Inclusion Criteria for Extubation Readiness Testing in the Pediatric ICU: Too Exclusive?

Abstract

Background:

Extubation Readiness Testing (ERT) is a respiratory therapist (RT)-driven and monitored protocol of minimal ventilator support to test readiness for ventilator discontinuation. A protocol was developed and implemented as a quality improvement initiative in our pediatric intensive care unit in March 2017. Upon QI implementation, we observed ERT completed on patients who did not meet inclusion criteria, as decisions were made by the medical team on a case-by-case basis. The objective of this study was to determine if meeting inclusion criteria for ERT is predictive of ERT success.

Methods:

ERT data from March 2017-May 2018 was included (IRB approval). ERT was completed by the bedside RT at the direction of the medical team. Documentation, including ventilator settings and baseline and post-ERT physiologic parameters were entered into the electronic medical record by the bedside RT. Additional data extraction by the research team included demographics (age, sex, days of mechanical ventilation), information about screening and inclusion criteria. Patients receiving ERT were divided into 2 groups for data analysis: those who met inclusion criteria for ERT and those who did not.

Results:

During the study period, ERT was completed 158 times in 121 patients ages 5 days-24 y. Of these tests, 56% did not meet inclusion criteria. In patients who met inclusion criteria, 55% passed ERT, while 42% of those patients who did not meet inclusion criteria passed their ERT (P=0.15). After adjusting for age and ventilator days, meeting inclusion criteria was not significantly associated with passing ERT (OR 1.54; CI: 0.71-3.3). Primary reasons for not meeting inclusion criteria among those who passed ERT was a recent increase in ventilator support 48% and a blood gas outside the desired pH 36%. Among all tests where extubation occurred within 24 h, only one child who passed ERT required re-intubation within 48 h. In contrast, 6 of 51 (12%) children who failed ERT were re-intubated within 48 h of extubation (P=0.046) -none of these patients had met the inclusion criteria for the ERT.

Conclusions:

Our data suggests meeting inclusion criteria is not consistently predictive of ERT success, however failure is associated with re-intubation if extubation is performed. Further investigation is needed to determine ideal inclusion criteria to streamline patient selection for ERT and optimize respiratory outcomes for a heterogeneous population of PICU patients.

Disclosures None.

PICU ERT Inclusion Criteria

●Spontaneously breathing

●pH 7.32- 7.45 on most recent blood gas

●PEEP < 6, FiO2 < 0.5 with SpO2 > 95% or SpO2 within ordered range

●No increase in vent support in past 24 hours

●Temperature >35.5°