SCCMPod-553: Pediatric Ventilator Liberation: Challenges and Progress

Dr. Madden: Hello and welcome to the Society of Critical Care Medicine podcast. I'm your host Maureen Madden. Today we're joined by Jeremy Lohberger to discuss Pediatric Current Concepts Ventilation Liberation.
Dr. Loberger is Assistant Professor of Pediatrics and Medical Director of the Pediatric Intensive Care Unit at the University of Alabama at Birmingham. He's also a faculty for this year's Pediatric Current Concepts course and lead author for implementing the Pediatric Ventilator Liberation Guidelines. More than that, he is also co-PI for a multi-center pediatric ventilator liberation collaborative called Ventilation Liberation for Kids.
So welcome.

Dr. Loberger: Thank you for having me.

Dr. Madden: It's my pleasure to have you. I hope we have a good time chatting about this. I expect that there should be some interesting discussion and maybe a little bit of potential controversy, but we'll see.
So I first wanted to start and ask, can you tell me how you got interested in ventilation liberation for children?

Dr. Loberger: Sure. So I've always been pretty passionate about limiting any iatrogenic things that can occur in the hospital. I think there's a lot of great things we do.

There's a lot of harm that we can potentially cause. And I saw firsthand as a critical care fellow just how different the practices were around vent liberation. And I became passionate pretty early on in my training about trying to standardize that care, at least so we were talking the same language.

Even if there wasn't great evidence for one way over the other, let's all speak the same language. And it's just snowballed from there and I've stayed into it into my years as faculty.

Dr. Madden: Well, I think it's a hugely important topic in knowing that our population in the pediatric ICU is not homogeneous. There are so many variables, and to think that we could construct a protocol or a pathway or guidelines, whatever you want to phrase it, to address that population seems a little bit overwhelming. So I know the initial guidelines for pediatric ventilation were published in 2023.

So that seems, first of all, a long time in coming. But it provided a conceptual framework with mainly evidence-based conditional recommendations for 15 best practice. But they all had low to very low certainty of evidence, as you said, in terms of is there evidence to support these things.

So from there, you went and your group of authors, you had a narrative review where you looked at those 15 recommendations and what you broke it apart to look at was looking at the recent evidence and identified practice gaps related to the recommendations. You also discussed barriers in how to facilitate their implementation in clinical practice. And implementation science is really becoming a huge component of how we get these clinical practice guidelines into practice.

So I just wanted to get a sense of how you got involved in this narrative review and we'll talk about some of the concepts in there.

Dr. Loberger: Yeah, absolutely. I think this has also been years coming where my partners and I in the academic world have talked about, well, how can we move this field forward? And it always seemed to us that the first step was going back to what I said earlier, can we all speak the same language?

Can we limit some practice variation around things that maybe aren't as hotly contested? For example, maybe we're not going to argue about pressure support or not with an SBT, but can we agree to just do an SBT? Can we agree to standardize that work?

And in doing so, you can start to answer some of these questions that are found in the research gaps that we discuss in our paper, as well as others have discussed. But we always felt like that was the first step. And to do that, you have to really consider the different contexts which you're trying to implement all these different things.
And I'm no implementation science expert, but I do have the opportunity to work with some of them on our team. And it's been a very interesting approach where it's clear that one size doesn't always fit all based on the center and certainly the patient.

Dr. Madden: That's absolutely true. And I go even further because you say talking the same language and taking similar approaches, but we also now have different types of ventilators, different modes. The practice of pediatric critical care is growing up, I should say.

And I know personally from when I started practicing the advances in the technology that we have, and I will date myself absolutely by saying this, we didn't have non-invasive mechanical ventilation previously. So now we have all these other modalities that we could certainly also discuss in terms of high-flow NIMV. I did have a very simple CPAP, but it's drastically changed.

So there's so much selection that goes into this process. And I still think that we're not speaking the same language. So what are your thoughts about that?

Dr. Loberger: Well, not only are we not speaking the same language, I think we don't all have the same goals. And so from my perspective, there's always been this, let's say, focus, preoccupation, whatever, about preventing extubation failure. And that goes back to data from the early 2000s that correlated extubation failure with as much as a five-fold increase in mortality.

That may or may not still hold true. And I would contend that it doesn't. It's a little bit outside the scope of this conversation.

But if that was always the focus, then the thing that follows is patients are going to stay on the ventilator longer to prioritize preventing extubation failure. You and I both know that that's a whole problem in and of itself and all the morbidity and mortality that's associated with invasive mechanical ventilation. But then to your point, which is an excellent one, we've had an explosion in non-invasive respiratory support over the last decade, specifically with high-flow nasal cannula.

