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Published on: January 17, 2011
Factors Associated With Successful Extubation Readiness Testing in Children With Congenital Heart Disease
Andrew G Miller1,2, Jessica Brown2, Olivia Marshburn2
1Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Andrew.g.miller@duke.edu.
Insights
Extubation readiness testing (ERT) in children with congenital heart disease is more successful with lower ventilator support. Protocols should consider using the dead-space-to-tidal-volume ratio for ERT eligibility.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiology
- Respiratory Therapy
Background:
- Extubation readiness testing (ERT) is crucial for weaning children with congenital heart disease off mechanical ventilation.
- Limited data exists on mechanical ventilation parameters influencing successful ERT in this population.
Purpose of the Study:
- To identify mechanical ventilation parameters associated with successful ERT in children with congenital heart disease.
- To hypothesize that specific ventilator settings correlate with ERT outcomes.
Main Methods:
- Retrospective analysis of daily ERT assessments from a quality improvement project.
- Evaluation of mechanical ventilation parameters including mode, pressures, and ratios.
- Primary outcome measured was ERT success, defined by successful extubation.
Main Results:
- 780 ERTs from 320 subjects were analyzed; 58% resulted in successful extubation.
- ERT pass rates differed significantly with ventilator mode, peak inspiratory pressure, Δ pressure, PEEP, mean airway pressure, and dead-space-to-tidal-volume ratio (all P < .001).
- Increased ventilator support (higher pressures, PEEP, Δ pressure, and dead-space-to-tidal-volume ratio) was associated with decreased ERT success.
Conclusions:
- ERT success is linked to ventilator support levels, with lower support correlating to higher success rates.
- The dead-space-to-tidal-volume ratio is a significant factor in ERT success, suggesting its use over PEEP thresholds in protocols.
- Congenital heart disease patients, including those with cyanotic lesions, can be considered for ERT protocols.
Background:
In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate the potential for liberation from mechanical ventilation. There is a paucity of data that suggests what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with certain mechanical ventilator parameters.
Methods:
Data on daily ERT assessments were recorded as part of a quality improvement project. In accordance with our respiratory therapist-driven ventilator protocol, patients were assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate the differences in levels of respiratory support. The primary outcome was ERT success.
Results:
A total of 780 ERTs from 320 subjects (median [interquartile range] age 2.5 [0.6-6.5] months and median weight [interquartile range] 4.2 [3.3-6.9] kg) were evaluated. A total of 528 ERTs (68%) were passed, 306 successful ERTs (58%) resulted in extubation, and 30 subjects (9.4%) were re-intubated. There were statistically significant differences in the ERT pass rate for ventilator mode, peak inspiratory pressure, Δ pressure, PEEP, mean airway pressure ([Formula: see text]), and dead-space-to-tidal-volume ratio (all P < .001) but not for [Formula: see text]. ERT success decreased with increases in peak inspiratory pressure, Δ pressure, PEEP, [Formula: see text], and dead-space-to-tidal-volume ratio. Logistic regression revealed neonates, Δ pressure ≥ 11 cm H2O, and [Formula: see text] > 10 cm H2O were associated with a decreased odds of ERT success, whereas children ages 1-5 years and an [Formula: see text] of 0.31-0.40 had increased odds of ERT success.
Conclusions:
ERT pass rates decreased as ventilator support increased; however, some subjects were able to pass ERT despite high ventilator support. We found that [Formula: see text] was associated with ERT success and that protocols should consider using [Formula: see text] instead of PEEP thresholds for ERT eligibility. Cyanotic lesions were not associated with ERT success, which suggests that patients with cyanotic heart disease can be included in ERT protocols.
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