Ventilator weaning and extubation practices in critically ill children: An Australian and New Zealand survey of practice

Published:August 27, 2022DOI:



      We aimed to (i) describe current weaning and extubation practices in children (protocols to identify weaning candidates, spontaneous breathing trials, and other aspects of care such as sedation weaning) and (ii) understand responsibilities for ventilation weaning decisions across Australia and New Zealand (ANZ).


      A cross-sectional survey of ANZ intensive care units who routinely intubate and ventilate children (<18 years) was conducted. We worked with the Australian and New Zealand Intensive Care Society Paediatric Study Group to identify units and potential respondents (senior nurse representative per unit) and to administer questionnaires. Survey questions (n = 35) examined current protocols, practices, unit staffing, and decision-making responsibilities for ventilation weaning and extubation. Open-ended questions examined respondents' experiences of weaning and extubation.


      A senior nursing respondent from 18/22 intensive care units (82%) completed the survey. Across units, most used sedation assessment tools (88%), and less often, sedation weaning tools (55%). Spontaneous awakening protocols were not used; one unit (5%) reported the use of a spontaneous breathing protocol. Two respondents reported that ventilation weaning protocols (11%) were in use, with 44% of units reporting the use of extubation protocols. Weaning and extubation practices were largely perceived as medically driven, with qualitative data demonstrating a desire from most respondents for greater shared decision-making.