I'll admit I'm not a big fan of high-flow nasal cannula, but then you have to start balancing not just extubation failure and invasive mechanical ventilation duration. Now, you got to balance duration of non-invasive respiratory support. And does that require sedation?

Well, how does that impact enteral nutrition? It's become even more complex. And then you add on top of that, that our patient population is getting more chronically ill, more complex.

The whole paradigm has completely shifted, certainly in the last 5 to 10 years.

Dr. Madden: I think I could sit and chat with you for a long time about many of these topics. And I think they all merit time. But as you said, it really is outside the scope of what we should be talking about today.
You had said you didn't necessarily want to debate pressure support, but I do. Let's do it. Yeah.
Let's talk about pressure support, particularly for spontaneous breathing trials. For or against?

Dr. Loberger: I'm going to be a politician here and say it depends. I think there's plenty of literature out there, a lot of it by one of my mentors, Ravi Kamani, who talks about how pressure support can definitely underestimate post-extubation work of breathing. I don't think that's disputable.

I think the whole thought process of breathing through a straw has been more or less debunked. Now, that's in a very sterile environment. When we talk about the patient themselves, I have to look at them or my team has to look at them as they're undergoing a spontaneous breathing trial, and they have to say they look good enough to extubate.

I don't think a patient needs to look perfect, but I also don't want to be fooled by a spontaneous breathing trial that uses too much or too little pressure support. The way I look at it is very similar to the way guidelines talk about it. If I consider a patient to be very high risk, high pre-test risk of failure, I tend towards no pressure support or even TPS trial.

A great example would be a patient with Guillain-Barre or another neuromuscular weakness issue. If I have a baby who has bronchiolitis who is not going to look good really at any point, I use a little bit of pressure support to understand can I support them with non-invasive respiratory support and get them off of the ventilator. Then the follow-up question to that is, well, Jeremy, how much pressure support?

Dr. Madden: Exactly.

Dr. Loberger: I think a little bit goes a long way. I know some centers use 8 to 10. We standardly use 5 for our SBP unless we want to modify and use less.

We almost never use more than 5 at our center.

Dr. Madden: Okay. It goes back again. It's a circular discussion and potentially argument that you touched on that we should expect a certain percentage of extubation failure.

Otherwise, we're saying that we are keeping our patients on the ventilator for too long.

Dr. Loberger: Right.

Dr. Madden: But with all of the advent of this technology and we've also altered how we use the technology from when it was implemented, specifically thinking about BiPAP. It was intended to be originally 24 hours or less in a bridge either direction. Now we know we don't pay any attention to that whatsoever.

But when you think about extubating them and then having all of this non-invasive modalities available, do you think that we're going faster in anticipating to extubate somebody or should we really still be checking all of those elements of readiness for extubation?

Dr. Loberger: I think we should be checking all the elements. You're talking about SBTs, neuromuscular strength, air leak testing, all those things. I think they're helpful.

I always think about the Pareto Principle from a quality improvement lens. These types of things should work for 75 to 80 percent of patients. But we have to take a unique approach to that subset that's different, that 20 percent that fall outside of our standard practices.

That's the first thing I would say about that. And I think that supports that there is an art to this. And people that have been doing this a long time, much longer than me, recognize that.

Now, I do think there needs to be a shift in the way we view this clinically, in the research world, really overall. Our primary focus shouldn't be invasive ventilation duration. It shouldn't be extubation failure.

It should be duration of respiratory support. When can you actually liberate them from, whether it's BiPAP, high flow, conventional oxygen, whatever. That needs to be the outcome we look at because that properly balances the importance of all of these different things.

And candidly, I don't know what the right benchmark is for that. That's a big gap that we need to be able to address. And it's hard when you've got such a wide range of ages and diagnoses and all these different confounding factors in our population.

Dr. Madden: And even the developmental characteristics that certainly impacts how we manage our patient population. And you had mentioned in terms of sedation practices and such and the advent of using or moving away from benzodiazepines for delirium components. And really, I've seen as a substitute using dexmedetomidine.

And now we're using it in my practice pretty liberally, both for those that are intubated or non-invasive for their cooperation with that. And I still wonder then about how that is impacting overall the length of, you said, respiratory support because it keeps them in the ICU. It may also inhibit some of the things that we talk about with liberation in terms of their movement and their pulmonary toileting or whatever.

So, thoughts about that?

Dr. Loberger: A lot of thoughts, but I'll condense them here. I think it's a little bit of a self-fulfilling prophecy. And what I mean by that is, well, the patient's agitated, so they need some more sedation.

Well, they get more sedation. And then for things you just mentioned, maybe their pulmonary toileting is impacted, their respiratory drive is impacted outside of Presidex. And then they go up on respiratory support, then they're more agitated.

