020; 21(8):e513–e521.
27.
BaischSD, WheelerWB, KurachekSC, CornfieldDN. Extubation failure in pediatric intensive care incidence and outcomes. Pediatr Crit Care Med, 2005; 6(3):312–318.
28.
KurachekSC, NewthCJ, QuasneyMW, RiceT, SachdevaRC, PatelNR, et al. Extubation failure in pediatric intensive care: A multiple-center study of risk factors and outcomes. Crit Care Med, 2003; 31(11):2657–2664.
29.
KapnadakSG, HerndonSE, BurnsSM, ShimYM, EnfieldK, BrownC, et al. Clinical outcomes associated with high, intermediate, and low rates of failed extubation in an intensive care unit. J Crit Care, 2015; 30(3):449–454.
30.
DuyndamA, HoumesRJ, van RosmalenJ, TibboelD, van DijkM, IstaE. Implementation of a nurse-driven ventilation weaning protocol in critically ill children: can it improve patient outcome?. Aust Crit Care, 2020; 33(1):80–88.
31.
Abu-SultanehS, HoleAJ, ToriAJ, BenneyworthBD, LutfiR, MastropietroCW. An interprofessional quality improvement initiative to standardize pediatric extubation readiness assessment. Pediatr Crit Care Med, 2017; 18(10):e463–e471.
32.
KrawiecC, CarlD, StetterC, KongL, CenevivaGD, ThomasNJ. Challenges with implementation of a respiratory therapist–driven protocol of spontaneous breathing trials in the pediatric ICU. Respir Care, 2017; 62(10):1233–1240.
33.
RandolphAG, WypijD, VenkataramanST, HansonJH, GedeitR, MeertK. Effect of mechanical ventilator weaning protocols on respiratory care outcomes in infants and children. A randomized controlled trial. JAMA, 2002; 288(20):2561–2568.
34.
LahamJ, BrehenyP. Extubations in the PICU - where are we now?. J Intensive & Crit Care, 2017; 3(3):34.
JonesB, KwongE, WarburtonW. Quality improvement made simple, What Everyone Should Know about Health Care Quality Improvement. 2021: 11–12, 28–29. Health Foundation.
37.
KarthikaM, SureshkumarVK, BennettA, NoorsheAH, MallatJ, PraveenBM. Quality management in respiratory care. Respir Care, 2021; 66(9):1485–1494.
38.
BockKR, SilverP, RomM, SagyM. Reduction in tracheal lumen due to endotracheal intubation and its calculated significance. Chest, 2000; 118(2):468–472.
39.
FaustinoEVS, GedeitR, SchwarzAJ, AsaroLJ, WypijD, CurleyMA. Accuracy of an extubation readiness test in predicting successful extubation in children with acute respiratory failure from lower respiratory tract disease. Crit Care Med, 2017; 45(1):94–102.
40.
JouvetP, PayenV, GauvinF, EmeriaudG, LacroixJ. Weaning children from mechanical ventilation with a computer-driven protocol: a pilot trial. Intensive Care Med, 2013; 39(5):919–925.
41.
Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med, 2015; 15(5):428–439.
42.
KneyberMCJ, de LucaD, CalderiniE, JarreauP-H, JavouheyE, Lopez-HerceJ, et al. on behalf of the section Respiratory Failure of the European Society for Pediatric and Neonatal Intensive Care. Recommendations for mechanical ventilation of critically ill children from the Pediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med, 2017; 43(12):1764–1780.
43.
FergusonLP, WalshBK, MunhallD, ArnoldJH. A spontaneous breathing trial with pressure support overestimates readiness for extubation in children. Pediatr Crit Care Med, 2011; 12(6):e330–e335.
44.
KhemaniRG, HotzJ, MorzovR, FlinkRC, KamerkarA, LaFortuneM, et al. Pediatric extubation readiness tests should not use pressure support. Intensive Care Med, 2016; 42(8):1214–1222.
45.
YehyaN. Gasping at straws: role of pressure support during spontaneous breathing trials in children. Pediatr Crit Care Med, 2020; 21(7):699–700.
46.
NewthCJ, HotzJ, KhemaniRG. Ventilator liberation in the pediatric ICU. Respir Care, 2020; 65(10):1601–1610.
47.
van DijkJ, BlokpoelRGT, KoopmanAA, BrandsemaR, NewthCJ, KneyberMC. Spontaneous breathing and imposed work during pediatric mechanical ventilation: a bench study. Pediatr Crit Care Med, 2020; 21(7):e449–e455.
