Implementing the Pediatric Ventilator Liberation Guidelines Using the Most Current Evidence

Abstract

Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation varies widely. As a first step to minimizing that variation, the first evidence-based pediatric ventilator liberation guidelines were published in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay before clinical guidelines reach widespread clinical practice. As such, it is important to consider barriers and facilitators using a systematic approach during implementation planning and design. In this narrative review, we will (1) summarize guideline recommendations, (2) discuss recent evidence and identify practice gaps relating to those recommendations, and (3) hypothesize about potential barriers and facilitators to their implementation in clinical practice.

Introduction

Every day pediatric intensivists strive to safely liberate (extubate) children from invasive mechanical ventilation and reduce associated short- and long-term complications. These complications include airway trauma, ventilator-associated infections, ventilator-induced lung injury and diaphragm dysfunction, critical care–induced neuropathy/myopathy, and cognitive impairment. Some of these complications are mediated through prolonged exposure to narcotics, sedatives, and neuromuscular blockade, with the cumulative dose closely tied to the duration of invasive mechanical ventilation.^1-7 Hence, there is a clear desire to reduce the duration of invasive mechanical ventilation, but this is often balanced against the risk of extubation failure and its associated complications.⁸ There is wide variation in pediatric ventilation liberation practices worldwide.^9-13 This is in part related to a lack of synthesized guidance on best practices. To address this gap, the first pediatric ventilator liberation guidelines were recently published.^14-17

This narrative review aims to summarize recommendations from the pediatric ventilator liberation guidelines as well as current practice gaps. In addition, whereas guidelines can inform practice, systems-based operationalization requires coordinated effort. We will conclude each section with a consideration of anticipated contextual factors that may influence implementation in pediatric ICUs (PICUs) and pediatric cardiac ICUs (CICUs).

Guideline Development

In 2023, a panel of 26 international, multi-professional experts in pediatric critical care, respiratory physiology, and ventilator liberation published the first international pediatric ventilator liberation guidelines.^14-17 These guidelines synthesized the available evidence to generate 15 recommendations covering many common aspects of pediatric ventilator liberation for children requiring invasive mechanical ventilation for > 24 h (Fig. 1). The guidelines used an established framework to report not only the recommendation but the level of certainty of each recommendation based on the available evidence.

Fig. 1.

Conceptualization of the ventilator liberation process according to guideline recommendations starting with intubation through recognition of weaning readiness (diagnostic triggering), deployment of the extubation readiness test bundle, and concluding with ventilator/respiratory support liberation. ERT = extubation readiness test; ETT = endotracheal tube; UAO = upper-airway obstruction; SBT = spontaneous breathing trial; PS = pressure support; P_Imax = maximal inspiratory pressure; HFNC = high-flow nasal cannula; BPAP = bi-level positive airway pressure.

Implementation Science Approach

On average, new guidelines take 17 years to reach routine clinical use; and when it takes this long to implement the guidelines, they often become obsolete.^18-19 Hence, after a guideline is published, we believe it is equally important to ensure timely and sustainable guideline implementation. Implementation science is a growing field that aims to close the gap between evidence and practice by focusing on real-life barriers and facilitators for implementation of evidence-based practice.²⁰ The field utilizes various frameworks to assess these contextual factors. Among the most cited is the Consolidated Framework for Implementation Research (CFIR).²¹ This framework, first published in 2009, was updated in 2022 and includes a list of constructs within 5 domains that impact implementation: the innovation, outer setting, inner setting, individuals, and the implementation process.^22-23 Here, the innovations are the pediatric ventilator liberation guideline recommendations; the outer setting is the hospital system and other external influences; the inner system is the PICU/CICU, and individuals are both those implementing the guidelines as well as patients and their families.

In this review, we will utilize the CFIR to identify potential important barriers and facilitators to implementing the pediatric ventilator liberation guidelines. We will focus on factors associated with the recommendation (innovation) itself, PICU/CICU context (inner system), and individuals working in or cared for in the PICU/CICU (individuals domain). We hope this approach helps readers contextualize what is needed to successfully implement the pediatric ventilator liberation guidelines within their own ICUs.

