RESPIRATORY CARE Paper in Press. Published on April 17, 2024 as DOI: 10.4187/respcare.

11708

Implementing the Pediatric Ventilator Liberation Guidelines Using the

Most Current Evidence
Jeremy M Loberger, Katherine Steffen, Robinder G Khemani, Akira Nishisaki, and
Samer Abu-Sultaneh

Introduction
Guideline Development
Implementation Science Approach
Extubation Readiness Testing Eligibility Screening
Recommendation Summary
Gap Analysis: Contemporary Practice and Evidence
Closing the Gap: Implementation Barriers and Facilitators
Spontaneous Breathing Trials
Recommendation Summary
Gap Analysis: Contemporary Practice and Evidence
Closing the Gap: Implementation Barriers and Facilitators
Postextubation Upper-Airway Obstruction Prevention
Recommendation Summary
Gap Analysis: Contemporary Practice and Evidence
Closing the Gap: Implementation Barriers and Facilitators
Postextubation Noninvasive Respiratory Support
Recommendation Summary
Gap Analysis: Contemporary Practice and Evidence
Closing the Gap: Implementation Barriers and Facilitators
Additional ERT Bundle Elements
Recommendation Summary
Gap Analysis: Contemporary Practice and Evidence
Closing the Gap: Implementation Barriers and Facilitators
Role of the Respiratory Therapist
Future Directions: VentLib4Kids

Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric
critical care teams must identify the best timing and approach to liberating (extubating) children
from this supportive care modality. Unsurprisingly, practice variation varies widely. As a first step to
minimizing that variation, the first evidence-based pediatric ventilator liberation guidelines were pub-
lished in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay
before clinical guidelines reach widespread clinical practice. As such, it is important to consider bar-
riers and facilitators using a systematic approach during implementation planning and design. In this
narrative review, we will (1) summarize guideline recommendations, (2) discuss recent evidence and
identify practice gaps relating to those recommendations, and (3) hypothesize about potential barriers
and facilitators to their implementation in clinical practice. Key words: mechanical ventilation; clinical
pathways; pediatrics; pediatric ICUs; airway extubation; noninvasive ventilation; artificial respiration;
airway obstruction. [Respir Care 2024;0(0):1–
. © 2024 Daedalus Enterprises]

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 RESPIRATORY CARE Paper in Press. Published on April 17, 2024 as DOI: 10.4187/respcare.11708

IMPLEMENTING PEDIATRIC VENTILATOR LIBERATION GUIDELINES

Introduction Implementation Science Approach

Every day pediatric intensivists strive to safely liberate On average, new guidelines take 17 years to reach rou-
(extubate) children from invasive mechanical ventilation and tine clinical use; and when it takes this long to implement
reduce associated short- and long-term complications. These the guidelines, they often become obsolete.18-19 Hence, after
complications include airway trauma, ventilator-associated a guideline is published, we believe it is equally important
infections, ventilator-induced lung injury and diaphragm dys- to ensure timely and sustainable guideline implementation.
function, critical care–induced neuropathy/myopathy, and Implementation science is a growing field that aims to close
cognitive impairment. Some of these complications are medi- the gap between evidence and practice by focusing on real-
ated through prolonged exposure to narcotics, sedatives, and life barriers and facilitators for implementation of evi-
neuromuscular blockade, with the cumulative dose closely dence-based practice.20 The field utilizes various frame-
tied to the duration of invasive mechanical ventilation.1-7 works to assess these contextual factors. Among the most
Hence, there is a clear desire to reduce the duration of inva- cited is the Consolidated Framework for Implementation
sive mechanical ventilation, but this is often balanced Research (CFIR).21 This framework, first published in 2009,
against the risk of extubation failure and its associated com- was updated in 2022 and includes a list of constructs within
plications.8 There is wide variation in pediatric ventilation 5 domains that impact implementation: the innovation, outer
liberation practices worldwide.9-13 This is in part related to setting, inner setting, individuals, and the implementation
a lack of synthesized guidance on best practices. To address process.22-23 Here, the innovations are the pediatric ventilator
this gap, the first pediatric ventilator liberation guidelines liberation guideline recommendations; the outer setting is the
were recently published.14-17 hospital system and other external influences; the inner system
This narrative review aims to summarize recommenda- is the PICU/CICU, and individuals are both those implement-
tions from the pediatric ventilator liberation guidelines as ing the guidelines as well as patients and their families.
well as current practice gaps. In addition, whereas guide- In this review, we will utilize the CFIR to identify poten-
lines can inform practice, systems-based operationalization tial important barriers and facilitators to implementing the
requires coordinated effort. We will conclude each section pediatric ventilator liberation guidelines. We will focus on
with a consideration of anticipated contextual factors that factors associated with the recommendation (innovation)
may influence implementation in pediatric ICUs (PICUs) itself, PICU/CICU context (inner system), and individuals
and pediatric cardiac ICUs (CICUs). working in or cared for in the PICU/CICU (individuals do-
main). We hope this approach helps readers contextualize
Guideline Development what is needed to successfully implement the pediatric ven-
tilator liberation guidelines within their own ICUs.
In 2023, a panel of 26 international, multi-professional
experts in pediatric critical care, respiratory physiology, and Extubation Readiness Testing Eligibility Screening
ventilator liberation published the first international pediat-
ric ventilator liberation guidelines.14-17 These guidelines Recommendation Summary
synthesized the available evidence to generate 15 recom-
mendations covering many common aspects of pediatric Systematic screening for extubation readiness testing
ventilator liberation for children requiring invasive me- (ERT) eligibility was suggested over no screening.14 An ERT
chanical ventilation for > 24 h (Fig. 1). The guidelines used is a bundle of elements that inform clinicians about potential
an established framework to report not only the recommen- readiness to extubate. A spontaneous breathing trial (SBT) is
dation but the level of certainty of each recommendation one but not the only component of an ERT.16 Physiologic,
based on the available evidence. ventilator, patient, and disease-specific variables are critical

