背景:尽管许多研究探索了拔管准备测试的要素,但仍缺乏儿科专用呼吸机释放指南。缺乏临床实践指南导致用于评估儿科患者拔管准备情况的方法发生了重大和不必要的变化。
方法:26位国际专家组成了一个多专业小组,以建立儿科专用呼吸机解放临床实践指南,重点是接受有创机械通气超过24小时的急性住院儿童。确定了11个关键问题,并首先使用“对建议和证据的意见的修正趋同”确定了优先次序。对未达到≥80%一致性的先验阈值的问题进行了系统评价,随着建议的分级,评估,发展,和用于制定准则的评估方法。小组评估了证据,起草,并对建议进行了投票。
结果:与系统筛查有关的三个问题,使用拔管准备测试束和使用自主呼吸试验作为束的一部分,符合改良的意见与建议的融合标准≥80%的一致性.剩下的8个问题5项系统评价产生了12项建议,涉及自主呼吸试验的方法和持续时间;呼吸肌力量的测量;拔管后上气道阻塞的风险评估及其预防;拔管后无创呼吸支持的使用;和镇静。大多数建议都是有条件的,并且基于低至非常低的证据确定性。
结论:本临床实践指南为儿科呼吸机释放相关的最佳实践提供了一个基于证据的建议的概念框架。本文是开放访问的,并根据知识共享归因非商业衍生工具许可证4.0(http://creativecommons.org/licenses/by-nc-nd/4.0/)的条款分发。
BACKGROUND: Pediatric specific ventilator liberation
guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice
guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients\' readiness for extubation.
METHODS: Twenty-six international experts comprised a multi-professional panel to establish pediatric specific ventilator liberation clinical practice
guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. Systematic review was conducted for questions which did not meet an a-priori threshold of ≥80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the
guidelines. The panel evaluated the evidence, drafted, and voted on the recommendations.
RESULTS: Three questions related to systematic screening, using an extubation readiness testing bundle and use of a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ≥80% agreement. For the remaining 8 questions, 5 systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials; measures of respiratory muscle strength; assessment of risk of post-extubation upper airway obstruction and its prevention; use of post-extubation non-invasive respiratory support; and sedation. Most recommendations were conditional and based on low to very low certainty of evidence.
CONCLUSIONS: This clinical practice
guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).