Extubation Readiness Testing Eligibility Screening

Recommendation Summary

Systematic screening for extubation readiness testing (ERT) eligibility was suggested over no screening.¹⁴ An ERT is a bundle of elements that inform clinicians about potential readiness to extubate. A spontaneous breathing trial (SBT) is one but not the only component of an ERT.¹⁶ Physiologic, ventilator, patient, and disease-specific variables are critical components of screening, but required elements and thresholds were not defined in the guideline. See examples in Table 1. Likewise, the ideal multi-professional team member responsible for screening was not identified given practice differences across ICUs.

Table 1.

Potential Extubation Readiness Test Eligibility Screening Variables

Gap Analysis: Contemporary Practice and Evidence

In a 2022 survey of 380 international PICUs/CICUs (also included mixed and other unit types), 47% reported use of a standardized ERT screening protocol with physician’s primarily doing the screening (63%), most often once a day (64%).¹⁰ Screening protocols were least prevalent in Europe (22%). The United States and Canada were the only regions where protocolized screening was primarily performed by respiratory therapists (RTs) (78%). These results align with a 2022 point prevalence study by Ista et al.¹³ Most contemporary interventional studies conducted in the United States report daily screening performed by RTs.^24-28

Invasive mechanical ventilation weaning begins with clinical suspicion that the patient is improved; this is often impacted by the many competing demands of the ICU.^29-30 Timely recognition of ERT eligibility should logically translate to better outcomes, but results are mixed. Three recent single-center quality improvement studies demonstrated general safety and acceptability of RT-driven screening with mixed results on patient-centered outcomes.^24,25,31 Two multi-center randomized controlled trials yielded contrasting results. The RESTORE trial (United States, 2015) compared a nursing-driven sedation protocol coupled with a daily ERT screen to usual care. There was no change in the primary outcome—duration of invasive mechanical ventilation.²⁸ More recently, the SANDWICH trial (United Kingdom, 2021) studied a similar strategy compared to usual care. The intervention group had a statistically significantly shorter time to first extubation (64.8 h vs 66.2 h).²⁶ However, the small effect size raises questions of clinical importance. Both studies included a bundle of interventions, which made it hard to dissect which interventions most impacted outcomes if at all. Whereas the adherence for ERT screening in the SANDWICH trial was 74%, only 39% of passed screens led to the initiation of an SBT. This may have decreased the effect size of the intervention bundle on duration of invasive mechanical ventilation.

Closing the Gap: Implementation Barriers and Facilitators

Screening is an intervention with low cost and high local adaptability. Moreover, a reasonable evidence base exists suggesting relative advantage over no screening. These factors make screening feasible and should promote acceptability and uptake (CFIR, innovation domain). However, barriers do exist including lack of agreement on design, optimal screening and ERT components, frequency, and responsibility. It is intuitive that certain patient populations may need tailored screening criteria (CFIR, individuals domain) (Table 2). As such, protocol design should aim to fit most but not all clinical situations. Little is known about specific cutoffs for screening components. This a critical research gap and potential barrier as well. Unit resources and infrastructure are important factors that may act as both barriers or facilitators. ERT screening might lead to earlier liberation from invasive mechanical ventilation and decreasing work load on the team members. At the same time, the screening process itself can increase the work load as well (CFIR, inner setting domain). Computerized decision support for ERT safety screening leveraging the electronic medical record or other automated tool is an attractive future direction for screening implementation. Screening frequency and responsibility are anticipated to be the most impacted by unit resources and infrastructure. In units with dedicated RTs, they can be the lead team that performs the ERT screening as they have the expertise and monitor the patient and ventilator around the clock. They collaborate with other team members like bedside nursing, advanced care providers, and physicians to ensure that other elements of ERT screening like sedation, neurological status, and hemodynamic stability are meeting the safety criteria.

Table 2.

Examples of Populations Who Might be Considered at High Risk for Extubation Failure During Guideline Implementation

When developing a screening implementation strategy, teams should design a protocol that prioritizes the most prevalent diagnoses, leverages the most readily available resources, and balances effort with outcomes. In our opinion, standardized ERT eligibility screening represents an ideal first step in guideline implementation given its appealing innovation profile, limited barriers, and potential impact on patient outcomes.