Dr Loberger is affiliated with Department of Pediatrics, Division of Pediatric The work was funded by the following grants: NIH/NICHD/NHLBI
Critical Care Medicine, University of Alabama at Birmingham, Birmingham, R13HD102137 PI: Khemani and Abu-Sultaneh. Indiana University,
Alabama. Dr Steffen is affiliated with Department of Pediatrics, Division of Department of Pediatrics/Riley Hospital for Children at IUH: Abu-
Pediatric Critical Care Medicine, Stanford University, Palo Alto, California. Sultaneh. Dr Nishisaki discloses relationships with Chiesi, Agency for
Dr Khemani is affiliated with Department of Anesthesiology and Critical Healthcare Quality and Research, and the National Institute of Child
Care Medicine, Children’s Hospital of Los Angeles, Los Angeles, California. Health and Human Development. The remaining author have no conflicts
Dr Nishisaki is affiliated with Department of Anesthesiology and Critical to disclose.
Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr Abu- Correspondence: Jeremy M Loberger MD, CPPI Suite 102, 1600 7th
Sultaneh is affiliated with Department of Pediatrics, Division of Pediatric Avenue South, Birmingham, AL 35233. E-mail: [email protected].
Critical Care Medicine, Indiana University School of Medicine and Riley
Hospital for Children at Indiana University Health, Indianapolis, Indiana. DOI: 10.4187/respcare.11708

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 RESPIRATORY CARE Paper in Press. Published on April 17, 2024 as DOI: 10.4187/respcare.11708

IMPLEMENTING PEDIATRIC VENTILATOR LIBERATION GUIDELINES

Patients intubated
START OF INVASIVE VENTILATION

ESCALATION AND
STABILIZATION
PERIOD
DIAGNOSTIC TRIGGERING

WEANING ERT Eligibility

PERIOD Screening

ERT ELIGIBILITY

(with or without titration protocol)

Targeted Sedation Management
Assess cough strength, capacity to manage oropharyngeal secretion,
neourlogic/sedation status

High Risk for Post-Extubation UAO

Perform air leak test Prescribe dexamethasone
EXTUBATION
(cuffed ETT only) (at least 6 h prior to extubation)
READINESS
TESTING BUNDLE

Extubation failure risk

stratification

High risk Standard risk

● SBT: CPAP without ● SBT: CPAP with or

PS augmentation without PS
(60-120 mins) augmentation
● Check PImax (30 or 60-120 mins)

VENTILATOR LIBERATION

Planned Noninvasive Respiratory

Support POST-EXTUBATION
Room air or MONITORING AND
● ≥ 1 yo: HFNC, BPAP, or conventional WEANING OF
CPAP over conventional oxygen therapy NONIVASIVE SUPPORT
oxygen therapy
(IF INDICATED)
● < 1 yo: CPAP over HFNC

RESPIRATORY SUPPORT LIBERATION

Fig. 1. Conceptualization of the ventilator liberation process according to guideline recommendations starting with intubation
through recognition of weaning readiness (diagnostic triggering), deployment of the extubation readiness test bundle, and conclud-
ing with ventilator/respiratory support liberation. ERT ¼ extubation readiness test; ETT ¼ endotracheal tube; UAO ¼ upper-airway
obstruction; SBT ¼ spontaneous breathing trial; PS ¼ pressure support; PImax ¼ maximal inspiratory pressure; HFNC ¼ high-flow
nasal cannula; BPAP ¼ bi-level positive airway pressure.

