Intensive Care Medicine

, Volume 42, Issue 8, pp 1214–1222 | Cite as

Pediatric extubation readiness tests should not use pressure support

  • Robinder G. KhemaniEmail author
  • Justin Hotz
  • Rica Morzov
  • Rutger C. Flink
  • Asvari Kamerkar
  • Marie LaFortune
  • Gerrard F. Rafferty
  • Patrick A. Ross
  • Christopher J. L. Newth
Pediatric Original



Pressure support is often used for extubation readiness testing, to overcome perceived imposed work of breathing from endotracheal tubes. We sought to determine whether effort of breathing on continuous positive airway pressure (CPAP) of 5 cmH2O is higher than post-extubation effort, and if this is confounded by endotracheal tube size or post-extubation noninvasive respiratory support.


Prospective trial in intubated children. Using esophageal manometry we compared effort of breathing with pressure rate product under four conditions: pressure support 10/5 cmH2O, CPAP 5 cmH2O (CPAP), and spontaneous breathing 5 and 60 min post-extubation. Subgroup analysis excluded post-extubation upper airway obstruction (UAO) and stratified by endotracheal tube size and post-extubation noninvasive respiratory support.


We included 409 children. Pressure rate product on pressure support [100 (IQR 60, 175)] was lower than CPAP [200 (120, 300)], which was lower than 5 min [300 (150, 500)] and 60 min [255 (175, 400)] post-extubation (all p < 0.01). Excluding 107 patients with post-extubation UAO (where pressure rate product after extubation is expected to be higher), pressure support still underestimated post-extubation effort by 126–147 %, and CPAP underestimated post-extubation effort by 17–25 %. For all endotracheal tube subgroups, ≤3.5 mmID (n = 152), 4–4.5 mmID (n = 102), and ≥5.0 mmID (n = 48), pressure rate product on pressure support was lower than CPAP and post-extubation (all p < 0.0001), while CPAP pressure rate product was not different from post-extubation (all p < 0.05). These findings were similar for patients extubated to noninvasive respiratory support, where pressure rate product on pressure support before extubation was significantly lower than pressure rate product post-extubation on noninvasive respiratory support (p < 0.0001, n = 81).


Regardless of endotracheal tube size, pressure support during extubation readiness tests significantly underestimates post-extubation effort of breathing.


Airway extubation Work of breathing Pediatrics Ventilator weaning 



The authors would like to thank Aaron Clute, Ed Guerrero, Edwin Khatchetourian, and Cary Sodetani RCPs for their assistance with the study protocol; Anoopindar Bhalla, Sarah Rubin, and Timothy Deakers for their assistance with consents; Jeffery Terry and Paul Vee for administrative support, and all the bedside providers in the Children’s Hospital Los Angeles pediatric intensive care unit and cardiothoracic intensive care unit for their participation and support. Sources of support National Institutes of Health/NICHD 1K23HL103785, Los Angeles Basin Clinical Translational Science Institute.

Compliance with ethical standards

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.


