Weaning Protocol Research Articles

STATIC LUNG COMPLIANCE AS A PREDICTOR OF EXTUBATION FAILURE IN NON-COVID-19 PATIENTS WITH ACUTE RESPIRATORY FAILURE

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Ventilator weaning protocols rely in part on objective indices to best predict extubation failure in the critically ill. In this study, we investigated static lung compliance (LC) as a predictor of extubation failure, in comparison to extubation readiness using rapid shallow breathing index (RSBI). METHODS: A cross-sectional, multi-institutional study of 2,334 mechanically ventilated patients admitted from 12/01/2017-12/01/2019. We included all older than 18 years with a documented spontaneous breathing trial and extubation trial. Static lung compliance and RSBI were calculated prior to extubation trial. The primary outcome was extubation failure - defined as need for reintubation within 24 hours from time of extubation. RESULTS: Of the 2,334 patients, 55.6% were males with a mean age of 66-years. The population consisted mostly of Caucasians (74%) and African Americans (20%). 183 of 2,334 (7.84%) patients required reintubation within 24 hours. There was a negative correlation between RSBI and lung compliance at time of extubation trial. The logLC of patients requiring reintubation was significantly lower than those who remained extubated with a mean of 3.58 ± 0.43 vs. 3.69 ± 0.49 (95% CI in difference:0.041 -0.17;p = 0.001). Whereas, log RSBI was not significant for 24-hour reintubation (p = 0.521). Patients were then dichotomized to a compliance of less or greater than 50 and RSBI of less or greater than 104. LC 104 was not associated with extubation failure (OR 1.53;98% CI:0.20 -11.57;p = 0.674). On multivariate logistic regression after adjusting for age, mode of ventilation, ventilator days, and P/F ratio, LC remained the strongest predictor for 24-hr reintubation (OR 1.56;95% CI: 1.14-2.13). CONCLUSIONS: Static lung compliance measured at the day of extubation is a promising physiological discriminant to evaluate extubation readiness. We recommend further validation studies in prospective cohorts. CLINICAL IMPLICATIONS: Static lung compliance may potentially be used as a discriminant to risk stratify patients with acute respiratory failure for extubation success. DISCLOSURES: No relevant relationships by Lauren Abplanalp, source=Web Response No relevant relationships by Girish Balachandran Nair, source=Admin input No relevant relationships by Enrique Calvo Ayala, source=Web Response No relevant relationships by Limin Yu, source=Web Response

Weaning from mechanical ventilation in people with neuromuscular disease: a systematic review

ObjectiveThis systematic review aimed in assessing the effects of different weaning protocols in people with neuromuscular disease (NMD) receiving invasive mechanical ventilation, identifying which protocol is the best and how...

In-vitro and in-vivo comparisons of high versus low concentrations of inhaled epoprostenol to adult intubated patients

BackgroundInhaled epoprostenol (iEPO) has been shown to reduce pulmonary artery pressure and improve oxygenation. iEPO is mainly delivered via a syringe pump with feed tubing connected to a vibrating mesh nebulizer with high or low formulation concentration delivery.MethodsAn in vitro study and a two-period retrospective case–control study were implemented. The in vitro study compared iEPO delivery via invasive ventilation at low concentrations of 7.5, and 15 mcg/mL and high concentration at 30 mcg/mL, to deliver the ordered dose of 30 and 50 ng/kg/min for three clinical scenarios with predicted body weight of 50, 70 and 90 kg. While in the clinical study, adult patients receiving iEPO via invasive ventilation to treat refractory hypoxemia, pulmonary hypertension, or right ventricular failure were included. 80 patients received low concentration iEPO at multiple concentrations (2.5, 7.5, and 15 mcg/mL, depending on the ordered dose) from 2015 to 2017, while 84 patients received high concentration iEPO at 30 mcg/mL from 2018 to 2019.ResultsIn the in vitro study, there were no significant differences in aerosol deposition between high vs low concentrations of iEPO at a dose of 50 ng/kg/min. In the clinical study, age, gender, ethnicity, and indications for iEPO were similar between high and low concentration groups. After 30–120 min of iEPO administration, both delivery strategies significantly improved oxygenation in hypoxemic patients and reduced mean pulmonary arterial pressure (mPAP) for patients with pulmonary hypertension. However, no significant differences of the incremental changes were found between two delivery groups. Compared to low concentration, high concentration delivery group had better adherence to the iEPO weaning protocol (96% vs 71%, p < 0.001), fewer iEPO syringes utilized per patient (5 [3, 10] vs 12 [6, 22], p = 0.001), and shorter duration of invasive ventilation (6 [3, 12] vs 9 [5, 18] days, p = 0.028). Intensive care unit length of stay and mortality were similar between two groups.ConclusionCompared to low concentration delivery of iEPO, high concentration iEPO via a vibrating mesh nebulizer maintained clinical benefits and increased clinician compliance with an iEPO weaning protocol, required less medication preparation time, and shortened duration of invasive ventilation.

ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries.

To evaluate current international practice in PICUs regarding components of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment" (ABCDEF) bundle. Online surveys conducted between 2017 and 2019. One-hundred sixty-one PICUs across the United States (n = 82), Canada (n = 14), Brazil (n = 27), and Europe (n = 38) participating in the Prevalence of Acute Rehabilitation for Kids in the PICU study. None. Of the 161 participating PICUs, 83% were in academic teaching hospitals and 42% were in free-standing children's hospitals. Median size was 16 beds (interquartile range, 10-24 beds). Only 15 PICUs (9%) had incorporated all six ABCDEF bundle components into routine practice. Standardized pain assessment (A) was the most common (91%), followed by family engagement (F, 88%) and routine sedation assessment (C) with validated scales (84%). Protocols for testing extubation readiness or conducting spontaneous breathing trials (B) were reported in 57%, with 34% reporting a ventilator weaning protocol. Routine delirium monitoring with a validated screening tool (D) was reported by 44% of PICUs, and 26% had a guideline, protocol, or policy for early exercise/mobility (E). Practices for spontaneous breathing trials were variable in 29% of Canadian PICUs versus greater than 50% in the other regions. Delirium monitoring was lowest in Brazilian PICUs (18%) versus greater than 40% in other regions, and family engagement was reported in 55% of European PICUs versus greater than 90% in other regions. ABCDEF bundle components have been adopted with substantial variability across regions. Additional research must rigorously evaluate the efficacy of specific elements with a focus on B, D, E, and full ABCDEF bundle implementation. Implementation science is needed to facilitate an understanding of the barriers to ABCDEF implementation and sustainability with a focus on specific cultural and regional differences.

Strategies for Continuous Renal Replacement Therapy De-escalation.

Strategies for Continuous Renal Replacement Therapy De-escalation.

Weaning Protocol for Severe COVID-19 Patients on High-Flow Nasal Cannula Oxygen Therapy

Weaning Protocol for Severe COVID-19 Patients on High-Flow Nasal Cannula Oxygen Therapy

A guide to reducing adverse outcomes in rabbit models of sciatic nerve injury

BackgroundPeripheral nerve damage can have debilitating consequences. Rabbit sciatic nerve transection models allow the effective evaluation of surgical repair strategies for large nerve gaps. Despite advantages in size, ease of handling, and functional utility, rabbits can suffer from a number of side effects that affect animal welfare and the quality of scientific inquiry. Such side-effects, which include pressure ulcers and traumatic damage to the foot, are primarily a consequence of insensitivity of the distal hindlimb following sciatic nerve injury. In this study, we present a number of methodologies for identifying, treating, and preventing unintended adverse effects in rabbit sciatic nerve injury models.ResultsFirst, we categorize pressure ulcers according to their severity and describe the deployment of a padded bandaging technique to enable ulcer healing. We also introduce a proactive bandaging approach to reduce the likelihood of pressure ulcer formation. Second, we define phenotypes that distinguish between foot injuries resulting from self-mutilation (autotomy) from those caused by incidental traumatic injury secondary to sensori-motor damage. Finally, we detail an effective strategy to reduce the usage of Elizabethan collars; through a gradual weaning protocol, their usefulness in preventing autotomy is retained, while their propensity to impede rabbit grooming and cause abrasion-injury to the neck region is minimized.ConclusionsWe suggest that application of these methods offer a practical and systematic approach to avoid adverse side effects associated with rabbit sciatic nerve damage, enabling improved animal welfare and scientific outcomes in a powerful nerve injury model.