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IMPLEMENTING PEDIATRIC VENTILATOR LIBERATION GUIDELINES

Table 1. Potential Extubation Readiness Test Eligibility Screening Variables

Physiologic Variables Ventilator Setting Variables Patient Variables Disease-Specific Variables

Respiratory system compliance PEEP Sedation Improvement or resolution in

SpO2 and/or PaO2 Set breathing frequency Current and baseline underlying process
ETCO2 and/or PaCO2 FIO2 Neurologic status Hemodynamic stability
Dead-space fraction PS Impending procedure(s)
Tidal volume
Inspiratory pressure

PIP ¼ peak inspiratory pressure

Pplat ¼ plateau pressure
ETCO2 ¼ end-tidal carbon dioxide
PS ¼ pressure support

components of screening, but required elements and thresh- interventions most impacted outcomes if at all. Whereas the
olds were not defined in the guideline. See examples in adherence for ERT screening in the SANDWICH trial was
Table 1. Likewise, the ideal multi-professional team mem- 74%, only 39% of passed screens led to the initiation of an
ber responsible for screening was not identified given SBT. This may have decreased the effect size of the interven-
practice differences across ICUs. tion bundle on duration of invasive mechanical ventilation.

Gap Analysis: Contemporary Practice and Evidence Closing the Gap: Implementation Barriers and
Facilitators
In a 2022 survey of 380 international PICUs/CICUs
(also included mixed and other unit types), 47% reported Screening is an intervention with low cost and high local
use of a standardized ERT screening protocol with physi- adaptability. Moreover, a reasonable evidence base exists
cian’s primarily doing the screening (63%), most often suggesting relative advantage over no screening. These fac-
once a day (64%).10 Screening protocols were least prev- tors make screening feasible and should promote accept-
alent in Europe (22%). The United States and Canada ability and uptake (CFIR, innovation domain). However,
were the only regions where protocolized screening was barriers do exist including lack of agreement on design,
primarily performed by respiratory therapists (RTs) optimal screening and ERT components, frequency, and
(78%). These results align with a 2022 point prevalence responsibility. It is intuitive that certain patient populations
study by Ista et al.13 Most contemporary interventional may need tailored screening criteria (CFIR, individuals do-
studies conducted in the United States report daily main) (Table 2). As such, protocol design should aim to fit
screening performed by RTs.24-28 most but not all clinical situations. Little is known about
Invasive mechanical ventilation weaning begins with specific cutoffs for screening components. This a critical
clinical suspicion that the patient is improved; this is often research gap and potential barrier as well. Unit resources
impacted by the many competing demands of the ICU.29-30 and infrastructure are important factors that may act as both
Timely recognition of ERT eligibility should logically barriers or facilitators. ERT screening might lead to earlier
translate to better outcomes, but results are mixed. Three liberation from invasive mechanical ventilation and
recent single-center quality improvement studies demon- decreasing work load on the team members. At the same
strated general safety and acceptability of RT-driven time, the screening process itself can increase the work
screening with mixed results on patient-centered out- load as well (CFIR, inner setting domain). Computerized
comes.24,25,31 Two multi-center randomized controlled decision support for ERT safety screening leveraging the
trials yielded contrasting results. The RESTORE trial electronic medical record or other automated tool is an
(United States, 2015) compared a nursing-driven sedation attractive future direction for screening implementation.
protocol coupled with a daily ERT screen to usual care. Screening frequency and responsibility are anticipated to
There was no change in the primary outcome—duration be the most impacted by unit resources and infrastructure.
of invasive mechanical ventilation.28 More recently, the In units with dedicated RTs, they can be the lead team that
SANDWICH trial (United Kingdom, 2021) studied a simi- performs the ERT screening as they have the expertise and
lar strategy compared to usual care. The intervention group monitor the patient and ventilator around the clock. They
had a statistically significantly shorter time to first extubation collaborate with other team members like bedside nursing,
(64.8 h vs 66.2 h).26 However, the small effect size raises advanced care providers, and physicians to ensure that other
questions of clinical importance. Both studies included a elements of ERT screening like sedation, neurological status,
bundle of interventions, which made it hard to dissect which and hemodynamic stability are meeting the safety criteria.

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IMPLEMENTING PEDIATRIC VENTILATOR LIBERATION GUIDELINES

Table 2. Examples of Populations Who Might be Considered at High Risk for Extubation Failure During Guideline Implementation

General Considerations Cardiac Specific

Premature neonates/infants Single-ventricle physiology

Chronic lung disease Moderate or severe ventricular dysfunction
Chronic critical illness Moderate or greater atrioventricular valve regurgitation
Upper-airway anomalies History of cardiopulmonary bypass
Severe neurologic injury/impairment Pulmonary hypertension
Prolonged invasive mechanical ventilation (> 14 d) Shunt-dependent pulmonary blood flow
Extracorporeal support pre-extubation
Neuromuscular disease
Neurocognitive impairment
Chronic noninvasive ventilation use
Genetic syndromes
Previous failed extubation

