Browsing by Author "Loberger, Jeremy M."

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    Pediatric Ventilation Liberation: A Survey of International Practice Among 555 Pediatric Intensivists
    (Wolters Kluwer, 2022-09-02) Loberger, Jeremy M.; Campbell, Caitlin M.; Colleti, José, Jr.; Borasino, Santiago; Abu-Sultaneh, Samer; Khemani, Robinder G.; Pediatrics, School of Medicine
    Pediatric ventilation liberation has limited evidence, likely resulting in wide practice variation. To inform future work, practice patterns must first be described. Objectives: Describe international pediatric ventilation liberation practices and regional practice variation. Design setting and participants: International cross-sectional electronic survey. Nontrainee pediatric medical and cardiac critical care physicians. Main outcomes and measures: Practices focusing on spontaneous breathing trial (SBT) eligibility, SBT practice, non-SBT extubation readiness bundle elements, and post-extubation respiratory support. Results: Five-hundred fifty-five responses representing 47 countries were analyzed. Most respondents reported weaning followed by an SBT (86.4%). The top SBT eligibility variables reported were positive end-expiratory pressure (95%), Fio2 (93.4%), and peak inspiratory pressure (73.9%). Most reported use of standardized pressure support regardless of endotracheal tube size (40.4%) with +10 cm H2O predominating (38.6%). SBT durations included less than or equal to 30 minutes (34.8%), 31 minutes to 1 hour (39.3%), and greater than 1 hours (26%). In assigning an SBT result, top variables were respiratory rate (94%), oxygen saturation (89.3%), and subjective work of breathing (79.8%). Most reported frequent consideration of endotracheal secretion burden (81.3%), standardized pain/sedation measurement (72.8%), fluid balance (83%), and the endotracheal air leak test as a part of extubation readiness bundles. Most reported using planned high flow nasal cannula in less than or equal to 50% of extubations (83.2%). Top subpopulations supported with planned HFNC were those with chronic lung disease (67.3%), exposed to invasive ventilation greater than 14 days (66.6%), and chronic critical illness (44.9%). Most reported using planned noninvasive ventilation (NIV) following less than or equal to 20% of extubations (79.9%). Top subpopulations supported with planned NIV were those with neuromuscular disease (72.8%), chronic lung disease (66.7%), and chronic NIV use for any reason (61.6%). Regional variation was high for most practices studied. Conclusion and relevance: International pediatric ventilation liberation practices are heterogeneous. Future study is needed to address key evidence gaps. Many practice differences were associated with respondent region, which must be considered in international study design.
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    Predicting Duration of Invasive Mechanical Ventilation in the Pediatric ICU
    (Mary Ann Liebert, 2023-11-25) Rogerson, Colin M.; Abu-Sultaneh, Samer; Loberger, Jeremy M.; Ross, Patrick; Khemani, Robinder G.; Sanchez-Pinto, L. Nelson; Pediatrics, School of Medicine
    Background: Timely ventilator liberation can prevent morbidities associated with invasive mechanical ventilation in the pediatric ICU (PICU). There currently exists no standard benchmark for duration of invasive mechanical ventilation in the PICU. This study sought to develop and validate a multi-center prediction model of invasive mechanical ventilation duration to determine a standardized duration of invasive mechanical ventilation ratio. Methods: This was a retrospective cohort study using registry data from 157 institutions in the Virtual Pediatric Systems database. The study population included encounters in the PICU between 2012-2021 involving endotracheal intubation and invasive mechanical ventilation in the first day of PICU admission who received invasive mechanical ventilation for > 24 h. Subjects were stratified into a training cohort (2012-2017) and 2 validation cohorts (2018-2019/2020-2021). Four models to predict the duration of invasive mechanical ventilation were trained using data from the first 24 h, validated, and compared. Results: The study included 112,353 unique encounters. All models had observed-to-expected (O/E) ratios close to one but low mean squared error and R2 values. The random forest model was the best performing model and achieved an O/E ratio of 1.043 (95% CI 1.030-1.056) and 1.004 (95% CI 0.990-1.019) in the validation cohorts and 1.009 (95% CI 1.004-1.016) in the full cohort. There was a high degree of institutional variation, with single-unit O/E ratios ranging between 0.49-1.91. When stratified by time period, there were observable changes in O/E ratios at the individual PICU level over time. Conclusions: We derived and validated a model to predict the duration of invasive mechanical ventilation that performed well in aggregated predictions at the PICU and the cohort level. This model could be beneficial in quality improvement and institutional benchmarking initiatives for use at the PICU level and for tracking of performance over time.
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    Ventilation Liberation Practices Among 380 International PICUs
    (Wolters Kluwer, 2022-05-27) Loberger, Jeremy M.; Campbell, Caitlin M.; Colleti, José, Jr.; Borasino, Santiago; Abu-Sultaneh, Samer; Khemani, Robinder G.; Pediatrics, School of Medicine
    Objectives: 1) Characterize the prevalence of ventilator liberation protocol use in international PICUs, 2) identify the most commonly used protocol elements, and 3) estimate an international extubation failure rate and use of postextubation noninvasive respiratory support modes. Design: International cross-sectional study. Subjects: Nontrainee pediatric medical and cardiac critical care physicians. Setting: Electronic survey. Intervention: None. Measurements and main results: Responses represented 380 unique PICUs from 47 different countries. Protocols for Spontaneous Breathing Trial (SBT) practice (50%) and endotracheal tube cuff management (55.8%) were the only protocols used by greater than or equal to 50% of PICUs. Among PICUs screening for SBT eligibility, physicians were most commonly screened (62.7%) with daily frequency (64.2%). Among those with an SBT practice protocol, SBTs were most commonly performed by respiratory therapists/physiotherapists (49.2%) and least commonly by nurses (4.9%). Postextubation respiratory support protocols were not prevalent (28.7%). International practice variation was significant for most practices surveyed. The estimated median international extubation failure was 5% (interquartile range, 2.3-10%). A majority of respondents self-reported use of planned high-flow nasal cannula in less than or equal to 50% (84.2%) and planned noninvasive ventilation in less than or equal to 20% of extubations (81.6%). Conclusions: Variability in international pediatric ventilation liberation practice is high, and prevalence of protocol implementation is generally low. There is a need to better understand elements that drive clinical outcomes and opportunity to work on standardizing pediatric ventilation liberation practices worldwide.