• Kelby E Knox, Justin C Hotz, NewthChristopher J LCJLDepartment of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA., KhooMichael C KMCKDepartment of Biomedical Engineering, University of Southern California Viterbi School of Engineering, Los Angeles, CA., and Robinder G Khemani.
• Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA. Electronic address: kknox@chla.usc.edu.
• Chest. 2023 Jan 1; 163 (1): 115127115-127.

BackgroundThe optimal length of spontaneous breathing trials (SBTs) in children is unknown.Research QuestionsWhat are the most common reasons for SBT failure in children, and when do they occur? Can clinical parameters at the 30-min mark of a 120-min SBT predict outcome?Study Design And MethodsWe performed a secondary analysis of a clinical trial in pediatric ARDS, in which 2-h SBTs are conducted daily. SBT failure is based on objective criteria, including esophageal manometry for effort of breathing, categorized as passage, early failure (≤ 30 min), or late failure (30-120 min). Spirometry was used to calculate respiratory rate (RR), tidal volume (Vt), and rapid shallow breathing index (RSBI), in addition to pulse oximetry and capnography. Predictive models evaluated parameters at 30 min against SBT outcome, using receiver operating characteristic plots and area under the curve.ResultsWe included 100 children and 305 SBTs, with 42% of SBTs being successful, 32% failing within 30 min, and 25% failing between 30 and 120 min. Of the patients passing SBTs at 30 min, 40% went on to fail by 120 min. High respiratory effort (esophageal manometry) was present in > 80% of failed SBTs. At the 30-min mark, there were no clear thresholds for RR, Vt, RSBI, Fio2, oxygen saturation, or capnography that could reliably predict SBT outcome. Multivariable modeling identified RR (P < .001) and RSBI > 7 (P = .034) at 30 min, pre-SBT inspiratory pressure level (P = .009), and pre-SBT retractions (P = .042) as predictors for SBT failure, but this model performed poorly in an independent validation set with the receiver operating characteristic plot crossing the reference line (area under the curve, 0.67).InterpretationA 30-min SBT may be too short in children recovering from pediatric ARDS because many go on to fail between 30 and 120 min. Reassuring values of Vt, RR, and gas exchange at 30 min do not reliably predict SBT passage at 2 h, likely because they do not capture the effort of breathing.Clinical Trial RegistrationClinicalTrials.gov; No.: NCT03266016; URL: www.Clinicaltrialsgov.Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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