Randomized Clinical Trial of Spontaneous Breathing Test

Introduction Mechanical ventilation (MV) is a common procedure for patients admitted to pediatric intensive care units (PICUs). Although MV is often necessary and life-saving, it can be associated with complications such as ventilator-associated pneumonia, cardiovascular dysfunction, airway injury, and patient immobility. The longer the duration of MV, the greater the risk of morbidity, length of stay, and mortality. To reduce the risks associated with prolonged MV, clinicians should seek to continually optimize the process of weaning from ventilation (WVL), thereby increasing the likelihood of successful extubation. WVL is defined as "the gradual reduction of mechanical ventilatory support and the transfer of respiratory control and the work of breathing back to the patient." Traditionally, WVL was conducted through clinical judgment and a personal decision. Only in recent years have protocol-based approaches been implemented, with conflicting results, although most studies show that a protocolized approach tends to reduce the duration of mechanical ventilation. Extubation is defined as "removal of the endotracheal tube," and extubation failure occurs when a patient requires reintubation within hours or days of a planned extubation. More recently, extubation failure has been considered as reintubation within 48 hours of a planned extubation. Extubation failure may be secondary to the inability to maintain alveolar oxygenation and/or ventilation, airway patency and protection, secretion control, or any combination of these. Extubation failure occurs in 3-22% of patients regardless of the severity of the underlying disease, with evidence that its occurrence can directly worsen patient outcomes, including an increased mortality rate. Various clinical approaches are used to decide the best timing for extubation, ranging from the use of tools such as chest and diaphragm ultrasound to readiness testing and spontaneous breathing, but there is no clear evidence on which technique is best in children.

Rationale

When using MV, it is important to critically balance the minimization of procedural risks against the risks of extubation failure (EF) and its association with morbidities. The International Guidelines for Liberation from Mechanical Ventilation in Pediatrics were published in 2022 with the aim of guiding best practices for liberation from MV.(2) Experts have given their opinions on the various aspects of liberation from MV. Among several definitions, the most important for this study are:

Extubation readiness test (ERT): (95.7% agreement). It is a set of elements (bundle) that are used to assess the patient's eligibility to be liberated from invasive MV (IMV). In addition to the usual ERT components, such as values of the fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), the factor that led to tracheal intubation in resolution, ERT may include factors such as: assessment of the level of sedation; neurological adequacy of airway control (coughing and choking); probability of upper airway obstruction after extubation; assessment of respiratory muscle strength; magnitude of airway secretions; hemodynamic status and planning of respiratory support after extubation Spontaneous breathing trial (SBT): (91.3% agreement). Systematic method of reducing IMV support to predetermined parameters to assess the likelihood that the patient will be able to independently maintain minute ventilation and gas exchange without excessive respiratory effort, if released from IMV.

Among the recommendations of the guidelines: