Failure to Wean: Predictors and Adverse Outcomes Associated with Pediatric Postextubation Noninvasive Respiratory Support.

Abstract

To describe postextubation noninvasive respiratory support (NRS) use, and its variation based on clinical variables and institution, to identify factors associated with failure to liberate from NRS ≤ 48 hours postextubation, and to explore the association between postextubation NRS use and patient-centered outcomes. A retrospective cohort study of patients aged ≤ 18 years exposed to invasive mechanical ventilation (IMV) via endotracheal tube for ≥ 24 hours between January 1, 2013 and December 31, 2022, in the Virtual Pediatric Systems multicenter quality improvement database. Failure to liberate from NRS ≤ 48 hours postextubation was the primary outcome. Mixed-effects logistic regression models were developed for patient-centered outcomes. A total of 132,712 encounters from 158 institutions were included. High-flow nasal cannula was the most common NRS modality followed by bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) with rescue deployment more common than planned. Older age, later study year, high-risk primary diagnostic category, use of BiPAP or CPAP, and IMV duration ≥ 7 days were associated with higher odds of failure to liberate from NRS ≤ 48 hours. Patients who failed to be liberated from NRS ≤ 48 hours postextubation had longer NRS duration, longer intensive care unit and hospital lengths of stay, and higher pediatric intensive care unit all-cause mortality. Younger age, high-risk primary diagnostic category, use of rescue CPAP, use of planned as well as rescue BiPAP, and IMV duration ≥ 7 days were associated with higher odds of extubation failure ≤ 48 hours and 7 days. Postextubation NRS use is highly prevalent and most commonly deployed as a rescue strategy. Failure to liberate from NRS ≤ 48 hours postextubation is associated with worse patient-centered outcomes. Optimizing the postextubation NRS deployment and titration is an important gap in need of research and quality improvement interventions which may lead to improved patients' outcomes.