Table 3. Potential Spontaneous Breathing Trial Pass/Fail Variables

Physiologic Variables Measured Ventilator Variables Patient Variables Disease-Specific Variables

SpO2 and/or PaO2 Exhaled tidal volume Subjective work of breathing Stability of underlying
ETCO2 and/or PaCO2 P0.1 Objective work of breathing process during testing
Dead-space fraction End-expiratory flow Peripheral perfusion
Rapid shallow breathing index Neurologic status: wakefulness, agitation, etc
Breathing frequency
Heart rate
Hemodynamic stability
Serum lactate
Mixed venous oxygen saturation
Near-infrared spectroscopy
Pulmonary compliance
Oxygenation saturation index

ETCO2 ¼ end-tidal carbon dioxide

P0.1 ¼ occlusion pressure at 100 ms

When developing a screening implementation strategy, on extubation failure risk stratification. Among those with
teams should design a protocol that prioritizes the most standard failure risk, an SBT with or without pressure sup-
prevalent diagnoses, leverages the most readily available port (PS) augmentation for either 30 min or 60–120 min
resources, and balances effort with outcomes. In our opin- was suggested. Among patients deemed at high risk for
ion, standardized ERT eligibility screening represents an extubation failure, the guidelines suggest an SBT without
ideal first step in guideline implementation given its appeal- PS (ie, CPAP or T-piece) for 60–120 min. Regardless of
ing innovation profile, limited barriers, and potential impact methodology, an SBT protocol with objective pass/fail cri-
on patient outcomes. teria is critical. Whereas there was no recommendation for
specific pass/fail criteria or who should administer the SBT
Spontaneous Breathing Trials in the guidelines, using a common pass/fail criterion for
SBT may improve patients’ outcomes.14 Table 3 shows fac-
Recommendation Summary tors that may be important to consider as criteria, but most
are inadequate predictors of extubation failure in isolation.32
In comparison to clinical assessment of extubation readi-
ness, two additional recommendations emphasized the use Gap Analysis: Contemporary Practice and Evidence
of a protocolized ERT bundle that includes an SBT. An
SBT aims to predict if a patient is ready to reassume the In a survey of 555 international pediatric intensivists
work load of spontaneous breathing. Three conditional rec- (2022), most reported utilizing some form of SBT during
ommendations addressed specific SBT methodology based weaning (86%).11 The majority endorsed routine use of PS

