Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine Indianapolis, IN.
Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA.
Chest. 2024 Nov;166(5):1056-1070. doi: 10.1016/j.chest.2024.05.012. Epub 2024 Jun 7.
The 2023 International Pediatric Ventilator Liberation Clinical Practice Guidelines provided evidence-based recommendations to guide pediatric critical care providers on how to perform daily aspects of ventilator liberation. However, because of the lack of high-quality pediatric studies, most recommendations were conditional based on very low to low certainty of evidence.
What are the research gaps related to pediatric ventilator liberation that can be studied to strengthen the evidence for future updates of the guidelines?
We conducted systematic reviews of the literature in eight predefined Population, Intervention, Comparator, Outcome (PICO) areas related to pediatric ventilator liberation to generate recommendations. Subgroups responsible for each PICO question subsequently identified major research gaps by synthesizing the literature. These gaps were presented at an international symposium at the Pediatric Acute Lung Injury and Sepsis Investigators meeting in spring 2022 for open discussion. Feedback was incorporated, and final evaluation of research gaps are summarized herein. Although randomized controlled trials (RCTs) represent the highest level of evidence, the panel sought to highlight areas where alternative study designs also may be appropriate, given challenges with conducting large multicenter RCTs in children.
Significant research gaps were identified in six broad areas related to pediatric ventilator liberation. Several of these areas necessitate multicenter RCTs to provide definitive results, whereas other gaps can be addressed with multicenter observational studies or quality improvement initiatives. Furthermore, a need for some physiologic studies in several areas remains, particularly regarding newer diagnostic methods to improve identification of patients at high risk of extubation failure.
Although pediatric ventilator liberation guidelines have been created, the certainty of evidence remains low and multiple research gaps exist that should be bridged through high-quality RCTs, multicenter observational studies, and quality improvement initiatives.
2023 年国际儿科呼吸机撤离临床实践指南提供了循证建议，以指导儿科重症监护提供者如何进行呼吸机撤离的日常操作。然而，由于缺乏高质量的儿科研究，大多数建议都是有条件的，其证据确定性非常低或低。
与儿科呼吸机撤离相关的研究空白有哪些，可以进行研究以加强指南未来更新的证据？
我们对与儿科呼吸机撤离相关的八个预先定义的人群、干预、比较、结局（PICO）领域进行了系统评价，以生成建议。负责每个 PICO 问题的亚组通过综合文献确定了主要的研究空白。这些空白在 2022 年春季儿科急性肺损伤和脓毒症研究人员会议上的国际专题研讨会上进行了公开讨论。纳入了反馈意见，并在此总结了最终的研究空白评估。尽管随机对照试验（RCT）代表了最高水平的证据，但专家组试图强调在儿童中进行大型多中心 RCT 面临挑战的情况下，替代研究设计也可能适用的领域。
在与儿科呼吸机撤离相关的六个广泛领域确定了显著的研究空白。其中一些领域需要进行多中心 RCT 以提供明确的结果，而其他空白可以通过多中心观察性研究或质量改进计划来解决。此外，在几个领域仍然需要进行一些生理学研究，特别是关于新的诊断方法，以更好地识别拔管失败风险高的患者。
尽管已经制定了儿科呼吸机撤离指南，但证据的确定性仍然很低，存在多个研究空白，应通过高质量 RCT、多中心观察性研究和质量改进计划来填补。