  1. 1.
    Curley MA, Wypij D, Watson RS, Grant MJ, Asaro LS, Cheifetz IM, Dodson BL, Franck LS, Gedeit RG, Angus DC, Matthay MA, RESTORE, PALISI Network (2015) Protocolized sedation vs. usual care in pediatric patients mechanically ventilated for acute respiratory failure. JAMA 313:379–389CrossRefPubMedGoogle Scholar
  2. 2.
    Randolph AG, Wypij D, Venkataraman ST, Hanson JH, Gedeit RG, Meert KL, Luckett PM, Forbes P, Lilley M, Thompson J, Cheifetz IM, Hibberd P, Wetzel R, Cox PN, Arnold JH, PALISI Network (2002) Effect of mechanical ventilator weaning protocols on respiratory outcomes in infants and children: a randomized controlled trial. JAMA 288:2561–2568Google Scholar
  3. 3.
    Fiastro JF, Habib MP, Quan SF (1988) Pressure support compensation for inspiratory work due to endotracheal tubes and demand continuous positive airway pressure. Chest 93:499–505CrossRefPubMedGoogle Scholar
  4. 4.
    Mhanna MJ, Anderson IM, Iyer NP, Baumann A (2014) The use of extubation readiness parameters: a survey of pediatric critical care physicians. Respir Care 59:334–339CrossRefPubMedGoogle Scholar
  5. 5.
    Fujino Y, Uchiyama A, Mashimo T, Nishimura M (2003) Spontaneously breathing lung model comparison of work of breathing between automatic tube compensation and pressure support. Respir Care 48:38–45PubMedGoogle Scholar
  6. 6.
    Straus C, Louis B, Isabey D, Lemaire F, Harf A, Brochard L (1998) Contribution of the endotracheal tube and the upper airway to breathing workload. Am J Respir Crit Care Med 157:23–30CrossRefPubMedGoogle Scholar
  7. 7.
    Wilson AM, Gray DM, Thomas JG (2009) Increases in endotracheal tube resistance are unpredictable relative to duration of intubation. Chest 136:1006–1013CrossRefPubMedGoogle Scholar
  8. 8.
    Newth CJ, Venkataraman S, Willson DF, Meert KL, Harrison R, Dean JM, Pollack M, Zimmerman J, Anand KJ, Carcillo JA, Nicholson CE, Collaborative Pediatric Critical Care Research Network (2009) Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 10:1–11Google Scholar
  9. 9.
    Manczur T, Greenough A, Nicholson GP, Rafferty GF (2000) Resistance of pediatric and neonatal endotracheal tubes: influence of flow rate, size, and shape. Crit Care Med 28:1595–1598Google Scholar
  10. 10.
    Kolatat T, Aunganon K, Yosthiem P (2002) Airway complications in neonates who received mechanical ventilation. J Med Assoc Thai 85(Suppl 2):S455–S462PubMedGoogle Scholar
  11. 11.
    Oto J, Imanaka H, Nakataki E, Ono R, Nishimura M (2012) Potential inadequacy of automatic tube compensation to decrease inspiratory work load after at least 48 hours of endotracheal tube use in the clinical setting. Respir Care 57:697–703CrossRefPubMedGoogle Scholar
  12. 12.
    Fabry B, Haberthür C, Zappe D, Guttmann J, Kuhlen R, Stocker R (1997) Breathing pattern and additional work of breathing in spontaneously breathing patients with different ventilatory demands during inspiratory pressure support and automatic tube compensation. Intensive Care Med 23:545–552Google Scholar
  13. 13.
    Haberthür C, Elsasser S, Eberhard L, Stocker R, Guttmann J (2000) Total versus tube-related additional work of breathing in ventilator-dependent patients. Acta Anaesthesiol Scand 44:749–757Google Scholar
  14. 14.
    Aguilar G, Jover JL, Soro M, Belda FJ, Garcia-Raimundo M, Maruenda A (2005) Additional work of breathing and breathing patterns in spontaneously breathing patients during pressure support ventilation, automatic tube compensation and amplified spontaneous pattern breathing. Eur J Anaesthesiol 22:312–314CrossRefPubMedGoogle Scholar
  15. 15.
    Cohen J, Shapiro M, Grozovski E, Fox B, Lev S, Singer P (2009) Prediction of extubation outcome: a randomised, controlled trial with automatic tube compensation vs. pressure support ventilation. Crit Care 13:R21CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Cohen JD, Shapiro M, Grozovski E, Lev S, Fisher H, Singer P (2006) Extubation outcome following a spontaneous breathing trial with automatic tube compensation versus continuous positive airway pressure. Crit Care Med 34:682–686CrossRefPubMedGoogle Scholar
  17. 17.
    Haberthür C, Mols G, Elsasser S, Bingisser R, Stocker R, Guttmann J (2002) Extubation after breathing trials with automatic tube compensation, T-tube, or pressure support ventilation. Acta Anaesthesiol Scand 46:973–979Google Scholar
  18. 18.
    Willis BC, Graham AS, Yoon E, Wetzel RC, Newth CJL (2005) Pressure-rate products and phase angles in children on minimal support ventilation and after extubation. Intensive Care Med 31:1700–1705CrossRefPubMedGoogle Scholar
  19. 19.
    Khemani R, Flink R, Morzov R, Ross P, Newth C (2013) It’s not like breathing through a straw: effort of breathing on CPAP most accurately estimates post-extubation effort in children. Am J Resp Crit Care Med Suppl 2013.187.1:A3682Google Scholar
  20. 20.
    Khemani RG, Hotz J, Morzov R, Flink R, Kamerkar A, Ross PA, Newth CJ (2016) Evaluating risk factors for pediatric post-extubation upper airway obstruction using a physiology-based tool. Am J Respir Crit Care Med 193:198–209CrossRefPubMedGoogle Scholar
  21. 21.