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IMPLEMENTING PEDIATRIC VENTILATOR LIBERATION GUIDELINES

during that SBT (80%), with roughly half of those utilizing duration of mechanical ventilation without increasing extu-
PS inversely correlated with endotracheal tube (ETT) diam- bation failure rates or noninvasive ventilation use.45 In chil-
eter. CPAP alone (9%) and T-piece (9%) were uncom- dren with congenital heart disease, there was a reduction in
mon.11 This practice is likely related to concerns about both extubation failure and ICU length of stay.46
increased resistance in small ETTs. This has been chal-
lenged by pediatric studies published over the last two dec- Closing the Gap: Implementation Barriers and
ades, which highlight that any amount of PS augmentation Facilitators
(including automated tubing compensation) may underesti-
mate postextubation work of breathing.33-40 However, the SBTs are already prevalent in clinical practice; however,
impact on patient-centered clinical outcomes remains in limited evidence exists to inform how to conduct an SBT
question. Whereas CPAP alone might better estimate post- and whether this should differ based on a perceived high
extubation work of breathing and decrease extubation fail- risk of extubation failure. The guidelines suggest some cri-
ure rate, theoretical concern exists that SBT failure could teria to identify children at high risk of extubation failure
lead to delayed extubation. A recent randomized non-inferior- (Table 2), but these are supported by limited evidence and
ity trial found no difference in extubation success between may or may not align with clinician biases (CFIR, innova-
cohorts undergoing a 2-h SBT with PS versus no PS.41 tion and individuals domain). Moreover, risk stratification
Importantly, both groups demonstrated high first SBT pass is an additional step that must be standardized. Despite
rates (> 85%) and were on low support (mean peak inspir- these barriers, a risk-stratified approach is easy to trial,
atory pressure 18 cm H2O in both groups). This would highly adaptable to local context, and is likely to be accept-
suggest a low pretest probability of extubation failure, able in PICUs/CICUs demonstrating readiness to change
which may have biased the results. Moreover, Miller et (CFIR, innovation and inner setting domains).
al42 found no difference in time to extubation or extubation PS augmentation is another likely barrier. Among patients
failure in children with congenital heart disease exposed at standard risk, the guidelines suggested an SBT with or
to variable PS (pre implementation) and fixed PS (post without PS. The amount of PS, if used, is not delineated.
implementation). Importantly, no pediatric studies exist In patients at high risk, CPAP alone or T-piece is sug-
comparing SBTs with and without PS in a subpopulation gested over PS trials.47 However, this clinical practice
of subjects at high risk for extubation failure. with SBT without PS in patients at high risk has not been
Internationally, SBT duration varies widely and is roughly widely adopted (CFIR, individuals and innovation domain).
evenly distributed between # 30 min, 31 min–1 h, and > 1 We propose that a logical first step in implementation is
h based on provider self-report.11 Two recent pediatric stud- creating a standardized SBT clinical pathway with extuba-
ies have evaluated SBT duration. The first by Knox et al43 tion failure risk-stratification. This may not entirely mirror
was a single-center, secondary analysis of an active random- the guideline recommendations at the start. However, a
ized controlled trial enrolling subjects with pediatric ARDS. clinical pathway alone is a meaningful first step that can
Using esophageal manometry as part of the SBT process, positively impact patient-centered outcomes.48 Unit resour-
they found that 40% of those passing an SBT at 30 min went ces will dictate who directs such a pathway. Several quality
on to fail by 120 min. Failure was most commonly due to improvement studies have shown positive outcomes through
objective measurement of increased work of breathing using the implementation of such pathways driven by RTs.24,25,31
esophageal manometry. They concluded that a shorter SBT In our view, the RT is an ideal provider to administer the
for these subjects may miss subjects who will later fail due SBT where possible. Giving the difficulty of observing
to progressive increased work of breathing. The second study the patients during the entire duration of SBT, electronic
was a retrospective analysis of a single-center PICU quality health records and computerized decision support using
improvement project utilizing RT-directed SBTs.44 During high-fidelity data can aid in determining SBT results. As
the first improvement cycle, all invasively ventilated subjects with screening criteria, little is known about ideal cutoffs
were exposed to a 2-h SBT. During the second cycle, the for variables used to determine SBT passage. This represents
SBT was shortened to 1 h. No other factors were changed. an important research gap as well as a potential barrier
The authors found no statistically significant differences during implementation.
in the primary outcomes of extubation failure (7.3% vs
8.5%) and rescue noninvasive ventilation at 48 h (9.3% Postextubation Upper-Airway Obstruction
vs 8.2%), although the overall pass rate was significantly Prevention
higher for the 1-h SBT (71.4 % vs 51.1%).
Regardless of the components, a protocolized SBT may be Recommendation Summary
helpful in improving outcomes. Two randomized controlled
trials evaluated the impact of a protocolized SBT on patient- The guidelines addressed methods for predicting and pre-
centered outcomes. In the PICU population, it reduced the venting postextubation upper-airway obstruction (UAO).

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The air leak test was suggested for children with a cuffed their practice does not change if the ETT is cuffed or
(but not uncuffed) ETT to help predict postextubation sub- uncuffed, with most (81%) practitioners “almost always” or
glottic UAO. Among patients identified as high risk for “sometimes” utilizing the air leak test.11 However, only a
postextubation UAO, the guidelines suggest administering small percentage of all respondents (12%) reported using a
dexamethasone at least 6 h prior to extubation. Both rec- specific air leak pressure threshold when deciding to pre-
ommendations were conditional based on very low cer- scribe corticosteroids for the prevention of postextubation
tainty of evidence.14 UAO. Interestingly, nearly a quarter (23%) of respondents
indicated they routinely prescribe corticosteroids for all
Gap Analysis: Contemporary Practice and Evidence patients prior to extubation.11