Spontaneous Breathing Trials

Recommendation Summary

In comparison to clinical assessment of extubation readiness, two additional recommendations emphasized the use of a protocolized ERT bundle that includes an SBT. An SBT aims to predict if a patient is ready to reassume the work load of spontaneous breathing. Three conditional recommendations addressed specific SBT methodology based on extubation failure risk stratification. Among those with standard failure risk, an SBT with or without pressure support (PS) augmentation for either 30 min or 60–120 min was suggested. Among patients deemed at high risk for extubation failure, the guidelines suggest an SBT without PS (ie, CPAP or T-piece) for 60–120 min. Regardless of methodology, an SBT protocol with objective pass/fail criteria is critical. Whereas there was no recommendation for specific pass/fail criteria or who should administer the SBT in the guidelines, using a common pass/fail criterion for SBT may improve patients’ outcomes.¹⁴ Table 3 shows factors that may be important to consider as criteria, but most are inadequate predictors of extubation failure in isolation.³²

Table 3.

Potential Spontaneous Breathing Trial Pass/Fail Variables

Gap Analysis: Contemporary Practice and Evidence

In a survey of 555 international pediatric intensivists (2022), most reported utilizing some form of SBT during weaning (86%).¹¹ The majority endorsed routine use of PS during that SBT (80%), with roughly half of those utilizing PS inversely correlated with endotracheal tube (ETT) diameter. CPAP alone (9%) and T-piece (9%) were uncommon.¹¹ This practice is likely related to concerns about increased resistance in small ETTs. This has been challenged by pediatric studies published over the last two decades, which highlight that any amount of PS augmentation (including automated tubing compensation) may underestimate postextubation work of breathing.^33-40 However, the impact on patient-centered clinical outcomes remains in question. Whereas CPAP alone might better estimate postextubation work of breathing and decrease extubation failure rate, theoretical concern exists that SBT failure could lead to delayed extubation. A recent randomized non-inferiority trial found no difference in extubation success between cohorts undergoing a 2-h SBT with PS versus no PS.⁴¹ Importantly, both groups demonstrated high first SBT pass rates (> 85%) and were on low support (mean peak inspiratory pressure 18 cm H₂O in both groups). This would suggest a low pretest probability of extubation failure, which may have biased the results. Moreover, Miller et al⁴² found no difference in time to extubation or extubation failure in children with congenital heart disease exposed to variable PS (pre implementation) and fixed PS (post implementation). Importantly, no pediatric studies exist comparing SBTs with and without PS in a subpopulation of subjects at high risk for extubation failure.

Internationally, SBT duration varies widely and is roughly evenly distributed between ≤ 30 min, 31 min–1 h, and > 1 h based on provider self-report.¹¹ Two recent pediatric studies have evaluated SBT duration. The first by Knox et al⁴³ was a single-center, secondary analysis of an active randomized controlled trial enrolling subjects with pediatric ARDS. Using esophageal manometry as part of the SBT process, they found that 40% of those passing an SBT at 30 min went on to fail by 120 min. Failure was most commonly due to objective measurement of increased work of breathing using esophageal manometry. They concluded that a shorter SBT for these subjects may miss subjects who will later fail due to progressive increased work of breathing. The second study was a retrospective analysis of a single-center PICU quality improvement project utilizing RT-directed SBTs.⁴⁴ During the first improvement cycle, all invasively ventilated subjects were exposed to a 2-h SBT. During the second cycle, the SBT was shortened to 1 h. No other factors were changed. The authors found no statistically significant differences in the primary outcomes of extubation failure (7.3% vs 8.5%) and rescue noninvasive ventilation at 48 h (9.3% vs 8.2%), although the overall pass rate was significantly higher for the 1-h SBT (71.4 % vs 51.1%).

Regardless of the components, a protocolized SBT may be helpful in improving outcomes. Two randomized controlled trials evaluated the impact of a protocolized SBT on patient-centered outcomes. In the PICU population, it reduced the duration of mechanical ventilation without increasing extubation failure rates or noninvasive ventilation use.⁴⁵ In children with congenital heart disease, there was a reduction in both extubation failure and ICU length of stay.⁴⁶

Closing the Gap: Implementation Barriers and Facilitators

SBTs are already prevalent in clinical practice; however, limited evidence exists to inform how to conduct an SBT and whether this should differ based on a perceived high risk of extubation failure. The guidelines suggest some criteria to identify children at high risk of extubation failure (Table 2), but these are supported by limited evidence and may or may not align with clinician biases (CFIR, innovation and individuals domain). Moreover, risk stratification is an additional step that must be standardized. Despite these barriers, a risk-stratified approach is easy to trial, highly adaptable to local context, and is likely to be acceptable in PICUs/CICUs demonstrating readiness to change (CFIR, innovation and inner setting domains).

