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Updated: Dec 2, 2025
Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 17, 2011
Extubation Readiness Practices and Barriers to Extubation in Pediatric Subjects
Johnny M Krasinkiewicz1, Matthew L Friedman2, James E Slaven3
1Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana. jkrasink@iu.edu.
Insights
Pediatric extubation readiness protocols show variation, delaying ventilator liberation. Adjusting spontaneous breathing trials (SBTs) may improve efficiency without increasing failure rates.
Area of Science:
- Pediatric critical care medicine
- Respiratory therapy
- Mechanical ventilation
Background:
- Invasive mechanical ventilation is crucial but linked to patient morbidities.
- Extubation readiness protocols aim to reduce failure and ventilation duration.
- This study evaluated extubation practices and barriers in pediatric patients post-extubation readiness test (ERT).
Purpose of the Study:
- To analyze institutional extubation readiness practices.
- To identify barriers to extubation in pediatric patients who passed an extubation readiness test (ERT).
Main Methods:
- Retrospective chart review of pediatric patients on mechanical ventilation (April 2017-March 2018).
- Exclusion criteria included cardiac ICU, tracheostomy, chronic ventilation, limited resuscitation, and death before extubation.
- Data collected on ERT methods and reasons for extubation delay.
Main Results:
- 427 patients analyzed; 69% underwent an ERT.
- 39% were extubated via daily spontaneous breathing trial (SBT) protocol; 30% failed daily SBT but passed subsequent trials.
- Common ERT failures: lack of spontaneous breathing (30%), short intubation duration (24%). Common delays: planned procedures (29%), neurologic status (23%). Median time from ERT to extubation was 7 hours.
Conclusions:
- Institutional extubation readiness practices varied, causing significant delays in ventilator liberation.
- Adjusting SBTs to allow higher breathing rates and lower tidal volumes, plus sedation scoring, may optimize protocols without increasing extubation failure.
Background:
Invasive mechanical ventilation is a lifesaving intervention that is associated with short- and long-term morbidities. Extubation readiness protocols aim to decrease extubation failure rates and simultaneously shorten the duration of invasive ventilation. This study sought to analyze extubation readiness practices at one institution and identify barriers to extubation in pediatric patients who have passed an extubation readiness test (ERT).
Methods:
We performed a retrospective chart review of all pediatric subjects admitted between April 2017 and March 2018, and who were on mechanical ventilation. Exclusion criteria were cardiac ICU admission, tracheostomy, chronic ventilator support, limited resuscitation status, and death before extubation attempt. Data with regard to the method of ERT and reasons for delaying extubation were collected.
Results:
There were 427 subjects included in the analysis with 69% having had an ERT before extubation. Of those, 39% were extubated per our daily spontaneous breathing trial (SBT) protocol, and the daily SBT failed in 30% but they had passed a subsequent pressure support and CPAP trial on the same day. The most common reasons for failing the daily SBT were a lack of spontaneous breathing (30% [75/252]), being intubated < 24 h (24% [60/252]), breathing frequency outside the target range (22% [55/252]), and not meeting tidal volume goal (14% [34/252]). The most common documented reasons for delaying extubation despite passing daily SBT were planned procedure (29% [26/90]), neurologic status (23% [21/90]), and no leak around the endotracheal tube (18% [16/90]). The median time between passing ERT and extubation was 7 h (interquartile range, 5-10).
Conclusions:
In our institution, there was variation in extubation readiness practices that could lead to a significant delay in liberation from invasive ventilation. Adjustment of our daily SBT to tolerate a higher work of breathing, such as higher breathing frequencies and lower tidal volumes, and incorporating sedation scoring into the protocol could be made without significantly affecting extubation failure rates.
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