Around the Clock Spontaneous Breathing Trials and Outcomes in a Pediatric Intensive Care Unit

Abstract

Background:

Spontaneous breathing trials (SBTs) have been shown to increase the success rate of extubations and to potentially decrease ventilator days (VD) and length of stay. Studies demonstrate that immediate extubation after successful trials of spontaneous breathing expedites weaning and reduces the duration of mechanical ventilation. It may be favorable to extubate patients off-hours and as soon as weaning parameters are met, since this could decrease complications and decrease VD. Conversely, overnight extubation (OE) could be deleterious, as staffing varies during this time. In our Pediatric Intensive Care Unit (PICU), we maintain a consistent staffing model for all shifts and disciplines. We hypothesize that our patients would have a comparable failed extubation (FE) rate from baseline, regardless of the time of day the patients were extubated. We also anticipated increased OE would have a positive impact on total VD.

Methods:

With a team of Physicians and Respiratory Therapists (RT), we developed criteria based upon literature for an RT-driven SBT trial to be performed on each qualifying intubated patient in the PICU twice daily. This was implemented in March 2017. Noticing an increase in OE (1900-0659) since the SBT started, we did an IRB approved retrospective data analysis of our safety metrics and audits collected for the SBTs. We analyzed the data to see if there were any changes in the percentage of FE (reintubated within 48 h) and, more significantly, if it reduced our total VD. We reviewed the time of extubation, number of FE, number of failed OE, and total VD for one year before and after initiation of an SBT in our PICU.

Results:

From 3/2016 to 3/2017, there were 323 extubations. 76 of these were OE (23.5%), and there were 31 FE (10.4%). Twelve of these FE were OE (38.7%). After initiation of an RT driven SBT, from 3/2017-3/2018, there were 353 extubations. 99 of these were OE (28%), and there were 32 FE (9.1%). Nine of these FE were OE (28.1%). With an increase in OE post initiation of SBT, we still saw a decrease in failed OE (38.7% to 28.1%). Total VD was 2897 compared to 2777 days from before and after SBT initiation (decrease of 9.6%).

Conclusions:

By utilizing an around the clock model for our RT driven SBT, our facility was able to improve outcome metrics (FE rate and total VD) for PICU patients. Further studies should be done to explore the relationship between OE, staffing, and mortality.