Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.
Keck School of Medicine, University of Southern California, Los Angeles, California.
Respir Care. 2020 Oct;65(10):1601-1610. doi: 10.4187/respcare.07810.
Despite the accepted importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are often not clear, although a trial of spontaneous breathing on CPAP without pressure support seems an appropriate prerequisite in many cases. Several indexes have been developed to predict weaning and extubation success, but the available literature suggests they offer little or no improvement over clinical judgment. New techniques for assessing readiness for weaning and predicting extubation success are being developed but are far from general acceptance in pediatric practice. While there have been some excellent physiologic, observational, and even randomized controlled trials on aspects of pediatric ventilator liberation, robust research data are lacking. Given the lack of data in many areas, a determined approach that combines systematic review with consensus opinion of international experts could generate high-quality recommendations and terminology definitions to guide clinical practice and highlight important areas for future research in weaning, extubation readiness, and liberation from mechanical ventilation following pediatric respiratory failure.
尽管人们已经认识到尽量缩短机械通气时间的重要性，但儿科文献中提供的关于脱机和拔管的指导非常有限。实际上，许多接受脱机评估的患者已经可以拔管，这表明在通气过程中，脱机往往考虑得不够早。拔管的指征通常不明确，尽管在许多情况下，CPAP 上无压力支持的自主呼吸试验似乎是一个合适的前提。已经开发了几种预测脱机和拔管成功的指标，但现有文献表明，它们并不能比临床判断提供更多或更好的效果。正在开发新的技术来评估脱机准备情况和预测拔管成功，但在儿科实践中还远未被广泛接受。尽管在儿科呼吸机撤离的某些方面已经进行了一些出色的生理学、观察性甚至随机对照试验，但仍缺乏强有力的研究数据。鉴于许多领域缺乏数据，一种将系统评价与国际专家的共识意见相结合的坚定方法，可以生成高质量的建议和术语定义，以指导临床实践，并突出脱机、拔管准备和儿童呼吸衰竭后机械通气撤离方面的重要研究领域。
