Romer Amy J, Abu-Sultaneh Samer, Gaies Michael G, Klein Robin V, Mastropietro Christopher W, Todd Tzanetos Deanna R, Werho David K, Zaccagni Hayden J, Loberger Jeremy M
Dr. Romer is affiliated with Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania.
Dr. Abu-Sultaneh is affiliated with Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana.
Respir Care. 2025 Mar;70(3):319-326. doi: 10.1089/respcare.12239.
Mechanical ventilation is common in critically ill children with cardiac disease, but literature focused on ventilator liberation practices for this unique pediatric subpopulation is limited. We aimed to describe current ventilator liberation practices in critically ill children with cardiac disease. Through the Pediatric Cardiac Critical Care Consortium, an electronic survey was distributed to pediatric ICU attending physicians caring for patients with cardiac disease evaluating institutional protocols and individual practices around ventilator liberation including criteria for extubation readiness testing (ERT), ERT components, spontaneous breathing trial (SBT) method and duration, timing of extubation, and postextubation respiratory support. We received 133 responses representing 47 hospitals. ERT eligibility screening and SBT protocols were reported at 22 (47%) and 26 (55%) of the 47 institutions, respectively. Most respondents used SBTs in their assessment of extubation readiness (95%) and pressure support augmentation to CPAP for SBT (92%). Most respondents reported a maximum dose threshold for epinephrine (81%), above which they would not extubate. Some indices used for determination of extubation readiness were used by nearly all respondents: pulse oximetry (92%), serum lactate (86%), and arterial pH (85%); but some respondents also report using mixed venous saturation (68%), ventricular function (62%), near-infrared spectroscopy (62%), and systemic atrioventricular valve regurgitation (53%). Reported use of noninvasive respiratory support (NRS) after extubation was common, up to 90% in selected subgroups. There was wide variation in the type of NRS used in all populations. ERT eligibility screening and SBT protocols were reported in only half of the institutions surveyed, and notable variation exists between parameters surrounding extubation readiness assessment and postextubation respiratory support. These data suggest opportunities to increase protocol development to align with established clinical practice guidelines around ERT and conduct multi-center quality improvement to identify best practices for ventilator liberation in this patient population.
机械通气在患有心脏病的危重症儿童中很常见，但针对这一独特儿科亚群的呼吸机撤机实践的文献有限。我们旨在描述患有心脏病的危重症儿童当前的呼吸机撤机实践。通过儿科心脏重症监护联盟，向负责照顾心脏病患者的儿科重症监护病房主治医生发放了一份电子调查问卷，评估有关呼吸机撤机的机构方案和个人实践，包括拔管准备测试（ERT）标准、ERT组成部分、自主呼吸试验（SBT）方法和持续时间、拔管时间以及拔管后呼吸支持。我们收到了代表47家医院的133份回复。在47家机构中，分别有22家（47%）和26家（55%）报告了ERT资格筛查和SBT方案。大多数受访者在评估拔管准备情况时使用SBT（95%），并在SBT时对持续气道正压通气（CPAP）增加压力支持（92%）。大多数受访者报告了肾上腺素的最大剂量阈值（81%），超过该阈值他们不会进行拔管。几乎所有受访者都使用了一些用于确定拔管准备情况的指标：脉搏血氧饱和度（92%）、血清乳酸（86%）和动脉血pH值（85%）；但一些受访者也报告使用混合静脉血氧饱和度（68%）、心室功能（62%）、近红外光谱（62%）和体循环房室瓣反流（53%）。拔管后使用无创呼吸支持（NRS）很常见，在某些亚组中高达90%。在所有人群中，使用的NRS类型差异很大。在接受调查的机构中，只有一半报告了ERT资格筛查和SBT方案，并且在拔管准备评估和拔管后呼吸支持的参数之间存在显著差异。这些数据表明有机会加强方案制定，使其与围绕ERT的既定临床实践指南保持一致，并开展多中心质量改进，以确定该患者群体呼吸机撤机的最佳实践。
