Citation Information :
Kishore R, Jhamb U. Effect of Protocolized Weaning and Spontaneous Breathing Trial vs Conventional Weaning on Duration of Mechanical Ventilation: A Randomized Controlled Trial. Indian J Crit Care Med 2021; 25 (9):1059-1065.
Background: Identifying ventilated patients ready for extubation is a challenge for clinicians. Premature extubation increases risks of reintubation while delayed weaning increases complications of prolonged ventilation. We compared the duration of mechanical ventilation (MV) and extubation failure in children extubated using a weaning protocol based on pressure support spontaneous breathing trial (PS SBT) vs those extubated after nonprotocolized physician-directed weaning. Patients and methods: A prospective randomized controlled trial was conducted in the pediatric intensive care unit of a tertiary care hospital in children ventilated for ≥24 hours. All eligible patients underwent daily screening and were randomized once found fit. The intervention group underwent PS SBT of 2 hours duration followed by a T-piece trial and extubation. Controls underwent conventional weaning with synchronized intermittent mandatory ventilation mode and a T-piece trial before extubation. Results: Eighty patients were randomized into two groups of 40 each. About 77.5% of patients passed the PS SBT on the first attempt. No statistical difference was found either in the duration of MV between the two groups [median (interquartile range) in days: 4.77 (2.89, 9.46) in controls and 4.94 (2.23, 6.35) in cases, p = 0.62] or in the rate of extubation failure (13% and 10.5%, p = 1). Mortality was found to be significantly higher in the reintubated patients compared to those not reintubated in both groups (p = 0.002 in cases and 0.005 in controls). Conclusion: Weaning using PS SBT-based protocol though did not shorten the duration of MV, it was found to be safe for assessing extubation readiness and did not increase extubation failure (CTRI no—CTRI/2018/04/013270).
Kurachek SC, Newth CJ, Quasney MW, Rice T, Sachdeva RC, Patel NR, 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. DOI: 10.1097/01.CCM.0000094228.90557.85.
Newth CJ, Venkataraman S, Willson DF, Meert KL, Harrison R, Dean JM, et al. Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 2009;10(1):1. DOI: 10.1097/PCC.0b013e318193724d.
Farias JA, Monteverde E. We need to predict extubation failure. J Pediatr 2006;82(5):322–324. DOI: 10.2223/JPED.1539.
Esteban A, Frutos F, Tobin MJ, Alía I, Solsona JF, Valverdú I, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995;332(6):345–350. DOI: 10.1056/NEJM199502093320601.
Brochard L, Rauss A, Benito S, Conti G, Mancebo J, Rekik N, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994;150(4):896–903. DOI: 10.1164/ajrccm.150.4.7921460.
MacIntyre NR, Cook DJ, Ely EW, Epstein SK, Fink JB, Heffner JE, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. CHEST 2001;120(Suppl. 6):375S–396S. DOI: 10.1378/chest.120.6_suppl.375s.
Valenzuela J, Araneda P, Cruces P. Weaning from mechanical ventilation in paediatrics. State of the art. Arch Bronconeumol 2014;50(3):105–112. DOI: 10.1016/j.arbres.2013.02.003.
Hess D. Ventilator modes used in weaning. Chest 2001;120(6):474S– 476S. DOI: 10.1378/chest.120.6_suppl.474s.
Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. CHEST 2000;118(2):459–467. DOI: 10.1378/chest.118.2.459.
Kollef MH, Shapiro SD, Silver P, St John RE, Prentice D, Sauer S, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 1997;25(4):567–574. DOI: 10.1097/00003246-199704000-00004.
Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996;335(25):1864–1869. DOI: 10.1056/NEJM199612193352502.
Randolph AG, Wypij D, Venkataraman ST, Hanson JH, Gedeit RG, Meert KL, et al. Effect of mechanical ventilator weaning protocols on respiratory outcomes in infants and children: a randomized controlled trial. JAMA 2002;288(20):2561–2568. DOI: 10.1001/jama.288.20.2561.
Foronda F, Troster EJ, Farias JA, Barbas CS, Ferraro AA, Faria LS, et al. Impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial. Crit Care Med 2011;15:1–31. DOI: 10.1097/CCM.0b013e3182257520.
Farias J, Retta A, Alia I, Olazarri F, Esteban A, Golubicki A, et al. A comparison of two methods to perform a breathing trial before extubation in pediatric intensive care patients. Intensive Care Med 2001;27(10):1649–1654. DOI: 10.1007/s001340101035.