PS augmentation is another likely barrier. Among patients at standard risk, the guidelines suggested an SBT with or without PS. The amount of PS, if used, is not delineated. In patients at high risk, CPAP alone or T-piece is suggested over PS trials.⁴⁷ However, this clinical practice with SBT without PS in patients at high risk has not been widely adopted (CFIR, individuals and innovation domain).

We propose that a logical first step in implementation is creating a standardized SBT clinical pathway with extubation failure risk-stratification. This may not entirely mirror the guideline recommendations at the start. However, a clinical pathway alone is a meaningful first step that can positively impact patient-centered outcomes.⁴⁸ Unit resources will dictate who directs such a pathway. Several quality improvement studies have shown positive outcomes through the implementation of such pathways driven by RTs.^24,25,31 In our view, the RT is an ideal provider to administer the SBT where possible. Giving the difficulty of observing the patients during the entire duration of SBT, electronic health records and computerized decision support using high-fidelity data can aid in determining SBT results. As with screening criteria, little is known about ideal cutoffs for variables used to determine SBT passage. This represents an important research gap as well as a potential barrier during implementation.

Postextubation Upper-Airway Obstruction Prevention

Recommendation Summary

The guidelines addressed methods for predicting and preventing postextubation upper-airway obstruction (UAO). The air leak test was suggested for children with a cuffed (but not uncuffed) ETT to help predict postextubation subglottic UAO. Among patients identified as high risk for postextubation UAO, the guidelines suggest administering dexamethasone at least 6 h prior to extubation. Both recommendations were conditional based on very low certainty of evidence.¹⁴

Gap Analysis: Contemporary Practice and Evidence

Postextubation UAO is prevalent and is the cause of 33–50% of pediatric extubation failures.^8,49 UAO can occur along the entire upper airway, and it can be difficult to distinguish subglottic and supraglottic obstruction at the bedside. Using esophageal manometry and respiratory inductance plethysmography, Khemani et al⁵⁰ recently showed that half of UAO events are actually supraglottic. Nonetheless, subglottic obstruction is of specific interest in ERTs. It can be predicted with reasonable diagnostic accuracy using the air leak test (when the tube is cuffed) and can potentially be prevented with corticosteroid administration. Moreover, extubation failure due to subglottic UAO should be mitigated as it is associated with increased long-term airway morbidity.²

The guideline evaluated available studies to determine pooled sensitivities and specificities for the air leak test as a predictor for extubation failure as well as postextubation UAO. A reasonable relationship was only identified for cuffed tubes and postextubation UAO (pooled sensitivity 0.57 [95% CI 0.54–0.93]; specificity 0.91 [95% CI 0.32–1.00]).¹⁴ Importantly, air leak presence was defined as a leak < 25–30 cm H₂O. Whereas the air leak test has seen a long clinical tenure, new approaches are emerging. Most recently, point-of-care laryngeal ultrasound has shown promise as a pre-extubation predictor of subglottic UAO in adults and children.^51-58

Systemic corticosteroids are commonly prescribed to prevent postextubation UAO.⁵⁹ As part of the guideline development, a network meta-analysis of 8 trials that evaluated the impact of dexamethasone on postextubation UAO and extubation failure was performed.¹⁵ They compared groups of high (≥ 0.5 mg/kg/dose) versus low dose (< 0.5/mg/kg/dose) dexamethasone as well as early (≥ 12 h pre extubation) versus late exposure (< 12 h). Early, high-dose dexamethasone was found to be the most likely effective strategy for prevention of postextubation UAO, although early low-dose dexamethasone also appeared to be highly effective. Further, the studies included were underpowered for re-intubation. Therefore, no conclusions could be drawn for that outcome.

