(334) Association of Extubation Timing and Treatment Failure After Successful Extubation Readiness Trial

Introduction: Protocolized mechanical ventilation (MV) weaning and extubation readiness trials (ERT) decrease MV duration without increasing extubation failure rate. However, little is known about the association of extubation timing and treatment failure after successful ERTs in the pediatric intensive care unit (PICU). A MV weaning pathway with protocolized ERT was developed in our PICU in 2016 as a quality improvement initiative. We assessed ERT process metrics hypothesizing that treatment failure after successful ERT would not be associated with extubation within 6 hours of ERT.

Methods: We conducted a single-center, retrospective cohort study of children (age < 18 years) admitted to the PICU between 1/1/2023 and 7/10/2023 who required MV and were extubated after successful ERT. Exclusion criteria included reintubation for procedures or imaging studies. The primary outcome was treatment failure, defined as reintubation or escalation of respiratory support within 48 hours of extubation. Descriptive statistics (median and interquartile range (IQR)) and Fisher’s exact were used to assess differences in treatment failure rate between children extubated < 6 hours versus ≥6 hours after successful ERT.

Results: Of 422 MV episodes in 382 patients, 153 (36%) met eligibility criteria. The median age was 4 years, median duration of MV was 3 days, and median time to extubation after successful ERT was 9.7 hours (IQR 4.9-16.4). Forty-eight patients extubated < 6 hours (median 3.1 hours, IQR 1.8-4.6) and 105 patients ≥6 hours (median 13.6 hours, IQR 9.4-22.7) after successful ERT. There was no significant difference in treatment failure [2/48 (4.2%) vs. 6/105 (5.7%)] or reintubation rates [1/48 (2.1%) vs. 3/105 (2.9%)] between groups (p = 1.00).

Conclusions: Despite quality improvement efforts to expedite MV weaning and extubation within our PICU, a minority of children had documented ERTs performed. Extubation immediately after successful ERT was not associated with an increased rate of reintubation or treatment failure. Efforts should focus on implementation strategies to improve MV weaning pathway adoption including expeditious extubation after successful ERT.