Others ask, how many people practice pediatrics, just to give a few, which is good. So we are small in the SCCM community, but I think it's very important to ... I'm trying to summarize the event liberation guidelines, and after listening to Julie, there is a lot of topics that's similar. So for people that practice pediatrics, or pediatrics and adults in different places, it's good just to try to get a comparison between what's the issues, and if we treat them similarly. These are my disclosures. You know, the guidelines were supported by the NIH, and some funds from Indiana University. And as I said, I'll just give you a summary of the guidelines. There is a lot of articles in the guidelines. I will not be able to do all of them, so I didn't put a lot here. But for you guys who are interested, they can go through the guidelines and reference them. When we think about extubating a patient, there is two outcomes that we care about the most, is how much the patient will stay in the ventilation, and all of the complications associated with invasive mechanical ventilation, versus extubating the patient early. And with extubating the patient early, we need to make sure that the patient doesn't fail extubation, because if the patient fail extubation, that means additional morbidity. So that balance between extubating early versus keeping them for another day, that they are better optimized, we need to recognize that. The other thing that we need to understand, there is a balance between respiratory muscle strength and capacity, or load and capacity. And patients fail extubation for multiple reasons. Part of them is the patient is weak, or they have some residual lung disease, or they might have upper airway obstruction. So when you're trying to extubate a patient, you think about them, they might fail extubation for different reasons. What you are trying to do is mitigate these reasons to give them the best chance for succeeding extubation. So we published the guidelines for pediatrics in 2003. I think adults had already published two iterations of their guidelines. And we learned a lot from adults, but we used our literature to generate these guidelines. I'm proud of this bundle and this figure, and hopefully at the end I will have time to walk you through this. But this is our bundle that has different elements. And throughout the few slides that I will discuss, I discuss different elements, how we do it in pediatrics. And you can compromise that with how adults do it. The first thing is, which we all agree on, that we should do a systematic screening for patient readiness for ERT. And this is part of the ICU liberation for anybody that need to liberate a patient from the ventilator. And we need to have a standardized approach with bundle that has different elements that we discuss later. And we think SBT is an important and a core element of this bundle, but there is other elements that we need to add to make the ERT bundle perform much better. The first thing that people talk about, as Julia said, is how do you do the SBT? If the SBT is very important, how do you do it? And looking for our literature, we suggested using SBT with a pressure support or CPAP alone based on the risk stratification. If the patient has a high risk for extubation failure, this patient might do better off just doing a CPAP alone. We don't use a TBS as much, but CPAP alone is more prevalent. For patients with a standard risk for extubation, you can use either because they perform the same in this population. Now we define the same thing that Julia talked about, the age and BMI. In pediatrics, it's a little bit different, but you think about it for patient's age. Younger patient actually in our population fails more. Patients who stay in the mechanical ventilation for a longer period, they are weak and they are at a higher risk for extubation failure. And also patients with some chronic illnesses or neuromuscular weakness or the patient with a chronic critical illness, patient with myocardial dysfunction after post-cardiac surgery. These patients, you should think about them and treat them differently than just your patient with a status, epileptic has just come in and intubated for 12 or 24 hours. Duration was another discussion, again, adults discussion between 30 minutes and 120 minutes. And we try to stratify it the same way. For patients with standard risk, maybe you do any amount, doesn't matter. But for patients who are at a higher risk, you need to make sure that you better assist their readiness. And maybe you should do your SPT for about 60 to 120 minutes, just to make sure that actually they can extubate successfully. Now we talked about SPT as the primary thing that we need to do, but there is other elements. There is some accessories to the SPT to make it abundant. Now how we can assist their muscle strength. Julie talked about diaphragm, ultrasound, EDI. I think most of us think about NEFs or PI-MAX. And we suggest using that to better assist our patient risk for extubation and are they weak or not. Now the literature that we use, it's based on observational studies and there is no actual cutoff point. But if you get a patient with a PI-MAX or NEF less than 20 persistently, these patients most likely they have respiratory muscle weakness and they might fail extubation. But patients who has PI-MAX above 50, these patients most likely they have a preserved respiratory muscle strength and most likely they will not fail extubation from muscle weakness. This elegant study was done by Robby Kamania and his group from CHLA. And I was just trying to see if the mouse will work. So this is a fraction of reintubation. And in pediatrics, the standard or average is about 5% to 10%. If you are higher, usually it's a higher extubation failure. But lower, usually you're not extubating enough. And you can see there is different categories here depending on the PI-MAX. And as you increase your PI-MAX, you can see that your extubation failure rate decrease. Now what's the other thing that we need to talk about in pediatrics? Apparatus obstruction. You know, Julie talked about checking a leak and giving steroids. It's very important in pediatrics. It's a very common cause for extubation failure in pediatrics. So we suggest using an air leak test for cuffed ET tube to predict if the patient will have apparatus obstruction. Now for un-cuffed tube, the study showed that it's not a reliable method. Then maybe we need to use something else. Some people who are interested about POCUS, they start using more studies. The studies are not there yet to put them in the