Postextubation UAO is prevalent and is the cause of Closing the Gap: Implementation Barriers and
33–50% of pediatric extubation failures.8,49 UAO can Facilitators
occur along the entire upper airway, and it can be difficult
to distinguish subglottic and supraglottic obstruction at the The air leak test is widely used in clinical practice. De-
bedside. Using esophageal manometry and respiratory implementation for uncuffed ETTs remains an opportunity.
inductance plethysmography, Khemani et al50 recently Prescription of corticosteroids for UAO prevention is rela-
showed that half of UAO events are actually supraglottic. tively common practice; however, a specific pressure thresh-
Nonetheless, subglottic obstruction is of specific interest old is not routinely used to inform their prescription. Both
in ERTs. It can be predicted with reasonable diagnostic the air leak test and corticosteroids are utilized widely avail-
accuracy using the air leak test (when the tube is cuffed) able and low-cost resources. They have seen deep penetrance
and can potentially be prevented with corticosteroid into clinical practice and appear to be widely acceptable.
administration. Moreover, extubation failure due to sub- Therefore, modifying their implementation to include a leak
glottic UAO should be mitigated as it is associated with pressure threshold that guides corticosteroids prescrip-
increased long-term airway morbidity.2 tion for UAO prevention is a likely first step (CFIR,
The guideline evaluated available studies to determine innovation domain).
pooled sensitivities and specificities for the air leak test as a A key challenge to implementing this approach is timing
predictor for extubation failure as well as postextubation and work-flow integration (CFIR, inner setting and individ-
UAO. A reasonable relationship was only identified for uals domain). It is not always readily apparent that a patient
cuffed tubes and postextubation UAO (pooled sensitivity will extubate soon. In patients at high risk for UAO without
0.57 [95% CI 0.54–0.93]; specificity 0.91 [95% CI 0.32– an air leak who are otherwise ready to extubate, corticoste-
1.00]).14 Importantly, air leak presence was defined as a roids should be administered 6–12 h prior to extubation.
leak < 25–30 cm H2O. Whereas the air leak test has seen a Given the uncertainty of evidence for the outcome of re-
long clinical tenure, new approaches are emerging. Most intubation, the guideline specifically suggested against
recently, point-of-care laryngeal ultrasound has shown delaying extubation beyond 6 h to administer corticoste-
promise as a pre-extubation predictor of subglottic UAO in roids. However, to maximize the potential benefit of
adults and children.51-58 corticosteroids, for children with cuffed ETTs air leak
Systemic corticosteroids are commonly prescribed to should be monitored from the start of weaning and pre-
prevent postextubation UAO.59 As part of the guideline scribers must anticipate extubation to appropriately time
development, a network meta-analysis of 8 trials that eval- steroid prescription when indicated. Many institutions
uated the impact of dexamethasone on postextubation have standard practices to monitor for air leak routinely
UAO and extubation failure was performed.15 They com- to determine the volume of air to put into the cuff, and
pared groups of high ($ 0.5 mg/kg/dose) versus low dose timing of corticosteroid prescription can leverage this
(< 0.5/mg/kg/dose) dexamethasone as well as early ($ 12 h practice.11
pre extubation) versus late exposure (< 12 h). Early, high-
dose dexamethasone was found to be the most likely Postextubation Noninvasive Respiratory Support
effective strategy for prevention of postextubation UAO,
although early low-dose dexamethasone also appeared to Recommendation Summary
be highly effective. Further, the studies included were under-
powered for re-intubation. Therefore, no conclusions could Noninvasive respiratory support (NRS) is defined as
be drawn for that outcome. high-flow nasal cannula (HFNC), CPAP, or bi-level posi-
At the PICU/CICU level, international prevalence of tive airway pressure (BPAP).16 There were several guide-
ETT cuff management (56%) and postextubation UAO pre- line recommendations regarding postextubation NRS. Each
vention clinical pathways (42%) are limited.10 Among sur- was a conditional recommendation with very low certainty
veyed pediatric intensivists, a majority (88%) indicated of evidence. First, patients at high risk for extubation failure