And so, it's kind of a self-fulfilling prophecy in that way. I think we as a field in pediatric critical care, through a very noble mindset, kids cannot be uncomfortable. When really, when you look at it, if my kid, heaven forbid, were in the ICU, I want them to have some degree of distress, let's say, because that means that they're working, they're getting stronger.

Do I want them to be in pain and suffering? Absolutely not. Let's address pain first.

But sedation for general comfort may actually be counterproductive to our overall goal of getting kids better, faster out of the hospital, keeping them strong, maintaining their quality of life. Right.

Dr. Madden: And that's our ultimate goal, that we want to optimize their clinical condition and their recovery and get them away from us.

Dr. Loberger: That's right.

Dr. Madden: Because, as you said, we're inclined to react at times to the individual patient, whether or not it really is the most appropriate action at that moment. But I want to go back to something that you said in regards to spontaneous breathing trials and that you use, on occasion, teepees. Tell me a little bit about that thought and why you use that.

Dr. Loberger: Well, it goes back to, I think, a little bit of support goes a long way. So, if the pre-test probability of failure is incredibly high, again, using the example of a neuromuscular patient, I want to know how long they can truly sustain their unrestory workload. Now, obviously, that's taking out one huge component.
The majority of upper airway obstruction and resistance, or really resistance carried in the airway, is in the upper airway for children. And so, I'm going to pull out that tube. And the most common cause of failure is upper airway obstruction.

So, if I don't fully vet a weak patient's ability to resume the respiratory workload, then I add a resistor in series. If I remove me in the tracheal tube, I'm virtually guaranteeing failure. So, really, I don't do it a ton.
But for that high risk population, that's why I do it. And I do it for an hour. We have standard pass criteria in our SPT pathway.

And we go from there. And if they pass, I extubate them, usually to non-invasive.

Dr. Madden: And that was a key component with talking about readiness for extubation in terms of some of the recommendations, talking about that there really should be an expectation, depending upon the individual patient, that they get extubated to non-invasive support, whether it's for a short period of time or a longer duration. Do you have a bias to what type of non-invasive that you prefer?

Dr. Loberger: Not high flow. I know, you said. I think it comes down to a lot of different things.
I think we all know we're so limited in the smallest patients with our interfaces to deliver positive pressure. And so, the smallest neonate, I actually am not against high flow in that population or maybe ram cannula, those types of approaches. But when you get into that toddler range and kind of the early school kid age, depending on the interfaces that you have in their developmental state, they may or may not tolerate that.
And so, that's the group I struggle with and really don't know the best way to approach non-invasive respiratory support. It's far easier in the older school child and the teenager, certainly, where we have a lot of different options. And I tend towards BiPAP in that population.

But it all comes down to so many different things. What's going on with the patient? Like I said, their neurodevelopmental status, what their SPT look like, what the family's willing to tolerate, I think is really important as well.

Managing expectations there is critical. Or even just collaborating with them to say, all right, you know your kid the best. Are they going to tolerate an occlusive mask on their face for any period of time?
And often the answer is that's going to drive agitation. And you know, Jeremy, please don't do that. And then you have to take an alternative approach.

Dr. Madden: Or that toddler group is the majority that we talk about, at least in my environment, that dexmedetomidine infusion is going to be utilized. So yeah, and then now you're still committing them to potentially a longer ICU stay. Going back a little bit to the spontaneous breathing trials, just because of some of the challenges associated with it.

As we've improved our technology and it's become so sophisticated, we've run into the concept that the ventilator is so smart that we have to figure out ways to override the safety features so they don't go into backup ventilation. Do you have comments about that? Or is that possibly why the teepees at times is utilized?

Dr. Loberger: I mean, honestly, I haven't encountered that too much outside of the really the smallest babies or someone who gets a little bit too much sedation when they get a PRN dose of fentanyl or something like that. But I guess what immediately I thought of when you brought that up, though, was how much stock I put in a spontaneous breathing trial for a younger patient versus an older patient. And I tell the fellows and the nurses and the RTs this a lot, just because a baby had to come apart and maybe some breath holding or desaturated during a diaper change, that doesn't constitute an SBT failure.

And unfortunately, babies are getting diapers changed and all kinds of different cares all the time. They're going to respond poorly to that. So I put less stock into transient changes and vital signs and things like that during a spontaneous breathing trial for a baby.

I feel much differently if an older child is going into backup mode or is consistently desaturating or looking very, very distressed.

Dr. Madden: Okay. So let's talk a little bit about post-extubation airway obstruction and the ability to try and prevent it. What strategies have you implemented?

I know that in my work that we pretty much have had like a single approach, but let's talk about it.

