Contemporary Trends in Pediatric Extubation Failure and Noninvasive Respiratory Support Use.

Abstract

Prolonged invasive mechanical ventilation (IMV) is associated with morbidity and mortality in children. Timely extubation is essential and must balance the competing risks of extubation failure (EF) and prolonged use of noninvasive respiratory support after extubation. Did EF risk factors, EF rates, noninvasive respiratory support after extubation practices, and patient-centered outcomes changed between 2013 and 2022? Retrospective cross-sectional study of patients younger than 19 years receiving IMV for ≥ 24 hours and extubated between 2013 and 2022 from 158 North American sites in the Virtual Pediatric Intensive Care, LLC, quality improvement database. One hundred thirty-two thousand seven hundred twelve unique encounters were included. The overall EF rate was 8.5%. Postextubation noninvasive respiratory support use nearly doubled (2013 vs 2022: 20.9% vs 39.9%; relative risk [RR], 1.90 [95% CI, 1.83-1.98]; P < .01), whereas EF decreased slightly (≤ 48 hours: 8.9% vs 8.1%; RR, 0.92 [95% CI, 0.85-0.99]; P = .03; ≤ 7 days: 12.3% vs 11.0%; RR, 0.89 [95% CI, 0.83-0.95]; P < .01). Logistic regression identified increased odds of EF associated with younger age (< 6 weeks: OR, 1.39 [95% CI, 1.31-1.47]; P < .01; 6 weeks-12 months: OR, 1.24 [95% CI, 1.18-1.30]; P < .01), primary renal diagnosis (OR, 1.25 [95% CI, 1.04-1.48]; P = .01), respiratory diagnosis (OR, 1.15 [95% CI, 1.07-1.23]; P < .01), and cardiac diagnosis (OR, 1.10 [95% CI, 1.04-1.16]; P < .01), and ≥ 7 days of invasive ventilation before extubation (OR, 1.26 [95% CI, 1.21-1.32]; P < .01). EF rates were unchanged over time for patients with 0 or 1 risk factor. EF was associated with longer mechanical ventilation duration (11.6 days vs 4.0 days; P < .01), longer pediatric ICU length of stay (18.8 days vs 7.9 days; P < .01), and longer hospital length of stay (31.0 days vs 15.0 days; P < .01), but not with all-cause risk-adjusted mortality (8.5% vs 8.6%; RR, 1.16 [95% CI, 0.97-1.38]; P = .73). Our results demonstrate that in the last decade, noninvasive respiratory support after extubation has nearly doubled, with an approximately 10% reintubation risk reduction. High-risk groups may benefit, but overuse may exist in low-risk groups with respect to EF. EF is associated with morbidity, but not increased mortality.