    Khemani R, Flink R, Hotz J, Ross P, Ghuman A, Newth CJ (2015) Respiratory inductance plethysmography calibration for pediatric upper airway obstruction: an animal model. Pediatr Res 77:75–83CrossRefPubMedGoogle Scholar
  22. 22.
    Sackner MA, Watson H, Belsito AS, Feinerman D, Suarez M, Gonzalez G, Bizousky F, Krieger B (1989) Calibration of respiratory inductive plethysmograph during natural breathing. J Appl Physiol 66:410–420PubMedGoogle Scholar
  23. 23.
    Ross PA, Hammer J, Khemani R, Klein M, Newth CJ (2010) Pressure-rate product and phase angle as measures of acute inspiratory upper airway obstruction in rhesus monkeys. Pediatr Pulmonol 45:639–644CrossRefPubMedGoogle Scholar
  24. 24.
    Diblasi RM, Zignego JC, Tang DM, Hildebrandt J, Smith CV, Hansen TN, Richardson CP (2010) Noninvasive respiratory support of juvenile rabbits by high-amplitude bubble continuous positive airway pressure. Pediatr Res 67:624–629CrossRefPubMedGoogle Scholar
  25. 25.
    Argent AC, Hatherill M, Newth CJ, Klein M (2008) The effect of epinephrine by nebulization on measures of airway obstruction in patients with acute severe croup. Intensive Care Med 34:138–147CrossRefPubMedGoogle Scholar
  26. 26.
    Argent AC, Newth CJ, Klein M (2008) The mechanics of breathing in children with acute severe croup. Intensive Care Med 34:324–332CrossRefPubMedGoogle Scholar
  27. 27.
    Davis S, Gappa M, Rosenfeld M (2005) Respiratory mechanics. In: Hammer J, Eber E (eds) Paediatric pulmonary function testing. Karger, Basel, p 30Google Scholar
  28. 28.
    Masters IB, Seidenberg J, Hudson I, Phelan PD, Olinsky A (1987) Longitudinal study of lung mechanics in normal infants. Pediatr Pulmonol 3:3–7CrossRefPubMedGoogle Scholar
  29. 29.
    Hammer J, Patel N, Newth CJ (2003) Effect of forced deflation maneuvers upon measurements of respiratory mechanics in ventilated infants. Intensive Care Med 29:2004–2008CrossRefPubMedGoogle Scholar
  30. 30.
    Hammer J, Numa A, Newth CJ (1997) Acute respiratory distress syndrome caused by respiratory syncytial virus. Pediatr Pulmonol 23:176–183CrossRefPubMedGoogle Scholar
  31. 31.
    Kurachek SC, Newth CJ, Quasney MW, Rice T, Sachdeva RC, Patel NR, Takano J, Easterling L, Scanlon M, Musa N, Brilli RJ, Wells D, Park GS, Penfil S, Bysani KG, Nares MA, Lowrie L, Billow M, Chiochetti E, Lindgren B (2003) Extubation failure in pediatric intensive care: a multiple-center study of risk factors and outcomes. Crit Care Med 31:2657–2664CrossRefPubMedGoogle Scholar
  32. 32.
    Wratney AT, Benjamin DK Jr, Slonim AD, He J, Hamel DS, Cheifetz IM (2008) The endotracheal tube air leak test does not predict extubation outcome in critically ill pediatric patients. Pediatr Crit Care Med 9:490–496CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Mhanna MJ, Zamel YB, Tichy CM, Super DM (2002) The “air leak” test around the endotracheal tube, as a predictor of postextubation stridor, is age dependent in children. Crit Care Med 30:2639–2643CrossRefPubMedGoogle Scholar
  34. 34.
    Khemani R, Hotz J, Morzov R, Kamerkar A, Flink R, PA R, Newth CJ (2015) Risk factors for pediatric post-extubation upper airway obstruction. Am J Respir Crit Care Med 191:A4068Google Scholar
  35. 35.
    Jouvet PA, Payen V, Gauvin F, Emeriaud G, Lacroix J (2013) Weaning children from mechanical ventilation with a computer-driven protocol: a pilot trial. Intensive Care Med 39:919–925CrossRefPubMedGoogle Scholar
  36. 36.
    Emeriaud G, Larouche A, Ducharme-Crevier L, Massicotte E, Flechelles O, Pellerin-Leblanc AA, Morneau S, Beck J, Jouvet P (2014) Evolution of inspiratory diaphragm activity in children over the course of the PICU stay. Intensive Care Med 40:1718–1726CrossRefPubMedGoogle Scholar
  37. 37.
    Goligher EC, Fan E, Herridge MS, Murray A, Vorona S, Brace D, Rittayamai N, Lanys A, Tomlinson G, Singh JM, Bolz SS, Rubenfeld GD, Kavanagh BP, Brochard LJ, Ferguson ND (2015) Evolution of diaphragm thickness during mechanical ventilation. Impact of inspiratory effort. Am J Respir Crit Care Med 192:1080–1088CrossRefPubMedGoogle Scholar
  38. 38.
    Wolf GK, Walsh BK, Green ML, Arnold JH (2011) Electrical activity of the diaphragm during extubation readiness testing in critically ill children. Pediatr Crit Care Med 12:e220–224CrossRefPubMedGoogle Scholar
  39. 39.
    DiNino E, Gartman EJ, Sethi JM, McCool FD (2014) Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation. Thorax 69:423–427CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2016

Authors and Affiliations

  • Robinder G. Khemani
    • 1
    • 2
    Email author
  • Justin Hotz
    • 1
  • Rica Morzov
    • 1
  • Rutger C. Flink
    • 3
  • Asvari Kamerkar
    • 1
  • Marie LaFortune
    • 1
  • Gerrard F. Rafferty
    • 4
  • Patrick A. Ross
    • 1
    • 2
  • Christopher J. L. Newth
    • 1
    • 2
  1. 1.Department of Anesthesiology and Critical CareChildren’s Hospital Los AngelesLos AngelesUSA
  2. 2.Department of PediatricsUniversity of Southern California Keck School of MedicineLos AngelesUSA
  3. 3.Med-E LinkAmsterdamThe Netherlands
  4. 4.Department of Respiratory MedicineKing’s College LondonLondonUK

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