A Survey of Mechanical Ventilation Weaning Practices in ICUs of Bangladesh

Objective : To determine mechanical ventilation discontinuation (weaning) practices in Bangladesh as there is currently no data available on this issue.&#x0D; Method : Analyzing the Survey on Bangladeshi respondents using questionnaire developed by and used by a pan Asian study where Bangladesh critical care physicians participated.&#x0D; Result : 40 physicians from 10 ICUs of Bangladesh participated. Majority of our participating doctors (62.5%) came from private for profit hospital. 19 out of 40 respondents were certified in critical care medicine. In our study spontaneous breathing trial (SBT) was liberally used with pressure support being used by 30% respondents. Most of the extubation trial took place during day. As criteria for extubation, respondents mainly considered consciousness and cooperation and along with gag reflex, cough strength, suction frequency and cuff leak at different times. Noninvasive ventilation (NIV) was commonly used for early extubation in cases of COPD, cardiogenic pulmonary edema, neuromuscular disorders, post-operative cases and obesity. Slightly less than half of respondents did not follow any sedation protocol and 42.5% followed weaning protocol. Protocolized weaning by nurses are not known to be practiced in Bangladesh.&#x0D; Conclusion : Weaning practices are diverse in Bangladeshi ICUs. Protoclized weaning is rarely practiced in Bangladesh.&#x0D; Bangladesh Crit Care J March 2021; 9(1): 4-11

Transcutaneous electrical diaphragmatic stimulation reduces the duration of invasive mechanical ventilation in patients with cervical spinal cord injury: retrospective case series.

Study designRetrospective case series.ObjectivesTo compare individuals with cervical spinal cord injury (SCI) submitted to transcutaneous electrical diaphragmatic stimulation (TEDS) or a standard weaning protocol (SWP) according to the following variables: invasive mechanical ventilation (IMV) time, ventilator weaning time, intensive care unit (ICU) length of stay, and overall hospital length of stay.SettingsTertiary university hospital. Clinical Hospital of Campinas State University—UNICAMP—Campinas (SP), Brazil.MethodsRetrospective case study investigating ICU patients submitted to tracheostomy due to cervical SCI at a tertiary university hospital (Clinical Hospital of Campinas State University, Brazil). Data were extracted from medical records of patients seen between January 2007 and December 2016. According to medical records, four patients were submitted to TEDS and six to a SWP. Provision of training to patients in the TEDS group was based on consensus medical decision, preference of the physical therapy team and availability of electrostimulation equipment in the ICU.ResultsTotal IMV time in the TEDS and the SWP group was 33 ± 15 and 60 ± 22 days, respectively. Length of stay in ICU in the TEDS and the SWP group was 31 ± 18 and 63 ± 45 days, respectively.ConclusionTEDS appears to influence the duration of IMV as well as the length of stay in ICU. This physiotherapeutic intervention may be a potentially promising tool for treatment of patients with SCI. However, randomized clinical trials are warranted to support this assumption.

Quality Initiative to Reduce High-Flow Nasal Cannula Duration and Length of Stay in Bronchiolitis

High-flow nasal cannula (HFNC) use in bronchiolitis may prolong length of stay (LOS) if weaned more slowly than medically indicated. We aimed to reduce HFNC length of treatment (LOT) and inpatient LOS by 12 hours in 0- to 18-month-old patients with bronchiolitis on the pediatric hospital medicine service. After identifying key drivers of slow weaning, we recruited a multidisciplinary "Wean Team" to provide education and influence provider weaning practices. We then implemented a respiratory therapist-driven weaning protocol with supportive sociotechnical interventions (huddles, standardized orders, simplification of protocol) to reduce LOT and LOS and promote sustainability. In total, 283 patients were included: 105 during the baseline period and 178 during the intervention period. LOT and LOS control charts revealed special cause variation at the start of the intervention period; mean LOT decreased from 48.2 to 31.2 hours and mean LOS decreased from 84.3 to 60.9 hours. LOT and LOS were less variable in the intervention period compared with the baseline period. There was no increase in PICU transfers or 72-hour return or readmission rates. We reduced HFNC LOT by 17 hours and LOS by 23 hours for patients with bronchiolitis via multidisciplinary collaboration, education, and a respiratory therapist-driven weaning protocol with supportive interventions. Future steps will focus on more judicious application of HFNC in bronchiolitis.

Enough Is Enough: Quality Improvement to Deimplement High-Flow Nasal Cannula in Bronchiolitis.

