Introduction
Ventilation is considered one of the most critical procedures carried out for severely ill children who are admitted to the intensive care units of a hospital. It is seen that the longer the duration of the ventilator, the higher the risk of developing an infection. The mortality and morbidity increases with an increase in the duration of stay. There are various benefits of ventilation weaning based on protocols. In pediatrics, there are not many studies on ventilation weaning. Many methods have been described to define the best thing to extubate. This is done after trying to breathe before extubation. There is no clear evidence of the criteria that best predict extubation failure. Traditional clinical personal judgment was used to achieve ventilation weaning. This can fail if there is difficulty in maintaining oxygen and airway patency and also management of secretions. Extubation failure is usually seen in about 25 percent of the patients and is mostly associated with severely ill patients. There are various methods of understanding the best timing for extubation, but still, no clear knowledge about the method available in children is seen.
What Vitals Should Be Monitored During Weaning From Mechanical Ventilation?
During mechanical ventilation, it is important to have constant monitoring and access to the correct time of transition. The clinical factors that should be considered are level of consciousness, ability to clear the airway with cough, and absence of secretions. Hemodynamically stable patients should be considered for weaning. These patients should have adequate gas exchange and oxygenation. After every change in ventilation parameters, monitoring how the patient responds regarding breathing, oxygenation level, and blood gases is important.
What Are the Protocols for Weaning From Ventilation?
There is no clear protocol for pediatric weaning from ventilation as in adults. The approach in pediatric patients is still based on individual decisions made by the doctor. Studies show that protocol-based weaning leads to less time on a ventilator than doctor-decision-based weaning.
In patients who have a history of failed extubation, it does not significantly decrease ventilator time, even in protocol-based weaning. If a patient is weaned on production bases the doses of sedatives are decreased with less withdrawal symptoms and also reduced intensive care unit stay. Early tracheostomy and minimal sedation are applied for adults but do not apply for pediatric patients because of lack of cooperation. For children, a deep level of sedation is required for a longer time because of a lack of cooperation and agitation, and also, they are less tolerant of intubation.
What Is Extubation Failure?
The readiness of extubation means the patient is ready for weaning from the ventilator. Before that, the patient should be assessed for the ability to breathe effectively, protecting the airway from reflexes, and also, the patient should have stable hemodynamics.
Multiple tests are available for weaning. There were higher chances of success if the patient maintained the following normal parameters for almost two hours, such as 95 percent oxygen saturation and normal respiration rates for a particular age. Due to upper airway obstruction due to edema in the subglottic region, there are chances of complications after extubation, which are not rare in pediatric patients.
The variables and vitals checked at the bedside before weaning from the ventilator can also give an idea of the risk associated with extubation and the chances of failure. It has been noted that increased breathing work can lead to higher inspiratory pressure and reduced inspiration drive. The respiration rate and arterial blood gases are unreliable indicators of ventilator failure.
The cuff leak test was used to assess post-extubation stridor and this was common in patients with prolonged ventilator support and those with higher amounts of secretions. Ultrasound also helps in testing patients' position for extubation.
The indices such as diaphragm thickening fraction, lung US score, and diaphragmatic excursion help evaluate the status of the lungs and diaphragm. These parameters are higher in children who have successful extubation.
Is Any Medication Beneficial for Ventilation Weaning?
The primary cause of extubation failure in patients is the upper airway obstruction. This is seen in most of the pediatric patients with extubation failure. The focus should be to avoid trachea inflammation and edema in the subglottic region. Keeping these circumstances in mind, several studies focus on using corticosteroids that help prevent stridor after the extubation procedure. Injecting dexamethasone intravenously before extubation is the most common steroid treatment that is used. Many studies conclude that corticosteroids have proven beneficial for children and infants, but their efficiency is not very high. The exact timing and dose of the steroid to be injected before weaning from the ventilator is still not clear.
Which Induces Are Used to Evaluate Readiness for Weaning From a Ventilator?
Several indices are used to predict readiness for weaning.
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Rapid shallow breathing test is the ratio between rates of respiration and tidal volume calculated on unassisted breathing. If it is <105 breath/min/L, then it indicates success to be predicted.
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Maximum inspiration pressure is a maximal voluntary inspiratory effort applied against the Sb occluded airway. Measuring this index requires patients to cooperate and is difficult in children.
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The value of the pressure of the airway after 0.1 seconds of the start of inspiratory effort is occlusion pressure. Children with low occlusion pressure are noted to have higher chances of extubation failure. In pediatrics, these indices are not of much value because of the variable age and weight of the patient.
Conclusion
The basis of weaning from ventilator and extubation success and readiness is still a field that needs refinement. There is no accurate and reliable data that could support the superiority of this approach over the others. As there are no guidelines and protocols to be strictly followed for pediatric patients, the individual personal judgment of the doctor plays an important role. There is a further requirement for more studies to be carried out on ventilator weaning for pediatric patients.