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IMPLEMENTING PEDIATRIC VENTILATOR LIBERATION GUIDELINES

should receive planned NRS over conventional oxygen Closing the Gap: Implementation Barriers and
therapy (eg, nasal cannula or simple face mask). Second, Facilitators
for patients < 1 y old who are being started on NRS, CPAP
should be used over HFNC. Finally, and rather intuitively, Compared to conventional oxygen therapy, NRS modal-
patients demonstrating respiratory distress on conventional ities command more unit resources. These include nursing
oxygen therapy should be escalated to NRS.14 Importantly, and RT burden as well as costs. Whereas HFNC might
the guidelines prioritized avoiding postextubation treatment require less time to set-up and maintain compared to CPAP
failure when making these recommendations. and NIV, it requires more resources than conventional oxy-
gen therapy and can affect patient’s enteral nutrition and
length of stay in PICU and the hospital. Further, not all
Gap Analysis: Contemporary Practice and Evidence
NRS modalities may be available in resource-limited areas.
Preventing treatment failure should be balanced with these
The use of NRS is well established in pediatric critical
competing demands, which may be prioritized differently
care practice. Whereas CPAP and BPAP have been used
between units. As such, we anticipate postextubation NRS
for many years, HFNC use has seen a tremendous increase
use will have varying local acceptability, feasibility, and
recently both to prevent intubation and postextubation to
uptake profiles (CFIR, inner setting and innovation domains).
prevent re-intubation.60-61 A majority of international pedi-
In an effort to offset the increased resource utilization associ-
atric intensivists (83%) reported using planned HFNC fol-
ated with NRS, it may be beneficial to implement weaning
lowing # 50% of their planned extubations. CPAP and
pathways. Several recent studies have shown decreased
BPAP use was less prevalent, with most (80%) utilizing
HFNC duration using this approach. Most of those studies
them in # 20% of their planned extubations. Self-reported
used RT-driven management and weaning protocols.69-72
utilization rates were higher for certain high-risk popula-
Another resource factor to consider during implementation
tions, with HFNC being deployed most frequently postex-
is the availability and variety of interfaces (especially in
tubation for patients with chronic lung disease (67%) and
younger children). Creating an occlusive interface to deliver
CPAP/BPAP being most commonly used for patients with
CPAP or BPAP for some patients may be a barrier where
neuromuscular disease (73%).11
interface options are limited (CFIR, innovation and individu-
The guidelines identified 7 randomized controlled trials
als domains). Finally, the need for sedation in some patients
that compared conventional oxygen therapy and different
as well as the risks for pressure injury is important to balance.
NRS modalities.62-68 In pairwise analysis, NRS demon-
strated a lower odds of extubation failure when compared
to conventional oxygen therapy (odds ratio 0.60 [95% CI Additional ERT Bundle Elements
0.31–1.14]). In an attempt to determine which modality of
NRS was best for preventing extubation failure, a network Recommendation Summary
meta-analysis was performed showing that BPAP/CPAP
has the highest probability of being effective (60%). The As part of the ERT bundle, the guidelines suggest the use
authors also evaluated NRS methods for the broader out- of maximum inspiratory pressure (PImax) as an objective
come of treatment failure defined as re-intubation, cross assessment of respiratory muscle strength in patients at
over to another form of NRS, or escalation to BPAP. Once high risk. Three good practice statements also endorsed
again, BPAP/CPAP had the highest probability of being the evaluation of sedation status, cough effectiveness, and the
most effective strategy (68%).14 ability to manage oropharyngeal secretions. The methods
The most recent randomized controlled trial on this topic for cough and secretion assessment were not stated. The
was performed by Ramnarayan et al.62 This was a prag- guidelines suggested a targeted sedation strategy using a
matic, multi-center, non-inferiority trial comparing the im- validated assessment tool but stopped short of recommend-
mediate postextubation use of HFNC versus CPAP. The ing for or against a sedation titration protocol.14
primary outcome was time to liberation from all respiratory
support devices. Roughly 300 subjects were enrolled in Gap Analysis: Contemporary Practice and Evidence
each arm, and HFNC failed to meet the non-inferiority
threshold when compared to CPAP. Interestingly, mortality PImax is not commonly utilized in self-reported extuba-
at day 180 was significantly higher in the HFNC group tion decision-making. More than half of pediatric critical
(odds ratio 3.07 [95% CI 1.10–8.80]). No other secondary care survey respondents (55%) indicated that they rarely or
outcomes were statistically significant. The median age never utilize this objective measure for respiratory muscle
was 3 months old in this trial. Likewise, the majority of strength.11 Two recent studies demonstrated inverse corre-
the studies included in the guidelines consisted mostly of lation of PImax and extubation failure. Khemani et al73
children < 1 y of age. reported a higher extubation failure rate for subjects with a

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and proofread. However, this version may differ from the final published version in the online and print editions of RESPIRATORY CARE
 RESPIRATORY CARE Paper in Press. Published on April 17, 2024 as DOI: 10.4187/respcare.11708