High-flow nasal cannula (HFNC): nobody seems to like it, but everyone seems to be using it as the newest treatment of bronchiolitis. Although supportive care is the mainstay of treatment,1 we as a medical community continue to seek interventions for this self-limited viral disease process, with the good intentions to minimize suffering and limit time families spend in the hospital. As hospitalists, we strive to provide efficient care and were quick to partner with our critical care colleagues to make HFNC therapy available on the acute care wards, in an attempt to avoid costly ICU stays. In the last several years, in 2 randomized controlled trials, researchers found that early initiation of HFNC reduces the need for later rescue therapy2,3 (notably, most often to HFNC), but that HFNC does little to mitigate the disease process and does not reduce the length of time oxygen therapy is needed nor the frequency of ICU transfers.4 Despite this, the use of HFNC nationally has risen.5 In this issue of Hospital Pediatrics , Charvat et al6 and Noelck et al7 share 2 quality improvement (QI) studies to implement standardized weaning protocols as a first step toward establishing appropriate HFNC therapy use. Both Charvat et al6 and Noelck et al7 used QI methodology to address the discontinuation of HFNC, one …

Evaluating the effectiveness of the ventilator weaning protocol

Evaluating the effectiveness of the ventilator weaning protocol

Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation.

Analgesics and sedatives are key elements to reduce physiological and psychological stress associated with treatment in paediatric intensive care. Prolonged drug use may induce tolerance and development of iatrogenic withdrawal syndrome (IWS) during the tapering phase. Our primary aim was to describe the prevalence of IWS among critically ill ventilated patients in two Norwegian paediatric intensive care units (PICUs), and secondary to investigate what motivated bedside nurses to administer additional drug doses. Mechanically ventilated patients (n=40) from newborn to eighteen years of age, with continuous infusions of opioids and benzodiazepines for 5days or more, were included consecutively from May 2016 to June 2018. By using Withdrawal Assessment Tool-1 (WAT-1) twice daily we recorded the prevalence of IWS. Additionally, we recorded signs and symptoms that led bedside nurses to administration extra bolus medication. Peak WAT-1 score indicated an IWS prevalence of 95% in this selected group. The first days of the tapering phase were most critical for IWS. The most frequent symptoms triggering administration of additional bolus doses were agitation/restlessness, and thiopental and propofol were the bolus drugs used most frequently. IWS affected 95% of the children having received infusions of opioids and benzodiazepines for 5days or more in PICUs without a tapering protocol for these drugs. This calls for implementation and testing of such weaning protocols.

Berlin Heart Explantation Systematic Approach Protocol in a Single Center Experience

Introduction Berlin Heart EXCOR ventricular assist device (VAD) implantation in children is widely used as a bridge-to-heart transplantation. VAD support as a bridge-to-recovery is rare. There is scarcity of literature describing systematic evaluation of cardiac recovery employed in VAD explanation in children. Case Report A 13 month-old boy presented to the emergency department with acute congestive heart failure secondary to myocarditis. Echocardiogram demonstrated severely depressed left ventricular (LV) function with severe mitral regurgitation. He developed ventricular tachycardia with hemodynamic compromise necessitating institution of veno-arterial extracorporeal membranous oxygenation (ECMO). He was decannulated 11 days later after a successful trial off, but due to no further improvement in cardiac status, he underwent Berlin Heart EXCOR LVAD placement as a bridge-to-transplant. After 3 months of VAD support, we noted evidence of myocardial recovery and discussed the possibility of VAD explant. A weaning protocol was developed that consisted of two phases. The first phase consisted of a trial off with echocardiographic monitoring of biventricular function, atrioventricular valve regurgitation and LV diastolic dimension. The second phase was performed one week later in the cardiac catheterization suite, while monitoring hemodynamic measurements at baseline and with manual pumping followed by dobutamine challenge at the end of trial off. Clinical data was satisfactory and patient met established goals to undergo explant. Berlin explantation was succesfully performed the following day. His recovery was unremarkable and was discharged 2 weeks after explant. Patient was seen for follow-up at 1, 2 and 3 months post-discharge and he is doing well. Summary We established guidelines for trialing off VAD support to maximize the identification of potential candidates for VAD explantation. This protocol includes three main stages: screening, trial-off with echocardiography and trial-off in the catheterization suite. This case demonstrates that myocardial recovery can take longer than previously recognized in children with myocarditis and it highlights that strong consideration should be given to patients with a stable VAD course to remain inactive on the heart transplant waitlist to allow time for myocardial recovery and successful explantation.

