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Weaning children from mechanical ventilation: a prospective randomized trial of protocol-directed versus
T R Schultz1, R J Lin, H M Watzman
1The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104-4399, USA. schultz@email.chop.edu
Insights
Protocol-directed weaning significantly reduced weaning time in pediatric patients compared to physician-directed methods. This approach optimizes mechanical ventilation duration and resource utilization in pediatric intensive care units.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Therapy
- Clinical Outcomes Research
Background:
- Mechanical ventilation is a critical support in pediatric intensive care units (PICUs).
- Weaning from mechanical ventilation is a complex process with variable approaches.
- Optimizing weaning protocols can improve patient outcomes and resource management.
Purpose of the Study:
- To compare the effectiveness of protocol-directed versus physician-directed weaning from mechanical ventilation in pediatric patients.
- To evaluate the impact of a standardized weaning algorithm on ventilation duration and patient safety.
Main Methods:
- A prospective-randomized study was conducted in pediatric and cardiac intensive care units.
- 223 pediatric patients were enrolled, divided into physician-directed (n=116) and protocol-directed (n=107) weaning groups.
- Outcomes monitored included ventilation time, weaning time, extubation time, and incidence of complications like reintubation and pneumonia.
Main Results:
- The protocol-directed group demonstrated shorter overall total ventilation time, weaning time, pre-weaning time, and time to extubation.
- While not all differences remained significant after stratification by diagnosis, weaning time was significantly shorter in the protocol group.
- No significant differences were observed in mortality scores (PRISM III) or the incidence of reintubation, tracheitis, subglottic stenosis, or pneumonia.
Conclusions:
- Protocol-directed weaning is associated with a shorter weaning time in pediatric patients compared to physician-directed weaning.
- Standardized protocols may offer an efficient approach to mechanical ventilation management in pediatric critical care.
- Further research can explore the long-term benefits and broader applicability of protocol-directed weaning strategies.
Objective:
Compare outcomes between physician-directed and protocol-directed weaning from mechanical ventilation in pediatric patients.
Design:
Prospective-randomized.
Setting:
Pediatric and cardiac intensive care units in a 307-bed tertiary referral hospital for children.
Interventions:
The control group (physician-directed) was weaned according to individual physician order for reduction in minute ventilation, positive end-expiratory pressure, and ordered oxygen saturation parameters for reduction in fraction of inspired oxygen (F(IO)(2)). The study group (protocol-directed) was weaned according to a predetermined algorithm developed for the purpose of this investigation.
Methods:
The study enrolled 223 patients (116 physician-directed, 107 protocol-directed). All patients were monitored for hemodynamics, ventilator parameters, arterial blood gas values when available, oxygen saturation, weaning time, pre-weaning time, extubation time, and time on F(IO)(2) > or = 0.40. We also monitored the incidence of reintubation, subglottic stenosis, tracheitis, and pneumonia. The protocol-directed group had additional measurements of actual versus predicted minute volume, comparisons of respiratory rate (actual versus predicted for age), and presence of spontaneous breathing effort for 10 consecutive minutes. Data analysis was done according to intent to treat.
Results:
There was no significant difference in 12-hour and 24-hour pediatric risk of mortality (PRISM III) scores between groups. The protocol-directed group overall had shorter total ventilation time, weaning time, pre-weaning time, time to extubation, and time on F(IO)(2) >0.40, although after stratification for respiratory diagnosis, only the difference in weaning time remained significant. There was no difference in the incidence of reintubation, new-onset tracheitis, subglottic stenosis, or pneumonia.
Conclusions:
Protocol-directed weaning resulted in a shorter weaning time than physician-directed weaning in these pediatric patients.
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