At the PICU/CICU level, international prevalence of ETT cuff management (56%) and postextubation UAO prevention clinical pathways (42%) are limited.¹⁰ Among surveyed pediatric intensivists, a majority (88%) indicated their practice does not change if the ETT is cuffed or uncuffed, with most (81%) practitioners “almost always” or “sometimes” utilizing the air leak test.¹¹ However, only a small percentage of all respondents (12%) reported using a specific air leak pressure threshold when deciding to prescribe corticosteroids for the prevention of postextubation UAO. Interestingly, nearly a quarter (23%) of respondents indicated they routinely prescribe corticosteroids for all patients prior to extubation.¹¹

Closing the Gap: Implementation Barriers and Facilitators

The air leak test is widely used in clinical practice. De-implementation for uncuffed ETTs remains an opportunity. Prescription of corticosteroids for UAO prevention is relatively common practice; however, a specific pressure threshold is not routinely used to inform their prescription. Both the air leak test and corticosteroids are utilized widely available and low-cost resources. They have seen deep penetrance into clinical practice and appear to be widely acceptable. Therefore, modifying their implementation to include a leak pressure threshold that guides corticosteroids prescription for UAO prevention is a likely first step (CFIR, innovation domain).

A key challenge to implementing this approach is timing and work-flow integration (CFIR, inner setting and individuals domain). It is not always readily apparent that a patient will extubate soon. In patients at high risk for UAO without an air leak who are otherwise ready to extubate, corticosteroids should be administered 6–12 h prior to extubation. Given the uncertainty of evidence for the outcome of re-intubation, the guideline specifically suggested against delaying extubation beyond 6 h to administer corticosteroids. However, to maximize the potential benefit of corticosteroids, for children with cuffed ETTs air leak should be monitored from the start of weaning and prescribers must anticipate extubation to appropriately time steroid prescription when indicated. Many institutions have standard practices to monitor for air leak routinely to determine the volume of air to put into the cuff, and timing of corticosteroid prescription can leverage this practice.¹¹

Postextubation Noninvasive Respiratory Support

Recommendation Summary

Noninvasive respiratory support (NRS) is defined as high-flow nasal cannula (HFNC), CPAP, or bi-level positive airway pressure (BPAP).¹⁶ There were several guideline recommendations regarding postextubation NRS. Each was a conditional recommendation with very low certainty of evidence. First, patients at high risk for extubation failure should receive planned NRS over conventional oxygen therapy (eg, nasal cannula or simple face mask). Second, for patients < 1 y old who are being started on NRS, CPAP should be used over HFNC. Finally, and rather intuitively, patients demonstrating respiratory distress on conventional oxygen therapy should be escalated to NRS.¹⁴ Importantly, the guidelines prioritized avoiding postextubation treatment failure when making these recommendations.

Gap Analysis: Contemporary Practice and Evidence

The use of NRS is well established in pediatric critical care practice. Whereas CPAP and BPAP have been used for many years, HFNC use has seen a tremendous increase recently both to prevent intubation and postextubation to prevent re-intubation.^60-61 A majority of international pediatric intensivists (83%) reported using planned HFNC following ≤ 50% of their planned extubations. CPAP and BPAP use was less prevalent, with most (80%) utilizing them in ≤ 20% of their planned extubations. Self-reported utilization rates were higher for certain high-risk populations, with HFNC being deployed most frequently postextubation for patients with chronic lung disease (67%) and CPAP/BPAP being most commonly used for patients with neuromuscular disease (73%).¹¹

The guidelines identified 7 randomized controlled trials that compared conventional oxygen therapy and different NRS modalities.^62-68 In pairwise analysis, NRS demonstrated a lower odds of extubation failure when compared to conventional oxygen therapy (odds ratio 0.60 [95% CI 0.31–1.14]). In an attempt to determine which modality of NRS was best for preventing extubation failure, a network meta-analysis was performed showing that BPAP/CPAP has the highest probability of being effective (60%). The authors also evaluated NRS methods for the broader outcome of treatment failure defined as re-intubation, cross over to another form of NRS, or escalation to BPAP. Once again, BPAP/CPAP had the highest probability of being the most effective strategy (68%).¹⁴

The most recent randomized controlled trial on this topic was performed by Ramnarayan et al.⁶² This was a pragmatic, multi-center, non-inferiority trial comparing the immediate postextubation use of HFNC versus CPAP. The primary outcome was time to liberation from all respiratory support devices. Roughly 300 subjects were enrolled in each arm, and HFNC failed to meet the non-inferiority threshold when compared to CPAP. Interestingly, mortality at day 180 was significantly higher in the HFNC group (odds ratio 3.07 [95% CI 1.10–8.80]). No other secondary outcomes were statistically significant. The median age was 3 months old in this trial. Likewise, the majority of the studies included in the guidelines consisted mostly of children < 1 y of age.