A Novel Protocol for the Evaluation and Management of Patients for Successful HeartMate III Explantation

<h3>Introduction</h3> Left ventricular assist devices (LVADs) are used in cases of heart failure refractory to medical therapy. In certain cases, myocardial function recovers and LVADs can be explanted. Weaning protocols and post explantation management are lacking. We describe the case of successful Heartmate III (HM III) LVAD insertion, followed by myocardial recovery and successful explanation. <h3>Case Report</h3> 35-year-old male with a history of chronic systolic heart failure due to poly-substance abuse with a left ventricular ejection fraction (EF) of 15% presented in acute cardiogenic shock, INTEMACS 2. A HM III was implanted and he remained stable. Over a period of 14 months, he was able to tolerate up titration of his goal directed medical therapy that included valsartan 160 mg twice daily, spironolactone 50 mg daily, digoxin 125 mcg daily, isosorbide mononitrate 60 mg daily, hydralazine 100 mg three times a day, and carvedilol 25 mg twice a day. On repeat imaging, he demonstrated a decrease in left ventricular (LV) size and an increase in intrinsic function (EF50%), represented by an aortic valve that opens with every beat and low flow alarms necessitating lower speeds. The decision was made to wean him from the LVAD. He was given 5000 units of IV heparin and under echo guidance his LVAD speed was decreased from 5000 to 4500 rpm. He walked 537 m on a 6-minute walk test. He was admitted for further reduction in HM III dependence. He received additional heparin and his LVAD speed was dropped to 4,000rpm for a cardiopulmonary exercise test, which was notable for peak VO₂ of 13 with an RER of 1.4 and a VE/VCO2 slope of 39. His RHC demonstrated acceptable intra-cardiac pressures with a normal cardiac index. HM III was explanted and he was discharged. <h3>Summary</h3> To date no weaning protocols for HM III have been accepted or standardized. We describe the case of a patient who required LVAD insertion, followed by myocardial recovery and explanation. We suggest the above protocol for the evaluation of patients deemed appropriate for LVAD explant.

Characteristics of LVAD Turn-Down Study to Predict Myocardial Recovery and Successful LVAD Decommissioning

<h3>Purpose</h3> Myocardial recovery after left ventricular device (LVAD) implantation is important to identify; however, identifying predictors of successful LVAD decommissioning, and recurrence of heart failure remains a challenge. <h3>Methods</h3> We performed a retrospective analysis on individuals who underwent a protocolized echocardiographic and invasive hemodynamic turn-down study. Patients were selected based on normalized hemodynamics, clinical stability and LVEDD <5.5 cm. <h3>Results</h3> A total of 12 patients underwent the LVAD weaning protocol. Of those patients, 42% (5/12) underwent LVAD decommissioning with sustained recovery (SR) (median 13 months) while 58% (7/12) failed recovery (FR) by requiring LVAD re-implantation after decommissioning or failed turn-down study precluding LVAD decommission. In FR versus SR patients LV-end systolic (LVESD) and -end diastolic (LVEDD) diameter were higher at the start (LVESD 4.8 ± 0.4 FR vs 3.5 ± 0.3 SR, p<0.05, Fig A; LVEDD 5.3 ± 0.3 FR vs 4.5 ± 0.2 mm SR, p = 0.066, Fig C) and end (LVESD 4.6 ± 0.5 FR vs 3.2 ± 0.3 mm SR, p<0.05, Fig B; LVEDD 5.4 ± 0.3 FR vs 4.6 ± 0.2 mm SR p = 0.10, Fig D) of the turn-down. Ejection fraction did not differ at start or end of the turn-down study between groups (Fig E,F). Hemodynamic parameters of right heart function differed between FR and SR patients. Central venous pressure (CVP) increased in the FR group through the turn-down study, whereas CVP decreased or did not change in the SR group (∆CVP 1.5 ± 0.8 FR; -1.0 ± 0.4 mmHg SR, p<0.05; Fig G). Pulmonary artery pulsatility index (PAPI) decreased in FR patients at the end of turn-down study, whereas PAPI increased in those with SR (∆PAPI -0.6 ± 0.2 FR; 0.6 ± 0.5 mmHg SR, p<0.05; Fig H). LVAD power prior to LVAD turn-down was higher in FR relative to SR patients (4.1 ± 0.3 FR; 2.9 ± 0.3 W SR, p<0.05, Fig I). <h3>Conclusion</h3> In our cohort of LVAD turn-down studies, we were able to identify echo parameters, invasive hemodynamics, and LVAD pump parameters that differed between patients with failed and sustained recovery.

