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A 30-Minute Spontaneous Breathing Trial Misses Many Children Who Go On to Fail a 120-Minute Spontaneous Breathing
Kelby E Knox1, Justin C Hotz1, Christopher J L Newth2
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
Insights
A 30-minute spontaneous breathing trial (SBT) may be insufficient for children with pediatric ARDS. Many children fail later in the trial, and early clinical parameters do not reliably predict outcomes, highlighting the need for longer trials.
Area of Science:
- Pediatric critical care medicine
- Respiratory physiology
- Mechanical ventilation weaning
Background:
- The optimal duration of spontaneous breathing trials (SBTs) for children is not established.
- Understanding SBT failure patterns in pediatric acute respiratory distress syndrome (ARDS) is crucial for safe extubation.
Purpose of the Study:
- To determine common reasons and timing for SBT failure in children.
- To assess if clinical parameters at 30 minutes of a 120-minute SBT can predict successful extubation in pediatric ARDS.
Main Methods:
- Secondary analysis of a clinical trial involving 2-hour daily SBTs in pediatric ARDS patients.
- SBT failure defined by objective criteria, including esophageal manometry for respiratory effort.
- Spirometry (respiratory rate, tidal volume, RSBI), pulse oximetry, and capnography were used; predictive models analyzed 30-minute data.
Main Results:
- 42% of 305 SBTs were successful; 32% failed early (≤30 min), 25% failed late (30-120 min).
- 40% of patients who passed the 30-minute mark ultimately failed by 120 minutes.
- Early clinical parameters at 30 minutes did not reliably predict SBT outcome; predictive models showed poor performance.
Conclusions:
- A 30-minute SBT may be too short for children recovering from ARDS, as late failures are common.
- Early measures of tidal volume, respiratory rate, and gas exchange do not capture breathing effort, limiting their predictive value for SBT success.
Background:
The optimal length of spontaneous breathing trials (SBTs) in children is unknown.
Research Questions:
What are the most common reasons for SBT failure in children, and when do they occur? Can clinical parameters at the 30-min mark of a 120-min SBT predict outcome?
Study Design And Methods:
We performed a secondary analysis of a clinical trial in pediatric ARDS, in which 2-h SBTs are conducted daily. SBT failure is based on objective criteria, including esophageal manometry for effort of breathing, categorized as passage, early failure (≤ 30 min), or late failure (30-120 min). Spirometry was used to calculate respiratory rate (RR), tidal volume (Vt), and rapid shallow breathing index (RSBI), in addition to pulse oximetry and capnography. Predictive models evaluated parameters at 30 min against SBT outcome, using receiver operating characteristic plots and area under the curve.
Results:
We included 100 children and 305 SBTs, with 42% of SBTs being successful, 32% failing within 30 min, and 25% failing between 30 and 120 min. Of the patients passing SBTs at 30 min, 40% went on to fail by 120 min. High respiratory effort (esophageal manometry) was present in > 80% of failed SBTs. At the 30-min mark, there were no clear thresholds for RR, Vt, RSBI, Fio2, oxygen saturation, or capnography that could reliably predict SBT outcome. Multivariable modeling identified RR (P < .001) and RSBI > 7 (P = .034) at 30 min, pre-SBT inspiratory pressure level (P = .009), and pre-SBT retractions (P = .042) as predictors for SBT failure, but this model performed poorly in an independent validation set with the receiver operating characteristic plot crossing the reference line (area under the curve, 0.67).
Interpretation:
A 30-min SBT may be too short in children recovering from pediatric ARDS because many go on to fail between 30 and 120 min. Reassuring values of Vt, RR, and gas exchange at 30 min do not reliably predict SBT passage at 2 h, likely because they do not capture the effort of breathing.
Clinical Trial Registration:
ClinicalTrials.gov; No.: NCT03266016; URL: www.
Clinicaltrials:
gov.
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