Closing the Gap: Implementation Barriers and Facilitators

Compared to conventional oxygen therapy, NRS modalities command more unit resources. These include nursing and RT burden as well as costs. Whereas HFNC might require less time to set-up and maintain compared to CPAP and NIV, it requires more resources than conventional oxygen therapy and can affect patient’s enteral nutrition and length of stay in PICU and the hospital. Further, not all NRS modalities may be available in resource-limited areas. Preventing treatment failure should be balanced with these competing demands, which may be prioritized differently between units. As such, we anticipate postextubation NRS use will have varying local acceptability, feasibility, and uptake profiles (CFIR, inner setting and innovation domains). In an effort to offset the increased resource utilization associated with NRS, it may be beneficial to implement weaning pathways. Several recent studies have shown decreased HFNC duration using this approach. Most of those studies used RT-driven management and weaning protocols.^69-72

Another resource factor to consider during implementation is the availability and variety of interfaces (especially in younger children). Creating an occlusive interface to deliver CPAP or BPAP for some patients may be a barrier where interface options are limited (CFIR, innovation and individuals domains). Finally, the need for sedation in some patients as well as the risks for pressure injury is important to balance.

Additional ERT Bundle Elements

Recommendation Summary

As part of the ERT bundle, the guidelines suggest the use of maximum inspiratory pressure (P_Imax) as an objective assessment of respiratory muscle strength in patients at high risk. Three good practice statements also endorsed evaluation of sedation status, cough effectiveness, and the ability to manage oropharyngeal secretions. The methods for cough and secretion assessment were not stated. The guidelines suggested a targeted sedation strategy using a validated assessment tool but stopped short of recommending for or against a sedation titration protocol.¹⁴

Gap Analysis: Contemporary Practice and Evidence

P_Imax is not commonly utilized in self-reported extubation decision-making. More than half of pediatric critical care survey respondents (55%) indicated that they rarely or never utilize this objective measure for respiratory muscle strength.¹¹ Two recent studies demonstrated inverse correlation of P_Imax and extubation failure. Khemani et al⁷³ reported a higher extubation failure rate for subjects with a P_Imax ≤ 30 cm H₂O (14% vs 6%). Extubation failure was even more likely when those weak subjects experienced postextubation UAO, which emphasizes the multifactorial nature of extubation failure.⁷³ Using a retrospective derivation and validation cohort, Toida et al⁷⁴ identified P_Imax > 50 cm H₂O as a predictor of extubation success, with a positive predictive value of 96%. Importantly, these studies evaluated a cross-section of invasively ventilated children rather than exclusively those at high risk for extubation failure.

In contrast to P_Imax, a majority reported “almost always” using secretion burden (53%) and a standardized sedation measure (53%) in ERTs in the same international survey. Cough effectiveness was not queried.¹¹ Cough effectiveness and the capacity to manage oropharyngeal secretions are generally subjective assessments. Cough strength can be objectively measured by cough peak flows, but it is unclear how this test is best performed in the intubated patient. A recent meta-analysis (2022) in adult subjects demonstrated an inverse association of cough peak flows with extubation failure. However, measurement methodology was widely variable in the included studies.⁷⁵ No pediatric studies have evaluated the association between cough peak flows and extubation outcome.

No studies have evaluated oropharyngeal secretions and pediatric extubation outcomes. However, several have looked at endotracheal secretions. A 2014 survey found that most pediatric intensivists consider endotracheal suction frequency of every 2–4 h as acceptable for extubation.⁷⁶ In a single-center prospective study comparing nursing and RT assessments of endotracheal secretions, nursing assignment of secretion tenacity (thick vs thin) was associated with extubation failure. Importantly, inter-rater reliability was poor.⁷⁷ In contrast, a retrospective evaluation of children with neurocritical illness found no relationship between endotracheal secretions and extubation failure or tracheostomy placement.⁷⁸

The guidelines did not identify any studies focused on sedation in the peri-extubation period. As such, protocolized sedation throughout the course of invasive mechanical ventilation was the focus of the guideline literature review. The most recent studies on this topic were previously discussed in this review (RESTORE, 2015 and SANDWICH, 2021).^26,28 Ista et al¹³ reported that standardized sedation assessment pathways are common internationally.

