open access publication

Article, 2023

Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document.

In: American Journal of Respiratory and Critical Care Medicine, ISSN 1535-4970, 1073-449X, Volume 207, 1, Pages 17-28, 10.1164/rccm.202204-0795so

Contributors (30)

Abu-Sultaneh, Samer M A (0000-0002-2659-2070) [1] [2] Iyer, Narayan Prabhu [3] [4] Fernández, Analía (0000-0002-5601-9742) [5] Gaies, Michael G [6] González-Dambrauskas, Sebastián (0000-0003-4775-227X) [7] Hotz, Justin Christian [4] Kneyber, Martin C J [8] [9] López-Fernández, Yolanda M (0000-0002-3918-1326) [10] Rotta, Alexandre Tellechea (0000-0002-4406-2276) [11] Werho, David K (0000-0003-0048-9806) [12] [13] Baranwal, Arun Kumar (0000-0003-4334-2652) [14] Blackwood, Bronagh [15] Craven, Hannah J (0000-0002-1701-3655) [1] Curley, Martha A Q [16] [17] Essouri, Sandrine (0000-0001-9144-0957) [18] [19] Fioretto, José Roberto [20] Hartmann, Silvia M M [21] [22] Jouvet, Philippe André (0000-0001-5684-3398) [18] [19] Korang, Steven Kwasi (0000-0002-6521-0928) [4] [23] Rafferty, Gerrard Francis (0000-0001-9520-6500) [24] Ramnarayan, Padmanabhan (0000-0003-0784-8154) [25] Rose, Louise (0000-0003-1700-3972) [26] Tume, Lyvonne Nicole (0000-0002-2547-8209) [27] Whipple, Elizabeth C (0000-0002-0103-6318) [1] Wong, Judith Ju-Ming [28] Emeriaud, Guillaume (0000-0001-6405-3054) [18] [19] Mastropietro, Christopher W (0000-0002-7409-7664) [1] [2] Napolitano, Natalie [17] Newth, Christopher J L [3] [4] Khemani, Robinder G [3] [4]


  1. [1] Indiana University – Purdue University Indianapolis
  2. [NORA names: United States; America, North; OECD]
  3. [2] Riley Hospital for Children
  4. [NORA names: United States; America, North; OECD]
  5. [3] University of Southern California
  6. [NORA names: United States; America, North; OECD]
  7. [4] Children's Hospital of Los Angeles
  8. [NORA names: United States; America, North; OECD]
  9. [5] El Hospital General de Agudos Carlos G. Durand
  10. [NORA names: Argentina; America, South]


Rationale: 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 multiprofessional panel to establish pediatrics-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. A systematic review was conducted for questions that 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 and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive 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.


Grading of Recommendations, MAIN, Pediatric Acute Lung Injury, acute lung injury, agreement, airway obstruction, assessment, assessment of risk, best practices, breathing trial, bundles, certainty, children, clinical practice guidelines, conceptual framework, convergence, criteria, development, documents, duration, elements, evaluation methodology, evidence, evidence-based recommendations, experts, extubation, extubation readiness testing, framework, grading, guidelines, hours, injury, international clinical practice guidelines, international experts, invasive mechanical ventilation, key questions, lack, liberation, low certainty, lung injury, measurements, measures, mechanical ventilation, method, methodology, most recommendations, muscle strength, network documents, noninvasive respiratory support, obstruction, opinion, panel, part, patient readiness, postextubation upper airway obstruction, practice, practice guidelines, prevention, questions, readiness, readiness testing, recommendation criteria, recommendations, respiratory muscle strength, respiratory support, review, risk, screening, sedation, spontaneous breathing trial, strength, study, support, systematic review, systematic screening, testing, threshold, trials, unnecessary variation, upper airway obstruction, use, variation, ventilation, ventilator liberation


  • Eunice Kennedy Shriver National Institute of Child Health and Human Development