Esteban A, Alia I, Gordo F, Fernández R, Solsona JF, Vallverdú I, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. Am J Respir Crit Care Med 1997;156(2):459–465. DOI: 10.1164/ajrccm.156.2.9610109.
Cabello B, Thille AW, Roche-Campo F, Brochard L, Gómez FJ, Mancebo J. Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients. Intensive Care Med 2010;36(7):1171–1179. DOI: 10.1007/s00134-010-1870-0.
Chittawatanarat K, Orrapin S, Orrapin S. Open-label randomized control trial between low pressure support and T-piece method for discontinuation from mechanical ventilator and extubation in general surgical ICUs. Crit Care 2015;19(1):P268. DOI: 10.1186/cc14348.
Gnanapandithan K, Agarwal R, Aggarwal AN, Gupta D. Weaning by gradual pressure support (PS) reduction without an initial spontaneous breathing trial (SBT) versus PS-supported SBT: a pilot study. Rev Port Pneumol 2011;17(6):244–252. DOI: 10.1016/j.rppneu.2011.06.015.
Gaffari S, Ghasempour M, Bilan N. Spontaneous breathing trial a reliable method for weaning in children. Int J Pediatr 2015;3(3.2):707– 712. DOI: 10.22038/ijp.2015.4424.
Bock KR, Silver P, Rom M, Sagy M. Reduction in tracheal lumen due to endotracheal intubation and its calculated clinical significance. CHEST 2000;118(2):468–472. DOI: 10.1378/chest.118.2.468.
Jarreau PH, Louis B, Dassieu G, Desfrere L, Blanchard PW, Moriette G, et al. Estimation of inspiratory pressure drop in neonatal and pediatric endotracheal tubes. J Appl Physiol 1999;87(1):36–46. DOI: 10.1152/jappl.19126.96.36.199.
Takeuchi M, Imanaka H, Miyano H, Kumon K, Nishimura M. Effect of patient-triggered ventilation on respiratory workload in infants after cardiac surgery. Anesthesiology 2000;93(5):1238–1244. DOI: 10.1097/00000542-200011000-00017.
Khemani RG, Hotz J, Morzov R, Flink RC, Kamerkar A, LaFortune M, et al. Pediatric extubation readiness tests should not use pressure support. Intensive Care Med 2016;42(8):1214–1222. DOI: 10.1007/s00134-016-4387-3.
Ferguson LP, Walsh BK, Munhall D, Arnold JH. A spontaneous breathing trial with pressure support overestimates readiness for extubation in children. Crit Care Med 2011;12(6):e330–e335. DOI: 10.1097/PCC.0b013e3182231220.
Farias JA, Alia I, Esteban A, Golubicki AN, Olazarri FA. Weaning from mechanical ventilation in pediatric intensive care patients. Intensive Care Med 1998;24(10):1070–1075. DOI: 10.1007/s001340050718.
Farias JA, Frutos F, Esteban A, Flores JC, Retta A, Baltodano A, et al. What is the daily practice of mechanical ventilation in pediatric intensive care units? A multicenter study. Intensive Care Med 2004;30(5):918–925. DOI: 10.1007/s00134-004-2225-5.
Faustino EVS, Gedeit R, Schwarz AJ, Asaro LA, Wypij D, Curley MA. 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. DOI: 10.1097/CCM.0000000000002024.
Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J 2007;29(5):1033– 1056. DOI: 10.1183/09031936.00010206.
Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002;287(3):345–355. DOI: 10.1001/jama.287.3.345.
Schultz TR, Lin RJ, Watzman HM, Durning SM, Hales R, Woodson A, 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.
Restrepo RD, Fortenberry JD, Spainhour C, Stockwell J, Goodfellow L. Protocol-driven ventilator management in children: comparison to nonprotocol care. Intensive Care Med 2004;19(5):274–284. DOI: 10.1177/0885066604267646.
Blackwood B, Murray M, Chisakuta A, Cardwell CR, O'Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients. Cochrane Database Syst Rev 2013;7. DOI: 10.1002/14651858.CD009082.pub2.
Chavez A, dela Cruz R, Zaritsky A. Spontaneous breathing trial predicts successful extubation in infants and children. Pediatr Crit Care Med 2006;7(4):405. DOI: 10.1097/01.PCC.0000225001.92994.29.