Dr. Loberger: Well, one of the big steps we've taken is going back to speaking the same language. We standardized how we do an air leak test. So we take the patient off the circuit and we manually bag them with the cuff deflated to determine a leak pressure.

And if that pressure, the pressure needed to generate a leak is greater than 25 centimeters of water, or there is no leak, that tells us that there's risk for upper airway obstruction, but it's not that simple. And I could bemoan the limitations of the air leak test, but it's the best that we have right now. But then I take pretest probability into it.

So the smaller the airway is, I mean, the smaller the patient is, the less they're going to tolerate any resistance. And I mentioned earlier resistors in series, if they have lung disease and they have some airway swelling, well, that's a bad setup. I tend to treat those patients with high dose dexamethasone and at least two doses prior to extubation, usually 12 hours prior to extubation.

But as the child gets older, I tend to care less and less about the air leak because of the airway diameter, especially if they're very strong. I don't consider that as much into my calculus for extubation. That's, I think, more of the art and everybody has a different way to approach that.

And I don't think we have great evidence for one way or the other outside of if you're going to treat with steroids, give them high dose, 0.5 milligrams per kilogram per dose, at least 12 hours prior to extubation.

Dr. Madden: And that's the practice that I'm accustomed to. And I think one of the overarching components of talking about ventilation liberation is being thoughtful about the process. So you said 12 hours before and you need to have the conversations about when are we anticipating this patient's readiness for extubation.
So this is where the clinical practice guidelines and other components come in. As you said, you have an SBT checklist, I believe is what you said. And knowing that we have to put these things in a process and ensure that we use them each and every time we're approaching a patient, whether or not they are, as we said, they're not homogeneous, they have such a breath.

And oftentimes this is in comparison to the adult literature, how do we apply it? But this is a plug in terms of the work that you're doing in looking at ventilation liberation and how to implement the guidelines. We're getting close to the end of the time we have, but I wanted to ask you if you wouldn't mind talking a little bit about the multicenter collaborative that you're involved in just to give people some information so they're aware it's occurring if they're not yet aware.

Dr. Loberger: Absolutely. So I am a co-PI with SAMR. SAMR was the first author of the guidelines themselves and we had been talking for years about where do we go after the guidelines. And we decided that the first step was to get some like-minded folks who are passionate about this and let's start understanding our practice and start systematically implementing the guidelines.

And so we developed VentLib for Kids or Ventilation Liberation for Kids based off of the success that Near for Kids had, the National Airway Emergency Registry led by Akira Nishizaki. He helped us get this started and we now have 30 centers. We're continuously onboarding centers.

We have some centers in Canada, one in the Netherlands, bunch in the United States. And we are in our first phase of implementation where we are doing SPT eligibility screening, SPT approach. So just pick a standardized approach.

We have some guard rails around that in airway testing and we're going to keep marching forward with each step. And what we're hoping to find is that there's all these different centers that do things slightly different way, but can we learn from each other in a way that doesn't require a massive randomized control trial. Let's look at our clinical outcomes, take a pragmatic approach here and teach each other through quality improvement and implementation science strategies.

And we love to have more people, the more the merrier. We're a group that's passionate and reach out to me if you're interested in joining.

Dr. Madden: That's excellent. I think the fact that we have a podcast on this topic highlights the fact that liberating pediatric patients off mechanical ventilation is a critical step in their recovery. And trying to have individuals such as yourself put forth best practices and to reduce the knowledge gaps is incredibly important in our work, as you said, because now that we have many children who have much more chronic components to their underlying conditions and we've seen a shift in our populations, but sadly we're out of time.
So before I conclude, I just wanted to ask if there was anything else that we hadn't touched on that you wanted to make sure the audience heard?

Dr. Loberger: You want to talk about high flow?

Dr. Madden: No, because that would be a suggestion for an entire other podcast, which I think we just made that.

Dr. Loberger: I appreciate you having me and happy to talk about high flow any day that you would like to do that.

Dr. Madden: Excellent. Well, maybe I can find you someday and we can sit and have a coffee or a drink and debate all of that. Yeah.

So this concludes another episode of the Society of Critical Care Medicine Podcast. Don't forget, if you're listening on your favorite podcast app and you like what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I'm Maureen Madden.

Announcer: Maureen A. Madden, DNP, RN, CPNC, AC, CCRN, FCCM, is a professor of pediatrics at Rutgers Robert Wood Johnson Medical School and a pediatric critical care nurse practitioner in the Pediatric Intensive Care Unit at Bristol-Myers Squibb Children's Hospital in New Brunswick, New Jersey. Join or renew your membership with SCCM, the only multiprofessional society dedicated exclusively to the advancement of critical care.

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