Closing the Gap: Implementation Barriers and Facilitators

It is likely that P_Imax is most frequently measured in patients with a known neuromuscular diagnosis. The recommendation would expand its use more broadly to those at high risk of extubation failure or respiratory muscle weakness. Supplies (eg, manometers) are generally low cost, routinely available, and easy to use (CFIR, individuals domain). We anticipate P_Imax testing methodology to be the most likely barrier to widespread adoption. However, the guidelines justification document includes detailed procedure instructions. Educational material on how to perform P_Imax may aid in overcoming this barrier. There is little risk to the patient, but the test should not be performed while the patient is connected to the ventilator as the validity of these built-in maneuvers for the pediatric patient varies among ventilators. The patient should be disconnected from the ventilator and the manometer attached. In cooperative, developmentally appropriate patients, an accurate P_Imax is relatively easy to obtain. However, because not all children can follow directions, a standardized approach such as continuous airway occlusion taking the largest P_Imax obtained in 3–5 breath attempts should be used (CFIR, inner setting and individuals domain). This method is described in the guideline supplement.¹⁴ Lastly, upper and lower cutoffs for P_Imax are described, but it is unclear how to act on intermediate values (20–50 cm H₂O). Clinical judgment is needed in those scenarios to consider the other risk factors for extubation failure and appropriately plan the peri-extubation strategy (ie, NRS, corticosteroids if risk for UAO; CFIR, innovation domain).

It is unclear how or who should evaluate cough effectiveness and oropharyngeal secretion management. Nonetheless, it seems both are already common in extubation decision making. As such, the primary barrier to widespread implementation of a standardized assessment is a lack of evidence (CFIR, innovation domain). Future studies are needed to determine the best standardized evaluation methods as part of an ERT. Accordingly, these were good practice statements in the guidelines. Clinicians should continue to consider those factors in a manner appropriate for their given unit and patient context.

Role of the Respiratory Therapist

The RT is an integral member of the multidisciplinary critical care team. That team functions most efficiently and effectively when all members are empowered to practice at their maximum scope of practice. The American Association for Respiratory Care position statement (updated in March 2023) describes a wide-ranging scope of practice for the RT including titration of invasive ventilation, providing and monitoring responses to therapeutic interventions, as well as the “utilization of protocols, guidelines, pathways, and policies driven by evidence-based medicine, expert opinion, and standards of practice.”⁷⁹ The RT, by virtue of their scope of practice and close interaction with the patient throughout the critical care continuum, is critical to the successful implementation of any ventilator liberation initiative.

Potential barriers to RT-driven ventilator liberation will be different in every location. As such, it is critical that a local contextual assessment serves as the foundation of any implementation effort (such as with the CFIR). Some possible barriers include prescriber resistance (CFIR, individuals domain), unit resource limitations (CFIR, inner setting domain), and work load (CFIR, individuals domain). Examples as well as possible strategies to overcome these barriers are shown in Table 4.

Table 4.

Potential Barriers and Mitigation Strategies for Respiratory Therapist–Driven Ventilator Liberation

Future Directions: VentLib4Kids

Rapid implementation of the pediatric ventilator liberation guidelines is critical. However, multi-center collaboration is equally important to determine the best implementation strategies and to identify best practices. The first multi-center Ventilation Liberation For Kids (VentLib4Kids) collaborative launched in July 2023. Through implementation of the guidelines, VentLib4Kids aims to improve outcomes for children requiring invasive mechanical ventilation for > 24 h using implementation and quality improvement science methodology. This collaborative will perform a gap analysis comparing current practice with guideline recommendations. This will be followed by sequential implementation of the guideline recommendations. Through ongoing evaluation of compliance of different elements of the ERT bundle and their effect on different competing patient-centered outcomes (ie, invasive mechanical ventilator duration, extubation failure rate, rate of NRS use, and duration of postextubation NRS), best practices will be identified from high-performing centers and disseminated throughout the collaborative. The collaborative will also aim to contribute to closing important evidence gaps identified in the guidelines.