Pediatric extubation readiness tests should not use pressure support.
OBJECTIVE
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 cmH2O 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 cmH2O, CPAP 5 cmH2O (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.
Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, 4650 Sunset Blvd Mailstop 12, Los Angeles, CA, 90027, USA. rkhemani@chla.usc.edu.|Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA. rkhemani@chla.usc.edu.
Robinder G
http://orcid.org/0000-0002-5815-0314
RG
Khemani
Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, 4650 Sunset Blvd Mailstop 12, Los Angeles, CA, 90027, USA.
Justin
J
Hotz
Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, 4650 Sunset Blvd Mailstop 12, Los Angeles, CA, 90027, USA.
Rica
R
Morzov
Med-E Link, Amsterdam, The Netherlands.
Rutger C
RC
Flink
Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, 4650 Sunset Blvd Mailstop 12, Los Angeles, CA, 90027, USA.
Asvari
A
Kamerkar
Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, 4650 Sunset Blvd Mailstop 12, Los Angeles, CA, 90027, USA.
Marie
M
LaFortune
Department of Respiratory Medicine, King's College London, London, UK.
Gerrard F
GF
Rafferty
Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, 4650 Sunset Blvd Mailstop 12, Los Angeles, CA, 90027, USA.|Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA.
Patrick A
PA
Ross
Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, 4650 Sunset Blvd Mailstop 12, Los Angeles, CA, 90027, USA.|Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA.
Christopher J L
CJ
Newth
D000293:Adolescent; D060666:Airway Extubation / Q000379:methods* / Q000592:standards*; D002648:Child; D002675:Child, Preschool; D045422:Continuous Positive Airway Pressure / Q000379:methods*; D003422:Critical Care / Q000592:standards*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D007442:Intubation, Intratracheal / Q000379:methods; D008297:Male; D011446:Prospective Studies; D012129:Respiratory Function Tests; D012131:Respiratory Insufficiency / Q000628:therapy*; D015300:Ventilator Weaning / Q000379:methods* / Q000592:standards*
Airway extubation; Pediatrics; Ventilator weaning; Work of breathing