Spontaneous breathing trial predicts successful extubation in infants and children Angelica Chavez, MD; Rogelio dela Cruz, MD; Arno Zaritsky, MD A lthough mechanical ventila- tion is a life-saving interven- tion for pediatric patients suf- fering from acute respiratory failure, it is associated with numerous grave complications and should be dis- continued at the earliest possible time (1, 2). The reported extubation failure rate ranges from 4.9% (3) to 29% (4). The capacity of intensive care unit (ICU) prac- titioners to clinically predict extubation outcome is limited, and studies have re- ported a range of success at predicting extubation failure using a variety of re- spiratory measurements and/or inte- grated indexes of respiratory function (4 – 10). These studies reveal the intense clinical effort to choose the appropriate time to safely extubate pediatric patients recovering from respiratory failure. This complex decision making is difficult to apply consistently at the bedside. Identi- fying a simple method of accurately pre- dicting when an infant or child with re- spiratory failure is ready for extubation would represent a significant contribu- tion to care. Currently, there are no sim- ple and practical bedside tests that en- hance the clinical prediction of successful extubation. In adults, a spontaneous breathing trial (SBT) is often used to help identify when a patient is ready for extu- bation, but this is used infrequently in children (11–15). Studies by Khan et al. (5) and Venkataraman et al. (9) indicate that the current practice of extubating patients from low ventilator settings with an assumed low level of pressure support may overestimate the patients’ ability to breathe independently. To eliminate un- recognized ventilator support, these re- sults support the use of a SBT to identify patient readiness for extubation. Two pediatric studies by Farias et al. (15, 16) demonstrated that children can be suc- cessfully weaned from mechanical ventila- tion after an SBT using either a T-piece or pressure support. Unfortunately, despite the successful completion of a breathing trial lasting 2 hrs, 12–15% of the patients required reintubation within 48 hrs indi- cating that the trials did not enhance a clinician’s clinical prediction of successful extubation. To date, there are no SBTs us- ing a flow-inflating bag, which provides fresh gas flow with a valve that regulates continuous positive airway pressure (CPAP) during spontaneous breathing. In both pediatric and adult studies performing SBTs, the duration of the tri- als was set arbitrarily at 2 hrs even though the optimal duration of a SBT that would be most predictive of success- ful extubation is unknown. In addition, pediatric and adult studies evaluating the efficacy of SBTs have not systematically extubated patients who failed the breath- ing trial. Therefore, the ability of a failed SBT to predict the need for ventilator support was not formally assessed. The primary goal of this study was to assess the value of a flow-inflating anes- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Florida College of Medicine, Gainesville, FL The authors do not have any financial interest to report. The authors have not disclosed any potential con- flicts of interest. Address requests for reprints to: Arno Zaritsky, MD, University of Florida, Department of Pediatrics, Division of Pediatric Critical Care, P.O. Box 100296, Gainesville, FL 32610-0296. E-mail: zarital@peds.ufl.edu. Copyright © 2006 by the Society of Critical Care Medicine and the World Federation of Pediatric Inten- sive and Critical Care Societies DOI: 10.1097/01.PCC.0000225001.92994.29 Objective: To assess the value of a spontaneous breathing trial (SBT) using a flow-inflating bag in predicting extubation success. Secondary goals were to evaluate the positive and negative pre- dictive accuracy of a 15-min SBT. Design: Prospective, blinded, clinical study. Setting: Pediatric intensive care unit (ICU) of a university hospital Patients: Infants and children intubated for >24 hrs. Interventions: Patients who met defined criteria for extubation underwent a 15-min SBT connected to a flow-inflating bag set to provide 5 cm H 2 O continuous positive airway pressure. Measurements and Main Results: Seventy patients underwent the SBT. Respiratory rate, heart rate, blood pressure, and pulse oxygen saturations were recorded at baseline and at 5 and 15 mins into the SBT. The ICU physicians were blinded to the results of the SBT, and all patients were extubated at the end of the trial. Patients were observed for the next 24 hrs, and the need for noninvasive ventilation or reintubation (i.e., extubation failure) was recorded. Sixty-four patients (91%) passed the SBT with a subsequent extubation failure rate of 7.8% (only 1.6% required reintubation). Six of the 70 (9%) patients enrolled failed the trial, but half were extubated successfully. Successful completion of the SBT has a 95% sensitivity for predicting successful extubation with a posi- tive predictive value of 92% and an odds ratio of 12 (95% confidence interval, 1.3, 53.7). The specificity of the SBT was 37% with a negative predictive value of 50%. Logistic regression analysis revealed a significant association between passing the SBT and extubation success (p  .017). Conclusions: A 15-min flow-inflating bag SBT represents a practical, reliable bedside test that has 95% sensitivity for pre- dicting extubation success in pediatric ICU patients. A trial failure is associated with but does not accurately predict extubation failure. (Pediatr Crit Care Med 2006; 7:324 –328) KEY WORDS: extubation; mechanical ventilation; weaning; anes- thesia bag; pediatric; positive end-expiratory pressure 324 Pediatr Crit Care Med 2006 Vol. 7, No. 4