IMPLEMENTING PEDIATRIC VENTILATOR LIBERATION GUIDELINES

PImax # 30 cm H2O (14% vs 6%). Extubation failure was most likely barrier to widespread adoption. However, the
even more likely when those weak subjects experienced guidelines justification document includes detailed proce-
postextubation UAO, which emphasizes the multifactorial dure instructions. Educational material on how to perform
nature of extubation failure.73 Using a retrospective deriva- PImax may aid in overcoming this barrier. There is little risk
tion and validation cohort, Toida et al74 identified PImax > 50 to the patient, but the test should not be performed while
cm H2O as a predictor of extubation success, with a positive the patient is connected to the ventilator as the validity of
predictive value of 96%. Importantly, these studies evaluated these built-in maneuvers for the pediatric patient varies
a cross-section of invasively ventilated children rather than among ventilators. The patient should be disconnected
exclusively those at high risk for extubation failure. from the ventilator and the manometer attached. In cooper-
In contrast to PImax, a majority reported “almost always” ative, developmentally appropriate patients, an accurate
using secretion burden (53%) and a standardized sedation PImax is relatively easy to obtain. However, because not all
measure (53%) in ERTs in the same international survey. children can follow directions, a standardized approach
Cough effectiveness was not queried.11 Cough effective- such as continuous airway occlusion taking the largest
ness and the capacity to manage oropharyngeal secretions PImax obtained in 3–5 breath attempts should be used
are generally subjective assessments. Cough strength can (CFIR, inner setting and individuals domain). This method
be objectively measured by cough peak flows, but it is is described in the guideline supplement.14 Lastly, upper
unclear how this test is best performed in the intubated and lower cutoffs for PImax are described, but it is unclear
patient. A recent meta-analysis (2022) in adult subjects how to act on intermediate values (20–50 cm H2O). Clinical
demonstrated an inverse association of cough peak flows judgment is needed in those scenarios to consider the other
with extubation failure. However, measurement methodol- risk factors for extubation failure and appropriately plan the
ogy was widely variable in the included studies.75 No pedi- peri-extubation strategy (ie, NRS, corticosteroids if risk for
atric studies have evaluated the association between cough UAO; CFIR, innovation domain).
peak flows and extubation outcome. It is unclear how or who should evaluate cough effective-
No studies have evaluated oropharyngeal secretions and ness and oropharyngeal secretion management. Nonetheless,
pediatric extubation outcomes. However, several have it seems both are already common in extubation decision
looked at endotracheal secretions. A 2014 survey found that making. As such, the primary barrier to widespread imple-
most pediatric intensivists consider endotracheal suction fre- mentation of a standardized assessment is a lack of evidence
quency of every 2–4 h as acceptable for extubation.76 In a sin- (CFIR, innovation domain). Future studies are needed to
gle-center prospective study comparing nursing and RT determine the best standardized evaluation methods as part
assessments of endotracheal secretions, nursing assignment of of an ERT. Accordingly, these were good practice state-
secretion tenacity (thick vs thin) was associated with extuba- ments in the guidelines. Clinicians should continue to con-
tion failure. Importantly, inter-rater reliability was poor.77 In sider those factors in a manner appropriate for their given
contrast, a retrospective evaluation of children with neurocriti- unit and patient context.
cal illness found no relationship between endotracheal secre-
tions and extubation failure or tracheostomy placement.78 Role of the Respiratory Therapist
The guidelines did not identify any studies focused on
sedation in the peri-extubation period. As such, protocol- The RT is an integral member of the multidisciplinary
ized sedation throughout the course of invasive mechanical critical care team. That team functions most efficiently and
ventilation was the focus of the guideline literature review. effectively when all members are empowered to practice at
The most recent studies on this topic were previously dis- their maximum scope of practice. The American Association
cussed in this review (RESTORE, 2015 and SANDWICH, for Respiratory Care position statement (updated in March
2021).26,28 Ista et al13 reported that standardized sedation 2023) describes a wide-ranging scope of practice for the RT
assessment pathways are common internationally. including titration of invasive ventilation, providing and
monitoring responses to therapeutic interventions, as well as
Closing the Gap: Implementation Barriers and the “utilization of protocols, guidelines, pathways, and poli-
Facilitators cies driven by evidence-based medicine, expert opinion, and
standards of practice.”79 The RT, by virtue of their scope of
It is likely that PImax is most frequently measured in practice and close interaction with the patient throughout the
patients with a known neuromuscular diagnosis. The rec- critical care continuum, is critical to the successful imple-
ommendation would expand its use more broadly to those mentation of any ventilator liberation initiative.
at high risk of extubation failure or respiratory muscle Potential barriers to RT-driven ventilator liberation will
weakness. Supplies (eg, manometers) are generally low be different in every location. As such, it is critical that a
cost, routinely available, and easy to use (CFIR, individuals local contextual assessment serves as the foundation of any
domain). We anticipate PImax testing methodology to be the implementation effort (such as with the CFIR). Some

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 RESPIRATORY CARE Paper in Press. Published on April 17, 2024 as DOI: 10.4187/respcare.11708

IMPLEMENTING PEDIATRIC VENTILATOR LIBERATION GUIDELINES

Table 4. Potential Barriers and Mitigation Strategies for Respiratory Therapist–Driven Ventilator Liberation

Potential Barrier Mitigation Strategies

Prescriber resistance to RT-driven Shared development of standardized clinical pathways

ventilator liberation Transparent data sharing using dashboards focusing on key process and outcome measures
Start with small changes involving lower risk interventions and/or patient groups (example: eligibility
screening of patients intubated for single organ failure)
Avoid initial implementation efforts targeting more controversial or tightly held unit cultural or prescriber
stylistic practices (example: PS practices during an SBT or nocturnal extubation)
Focus on early wins and publicize them to the entire multidisciplinary team
Identify potential early adopters as well as a prescriber champion
Meet regularly as a team to discuss progress and barriers
Promote willingness to adapt or scrap an intervention or implementation strategy that is not working
Share existing evidence for safety and efficacy of RT-driven interventions (within the same unit or from
other units/institutions)
Unit resource limitations Share responsibility with nurses and prescribers
Lack of unit-dedicated RTs Clearly delineate roles, maintain open communication, and practice detailed handoffs during transitions
Staffing limitations Focus interventions during times of optimal staffing (example: day shift)
Excessive work load Share the load with nurses and prescribers as appropriate
Cluster care. Structure interventions (example: screening) to coincide with existing processes (example:
ventilator checks or shift change)
Leverage opportunities for automation or support using the electronic medical record or computerized
decision support

RT ¼ respiratory therapist
PS ¼ pressure support
SBT ¼ spontaneous breathing trial

possible barriers include prescriber resistance (CFIR, indi- collaborative will also aim to contribute to closing important
viduals domain), unit resource limitations (CFIR, inner evidence gaps identified in the guidelines.
setting domain), and work load (CFIR, individuals domain).
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