guideline. But hopefully with the next iteration of the guidelines in the next 5, 10 years, hopefully we'll get the more advanced thing like POCUS to predict apparatus obstruction in the guidelines. Now do you need to give steroids? Who do you need to give steroids? We suggest giving steroids at least six hours before extubation. Not for all patients. We don't want to expose patients to steroids just, you know, because of that. You need just to give them for high-risk patients, high-risk patients for apparatus obstruction. And I'll elaborate more on this high-risk population. We defined the high-risk for apparatus obstruction not just including the patients with a leak pressure that is about 25, but also patients with multiple intubation attempts, traumatic intubations, if they had used a large 4H ET tube, and if there is some anatomical anomalies of the airway, you should consider giving steroids. Now the big question after you decide to give steroids is how much steroids? How early do you give steroids? So we performed something called network meta-analysis for people who are not familiar with it, but trying to compare different dosing and different timing in one shot and see which one were ranked the best. And what we found, as you can see here in this, you know, sucra, which tell you which one is best, high early rank first, low early rank second. So you know, most likely you need to use it early. But let's say that you want to extubate the patient and they don't have a leak pressure. Maybe you should use a high dose at that time. So high dose defined as 0.5 milligram per kilo per dose. We max at 10 in the guidelines, so we don't use like 30 milligrams of dexamethasone. And early is 12 hours, 6 to 12 hours per extubation. Now as Julie talk is, you are ready to extubate patient, you know, you situate the upper air obstruction stuff, patient pays best SPT, what respiratory support do you use? And there is different modes. We lump them together as non-invasive respiratory support, which include high flow, CPAP, and a BiPAP or an IV. So for patients with a high risk for extubation failure, we recommend using prophylactic or bland NRS. And I will go more in the next few slides. Now if you decide to extubate a patient with conventional oxygen therapy and they start failing, we recommend escalating. And I think this is, anybody will do that. Like nobody would just go reintubate without trying a more support. The second recommendation is for patients below one year, there is a couple of great studies. First, ABC studies is one of them. So based on that study, if you are planning to use NRS for less than one year, CPAP performs better. And I will go in the next slide on some of the network analysis that we did. Now for patients above one year, there's not that many studies to say which one is better. I think you need to put it in a context. If you have a patient with a neuromuscular disorder, you will not extubate them to high flow. Most likely you extubate them to an IV. This is another study that I would encourage everybody to look at. I think the guideline group did a great job with summarizing the evidence and published a few studies. And this is ranking the devices based on extubation failure and treatment failure. And as you can see that the CPAP is the first one, followed by high flow, followed by PIPAP and then conventional oxygen therapy. Now somebody would ask, like, PIPAP should be the first. Well, the problem is we don't have a lot of studies in pediatrics using PIPAP. We have just one study. So hopefully in the future, you know, there will be more studies and maybe it's different for different risk groups. But this is what we have at this moment for RCTs. We have actually RCTs in this area, about eight RCTs. The last thing in the bundle is sedation assessment prior to extubation. And there is a lot of good practice statements that everybody will use. And the first one is we recommend to check a level of sedation, cough effectiveness, and ability to manage oral pharyngeal secretions, and to use a management protocol using a validated reliable tool that everybody talks the same language when you talk about, you know, what's the level of sedation. Now the guidelines fall short, you know, recommending a protocol, no protocol, because there is two great studies in pediatrics, Sandwich and Restore, that they didn't find difference between protocol, no protocol. The last thing, which, you know, I know that I don't have a lot of, you know, time to go deep in this, but I think if you have time to go in the guidelines, we try to put everything in one place. So the first thing is what you think about if, before you try to extubate 12 to 24 hours to assist the patient, if the patient has risk for upper ear obstruction, and you check a leak, and give them steroids, because you don't need to delay that process. Then you screen them, if they are safe to go on SBT, you do SBT, depending on their risk, high versus standard, you know, you decide which SBT duration and method. And you have an objective criteria to extubate them. And if they pass that, you decide which support you want to put them in, based on their risk stratification. If they fail that, you shouldn't just wait for another two days. You should optimize their sedation, you should optimize their cardiovascular status, and screen them again. If they screen again to be safe to go on SBT, you go on SBT again within the next 12 to 24 hours. You know, you can do it more frequent if you have enough, you know, RTs to do that for you. The last thing is a small commercial for our group. If you are interested about vent liberation, we are implementing the guideline using implementation QI methodology. We call it Vent Lib for Kids. And I think it's very important, because we generate the evidence, took us a few years, but I think the big thing that everybody talks about is, how do you bridge the gap between knowledge or evidence and implementation? There was a nice JAMA paper that says that there's 17 years between having a guideline and implementing the guideline. Well, in 17 years, I will be hopefully retired, maybe I'll need a few years more. But the main thing is, you know, if you have a guideline, you need to have implementing it, improve the evidence, and, you know, keep updating it. You don't wait 17 years, because 17 years is different than now. And with that, I would thank you, everybody, and happy to take questions with the group. Thank you.

pediatric extubation guidelines

respiratory failure risk

extubation readiness screening

SBT and PI-MAX tools

healthcare implementation gap