Pediatric extubation readiness tests should not use pressure support

• Published in: Intensive care medicine Vol. 42; no. 8; pp. 1214 - 1222
• Main Authors: Khemani, Robinder G., Hotz, Justin, Morzov, Rica, Flink, Rutger C., Kamerkar, Asvari, LaFortune, Marie, Rafferty, Gerrard F., Ross, Patrick A., Newth, Christopher J. L.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-08-2016; Springer; Springer Nature B.V
• Subjects: Adolescent; Airway Extubation - methods; Airway Extubation - standards; Airway management; Anesthesiology; Catheters; Child; Child, Preschool; Comparative analysis; Continuous positive airway pressure; Continuous Positive Airway Pressure - methods; Critical care; Critical Care - standards; Critical Care Medicine; Emergency Medicine; Esophagus; Extubation; Female; Humans; Hypotheses; Infant; Infant, Newborn; Intensive; Intensive care; Intensive Care Units, Pediatric; Intubation, Intratracheal - methods; Male; Medical research; Medicine; Medicine & Public Health; Medicine, Experimental; Pain Medicine; Patients; Pediatric Original; Pediatrics; Pneumology/Respiratory System; Prospective Studies; Respiratory Function Tests; Respiratory Insufficiency - therapy; Ventilator Weaning - methods; Ventilator Weaning - standards; Ventilators; Pediatrics; Ventilator weaning; Work of breathing; Airway extubation
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-016-4387-3

Purpose
Pressure support is often used for extubation readiness testing, to overcome perceived imposed work of breathing from endotracheal tubes. We sought to determine whether effort of breathing on continuous positive airway pressure (CPAP) of 5 cmH
2
O is higher than post-extubation effort, and if this is confounded by endotracheal tube size or post-extubation noninvasive respiratory support.
Methods
Prospective trial in intubated children. Using esophageal manometry we compared effort of breathing with pressure rate product under four conditions: pressure support 10/5 cmH
2
O, CPAP 5 cmH
2
O (CPAP), and spontaneous breathing 5 and 60 min post-extubation. Subgroup analysis excluded post-extubation upper airway obstruction (UAO) and stratified by endotracheal tube size and post-extubation noninvasive respiratory support.
Results
We included 409 children. Pressure rate product on pressure support [100 (IQR 60, 175)] was lower than CPAP [200 (120, 300)], which was lower than 5 min [300 (150, 500)] and 60 min [255 (175, 400)] post-extubation (all
p
 < 0.01). Excluding 107 patients with post-extubation UAO (where pressure rate product after extubation is expected to be higher), pressure support still underestimated post-extubation effort by 126–147 %, and CPAP underestimated post-extubation effort by 17–25 %. For all endotracheal tube subgroups, ≤3.5 mmID (
n
 = 152), 4–4.5 mmID (
n
 = 102), and ≥5.0 mmID (
n
 = 48), pressure rate product on pressure support was lower than CPAP and post-extubation (all
p
 < 0.0001), while CPAP pressure rate product was not different from post-extubation (all
p
 < 0.05). These findings were similar for patients extubated to noninvasive respiratory support, where pressure rate product on pressure support before extubation was significantly lower than pressure rate product post-extubation on noninvasive respiratory support (
p
 < 0.0001,
n
 = 81).
Conclusions
Regardless of endotracheal tube size, pressure support during extubation readiness tests significantly underestimates post-extubation effort of breathing.