Fast-Tracking in Lung Transplantation: OR-Extubation

<h3>Purpose</h3> Fast-tracking in cardiac-thoracic surgery is highly challenging. It requires multimodal and transdisciplinary collaboration. Early postoperative extubation in the operating room (OR) is an aspect of this strategy1. The objective of the present study was to report our whole experience of immediate end-surgery extubation after lung transplantation. <h3>Methods</h3> The Ethical Board of the French Society for Anesthesia and Intensive Care approved this analysis of the prospectively Lung Transplant database. All consecutive patients undergoing double-lung transplantation from January 2012 to December 2018 were analyzed, except repeated transplantation during the study period, and transplantation under cardiopulmonary bypass. The cardio-respiratory weaning protocol has been previously published2 (Figure). The aims of the study were: to identify factors predicting immediate extubation, and to compare outcome among patients. <h3>Results</h3> Among the 410 patients included, 142 (34.6%) were extubated in the OR. Predictive factors for OR extubation are reported in Table 1. Postoperative outcomes are summarized in Table 2. <h3>Conclusion</h3> Immediate extubation via a fast-tracking protocol is feasible after lung transplantation. It forecasts a positive outcome. It requires transdisciplinary collaboration.

Clinical Approach to Decision-Making in Nasogastric Tube Weaning and Tracheostomy Tube Decannulation.

Extensive resections for advanced malignancies of the oral cavity quite often require patients to have a tracheostomy tube and nasogastric tube for prolonged periods leading to dependence. Timely and safe removal of these tubes would help hasten the recovery and rehabilitation of these patients. A simple bedside protocol for evaluation and weaning of nasogastric tube and tracheostomy tube is outlined in this communication. This would help health care workers in resource-poor settings make safe clinical decisions and improve care.

P0293 / #1640: BUBBLE CPAP AND HIGH FLOW NASAL CANNULA IN LOW- RESOURCE SETTINGS: PROMISING THERAPIES OR HAVE WE BURST THE BUBBLE?

Aims & Objectives: Pneumonia is a leading cause of mortality among children in low-resource settings (LRS). World Health Organization treatment recommendations include low-flow oxygen for children with severe pneumonia. Bubble continuous positive airway pressure (bCPAP) is a non-invasive respiratory support modality that may benefit children in LRS with severe pneumonia. We examine results from three randomized controlled trials comparing bCPAP with standard oxygen therapy among children with severe pneumonia in LRS. Methods: The data from the three trials1,2,3 vary greatly and were not amenable to a meta-analysis. However, a side-by-side comparison (Figure 1) will be used to foster discussion among session participants. Ongoing work will also be discussed. Results: Trials differed by location, access to critical care, and inclusion and exclusion criteria (Figure 1). Trials differed by bCPAP systems and pressures used, escalation and weaning protocols, frequency of monitoring, physician availability, nursing ratios and feeding protocols. Chisti et al., determined that bCPAP reduced treatment failure and mortality; Wilson et al., reported a survival benefit for patients under 12 months of age; the trial described by McCollum et al., was stopped early for futility and safety concerns. FIGURE 1Conclusions: bCPAP may offer benefit to children in LRS with severe pneumonia. Careful assessment must be made for children who will receive bCPAP. Areas of debate include: 1. Inclusion criteria; 2. Physician supervision and nurse ratios; 3. Escalation and weaning protocols; 4. Critical care access; 5. Ancillary care, including feeding. WFPICCS is an ideal platform in which to address the best practices for bCPAP in LRS.

IKanEat: protocol for a randomized controlled trial of megestrol as a component of a pediatric tube weaning protocol

BackgroundAlthough tube feeding routinely saves the lives of children who do not eat by mouth, chronic tube feeding can be a burden to patients, caregivers, and families. Very few randomized trials exist regarding the best methods for weaning children from their feeding tubes.MethodsThe current paper describes a randomized controlled trial of an empirically supported outpatient treatment protocol for moving children from tube to oral eating called iKanEat. Specifically, we describe the methods of randomized double-blind, placebo-controlled trial which includes a 4-week course of megestrol, the only medication used in the iKanEat protocol, to determine whether the addition of megestrol results in improved child outcomes. The primary and secondary aims are to assess the safety and efficacy of megestrol as part of the iKanEat protocol. The third aim is to provide critical information about the impact of the transition from tube to oral feeding on parent stress and parent and child quality of life.DiscussionThis trial will provide data regarding whether megestrol is a safe and effective component of the iKanEat tube weaning protocol, as well as important data on how the tube weaning process impacts parent stress and parent and child quality of life.Trial registrationClinicalTrials.gov NCT#03815019. Registered on January 17, 2019