Krawiec Conrad, Carl Dale, Stetter Christy, Kong Lan, Ceneviva Gary D, Thomas Neal J
Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA.
Penn State Health Respiratory Care and Pulmonary Diagnostics, Penn State Health Children's Hospital, Hershey, PA.
Respir Care. 2017 Oct;62(10):1233-1240. doi: 10.4187/respcare.05477. Epub 2017 Jul 18.
Timely ventilator liberation is crucial in the pediatric ICU. In many pediatric ICUs, the decision to initiate weaning is driven by the physician, which may lead to delays in ventilator liberation. The objectives of this quality improvement project were to develop and implement a respiratory therapist (RT)-led protocol for screening for spontaneous breathing trial (SBT) readiness, to test protocol feasibility, and to evaluate its impact on SBT timing.
A retrospective chart review was performed on all intubated patients in the pediatric ICU for 18 months prior to protocol institution. An RT-driven protocol was developed and implemented, enabling consistent screening for SBT readiness. When criteria were met, an SBT was initiated after order placement. The difference in the timing of the first SBT between physician-directed screening and the RT-driven protocol was evaluated.
A total of 219 subjects were included in this project (128 pre-intervention; 91 intervention). Baseline demographic data, including mortality risk and endotracheal tube size, were similar in both groups. The time of the first SBT (median [25th, 75th percentile]) was not significantly different between the intervention and preintervention groups (39.5 [25.3, 85.2] vs 42.6 [26.4, 81.3], respectively). There was no difference in mechanical ventilation duration, or length of hospital and ICU stay. The odds of being placed on noninvasive respiratory support were higher in the intervention group at 1 h (odds ratio [95% CI]: 2.29 [1.10, 4.78], = .03) and 12 h (odds ratio 2.53 [1.23, 5.20], = .01) postextubation, but the odds of re-intubation did not reach statistical significance (odds ratio 2.60 [0.73, 9.27], = .14). RT adherence with patient screening was 56.4%.
An RT-driven protocol was successfully introduced in an academic pediatric ICU. However, it did not impact time of SBT initiation, potentially due to the difficulty in maintaining adherence over time. RT-driven protocols require further study.
在儿科重症监护病房（PICU）中，及时撤机至关重要。在许多儿科重症监护病房，撤机的决定由医生主导，这可能导致撤机延迟。本质量改进项目的目标是制定并实施一项由呼吸治疗师（RT）主导的方案，用于筛查自主呼吸试验（SBT）的准备情况，测试方案的可行性，并评估其对SBT时机的影响。
对方案实施前18个月在儿科重症监护病房接受插管的所有患者进行回顾性病历审查。制定并实施了一项由RT主导的方案，以确保对SBT准备情况进行一致的筛查。当符合标准时，下达医嘱后启动SBT。评估了医生主导的筛查与RT主导的方案之间首次SBT时间的差异。
本项目共纳入219名受试者（干预前128名；干预组91名）。两组的基线人口统计学数据，包括死亡风险和气管插管尺寸，相似。干预组和干预前组首次SBT的时间（中位数[第25、75百分位数]）无显著差异（分别为39.5[25.3，85.2]和42.6[26.4，81.3]）。机械通气时间、住院时间和重症监护病房住院时间无差异。拔管后1小时（优势比[95%CI]：2.29[1.10，4.78]，P = 0.０3）和12小时（优势比2.５3[1.23，5.20]，P = 0.０1），干预组接受无创呼吸支持的几率更高，但再次插管的几率未达到统计学显著性（优势比2.60[0.73，9.27]，P = 0.14）。RT对患者筛查的依从率为56.4%。
在一家学术性儿科重症监护病房成功引入了由RT主导的方案。然而，它并未影响SBT启动时间，可能是由于难以长期维持依从性。由RT主导的方案需要进一步研究。
