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Published on: April 7, 2021
Ventilator-Weaning Pathway Associated With Decreased Ventilator Days in Pediatric Acute Respiratory Distress Syndrome
Sanjiv D Mehta1, Kelly Martin2, Nancy McGowan3
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
Protocolized ventilator weaning significantly reduced mechanical ventilation duration in pediatric acute respiratory distress syndrome survivors. This approach improved patient outcomes without increasing reintubation rates, offering a valuable clinical strategy.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Clinical Trial Methodology
Background:
- Limited evidence exists on protocolized ventilator weaning for pediatric acute respiratory distress syndrome (ARDS).
- Understanding the impact of standardized weaning protocols is crucial for optimizing care in pediatric intensive care units (PICUs).
Purpose of the Study:
- To evaluate if a protocolized ventilator weaning pathway reduces mechanical ventilation duration in pediatric ARDS survivors.
- To assess the effect of this pathway on Pediatric Intensive Care Unit (PICU) length of stay.
Main Methods:
- Secondary analysis of a prospective pediatric ARDS cohort (Berlin definition) from 2011-2019.
- Interrupted time series analysis compared outcomes before and after implementing a ventilator-weaning pathway in May 2016.
- Included survivors with <= 100 ventilator days; excluded nonsurvivors and those with prolonged ventilation.
Main Results:
- Pathway implementation was associated with a median decrease of 3.6 ventilator days (p < 0.001).
- No significant change in reintubation rates was observed post-intervention.
- Results remained robust after adjusting for confounders and performing sensitivity analyses.
Conclusions:
- Protocolized ventilator weaning effectively shortens invasive ventilation duration in pediatric ARDS survivors.
- The intervention demonstrates a significant benefit without compromising patient safety (reintubation rates).
- The observed effect size is comparable to targets in ARDS clinical trials, supporting its clinical utility.
Objectives:
There is limited evidence on the impact of protocolized ventilator weaning in pediatric acute respiratory distress syndrome, despite utilization in clinical trials and clinical care. We aimed to determine whether protocolized ventilator weaning shortens mechanical ventilation duration and PICU length of stay in pediatric acute respiratory distress syndrome survivors.
Design:
Secondary analysis of a prospective pediatric acute respiratory distress syndrome (Berlin definition) cohort from July 2011 to June 2019 analyzed using interrupted time series analysis pre- and postimplementations of a ventilator-weaning pathway. We compared duration of invasive ventilation and PICU length of stay in survivors before and after implementation of a ventilator-weaning pathway. We excluded PICU nonsurvivors and subjects with greater than 100 ventilator days.
Setting:
Large academic tertiary-care PICU.
Patients:
Children with acute respiratory distress syndrome who survived to PICU discharge with less than or equal to 100 days of invasive mechanical ventilation.
Interventions:
Implementation of a ventilator-weaning pathway on May 2016.
Measurements And Main Results:
Of 723 children with acute respiratory distress syndrome, 132 subjects died and six subjects with ventilation greater than 100 days were excluded. Of the remaining 585 subjects, 375 subjects had acute respiratory distress syndrome prior to pathway intervention and 210 after. Patients in the preintervention epoch were younger, more likely to have infectious acute respiratory distress syndrome, and had increased use of alternative ventilator modes. Pathway adoption was rapid and sustained. Controlling for temporality, pathway implementation was associated with a decrease of a median 3.6 ventilator days (95% CI, -5.4 to -1.7; p < 0.001). There was no change in the reintubation rates. Results were robust to multiple sensitivity analyses adjusting for confounders.
Conclusions:
Ventilator-weaning pathway implementation shortened invasive ventilation duration in pediatric acute respiratory distress syndrome survivors with no change in reintubation. The effect size of this intervention was comparable with those targeted in acute respiratory distress syndrome trials.
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