      In ANZ, ventilation weaning and extubation practices are largely medically driven with variation in the use of protocols to support mechanical ventilation weaning and extubation in children. Our findings highlight the importance of future research to determine the impact of greater collaboration of the multidisciplinary team on weaning practices.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Australian Critical Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • ANZICS Centre for Outcome and Resource Evaluation
        Report of the Australian and New Zealand paediatric intensive care Registry 2018.
        vol. 28. ANZICS CORE, Victoria, AUS2018
        • Cocoros N.M.
        • Priebe G.
        • Gray J.E.
        • Tolzis P.
        • Larsen G.Y.
        • Logan L.K.
        • et al.
        Factors associated with pediatric ventilator-associated conditions in six U.S. Hospitals: a nested case-control study.
        Pediatr Crit Care Med. 2017; 18: e536-e545
        • Wolfe H.A.
        • Mack E.H.
        Making care better in the pediatric intensive care unit.
        Transl Pediatr. 2018; 7 ([published Online First: 2018/11/22]): 267-274
        • Brilli R.J.
        • Sparling K.W.
        • Lake M.R.
        • Butcher J.
        • Myers S.S.
        • Clark M.D.
        • et al.
        The business case for preventing ventilator-associated pneumonia in pediatric intensive care unit patients.
        Joint Comm J Qual Patient Saf. 2008; 34 ([published Online First: 2008/11/26]): 629-638
        • Blackwood B.
        • Tume L.N.
        • Morris K.P.
        • Clarke M.
        • McDowell C.
        • Hemming K.
        • et al.
        Effect of a sedation and ventilator liberation protocol vs usual care on duration of invasive mechanical ventilation in pediatric intensive care units: a randomized clinical trial.
        JAMA. 2021; 326: 401-410
        • Blackwood B.
        • Murray M.
        • Chisakuta A.
        • Cardwell C.R.
        • Halloran P.
        Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients.
        Cochrane Database Syst Rev. 2013; ([published Online First: 2013/08/01])Cd009082
        • Blackwood B.
        • Agus A.
        • Boyle R.
        • Clarke M.
        • Hemming K.
        • Jordan J.
        • et al.
        Sedation AND Weaning in Children (SANDWICH): protocol for a cluster randomised stepped wedge trial.
        BMJ Open. 2019; 9 ([published Online First: 2019/11/13])e031630
        • Blackwood B.
        • Tume L.
        The implausibility of 'usual care' in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK).
        Trials. 2015; 16 ([published Online First: 2015/08/01]): 325
        • Elisa P.
        • Francesca C.
        • Marco P.
        • Davide V.
        • Laura Z.
        • Fabrizio Z.
        • et al.
        Ventilation weaning and extubation readiness in children in pediatric intensive care unit: a review.
        Front Pediatr. 2022; 10 ([published Online First: 2022/04/19])867739
        • Principi T.
        • Fraser D.D.
        • Morrison G.C.
        • Farsi S.A.
        • Carrelas J.F.
        • Maurice E.A.
        • et al.
        Complications of mechanical ventilation in the pediatric population.
        Pediatr Pulmonol. 2011; 46 ([published Online First: 2011/01/05]): 452-457
        • Monteverde E.
        • Fernández A.
        • Poterala R.
        • Vidal N.
        • Serrate A.S.
        • Castelani P.
        • et al.
        Characterization of pediatric patients receiving prolonged mechanical ventilation.
        Pediatr Crit Care Med. 2011; 12 ([published Online First: 2011/04/19]): e287-e291
        • Rose L.
        • Schultz M.J.
        • Cardwell C.R.
        • Jouvet P.
        • McAuley D.F.
        • Blackwood B.
        Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children.
        Cochrane Database Syst Rev. 2014; ([published Online First: 2014/06/11])Cd009235
        • Rose L.
        • Schultz M.
        • Cardwell C.
        • Jouvet P.
        • McAuley D.F.
        • Blackwood B.
        Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children.
        Cochrane Database Syst Rev. 2015;
        • Curley M.A.
        • Wypij D.
        • Watson R.S.
        • Grant M.J.
        • Asaro L.A.
        • Cheifetz I.M.
        • et al.
        Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial.
        JAMA. 2015; 313 ([published Online First: 2015/01/21]): 379-389
        • Tume L.N.
        • Kneyber M.C.
        • Blackwood B.
        • Rose L.
        Mechanical ventilation, weaning practices, and decision making in European PICUs.
        Pediatr Crit Care Med. 2017; 18 ([published Online First: 2017/02/16]): e182-e188
        • The American Association for Public Opinion Research
        Standard definitions: final dispositions of case codes and outcome rates for surveys.
        9th ed. The American Association for Public Opinion Research, 2016: 81
        • Polit D.F.
        • Beck C.T.
        The content validity index: are you sure you know what's being reported? Critique and recommendations.
        Res Nurs Health. 2006; 29 ([published Online First: 2006/09/16]): 489-497
        • Polit D.F.
        • Beck C.T.
        • Owen S.V.
        Is the CVI an acceptable indicator of content validity? Appraisal and recommendations.
        Res Nurs Health. 2007; 30 ([published Online First: 2007/07/27]): 459-467
        • Bacci S.
        • Pereira J.M.
        • da Silva Chagas A.C.
        • Carvalho L.R.
        • de Oliveira Azevedo V.M.
        Role of physical therapists in the weaning and extubation procedures of pediatric and neonatal intensive care units: a survey.
        Braz J Phys Ther. 2019; 23 ([published Online First: 2018/09/27]): 317-323
        • Blackwood B.
        • Junk C.
        • Lyons J.D.
        • McAuley D.F.
        • Rose L.
        • et al.
        Role responsibilities in mechanical ventilation and weaning in pediatric intensive care units: a national survey.
        Am J Crit Care. 2013; 22 ([published Online First: 2013/05/03]): 189-197
        • Burns K.E.A.
        • Raptis S.
        • Nisenbaum R.
        • Rizvi L.
        • Jones A.
        • Bakshi J.
        • et al.
        International practice variation in weaning critically ill adults from invasive mechanical ventilation.
        Ann Am Thorac Soc. 2018; 15: 494-502
        • Newth C.J.
        • Hotz J.C.
        • Khemani R.G.
        Ventilator liberation in the pediatric ICU.
        Respir Care. 2020; 65: 1601-1610
        • Foronda F.K.
        • Troster E.J.
        • Farias J.A.
        • Ferraro A.A.
        • Faria L.S.
        • Boussa A.
        • et al.
        The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial.
        Crit Care Med. 2011; 39: 2526-2533
        • Newth C.J.
        • Venkataraman S.
        • Willson D.F.
        • Meert K.L.
        • Harrison R.
        • Dean J.M.
        • et al.
        • Eunice Shriver Kennedy National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network
        Weaning and extubation readiness in pediatric patients.
        Pediatr Crit Care Med. 2009; 10: 1-11
        • Tume L.N.
        • Scally A.
        • Carter B.
        Paediatric intensive care nurses' and doctors' perceptions on nurse-led protocol-directed ventilation weaning and extubation.
        Nurs Crit Care. 2014; 19 ([published Online First: 2013/11/28]): 292-303
        • Duyndam A.
        • Houmes R.J.
        • van Rosmalen J.
        • Tibboel D.
        • van Dijk M.
        • Ista E.
        Implementation of a nurse-driven ventilation weaning protocol in critically ill children: can it improve patient outcome?.
        Aust Crit Care. 2020; 33 ([published Online First: 2019/03/17]): 80-88
        • Brown A.M.
        • Besunder J.
        • Bachmann M.
        Development of a pediatric intensive care unit nurse practitioner program.
        J Nurs Adm. 2008; 38 ([published Online First: 2008/08/12]): 355-359
        • Irving S.Y.
        Collaborative practice in the PICU: the Nurse Practitioner role complementing delivery of care [corrected].
        Aust Crit Care. 2012; 25 ([published Online First: 2012/09/25]): 210-211
        • Molitor-Kirsch S.
        • Thompson L.
        • Milonovich L.
        The changing face of critical care medicine: nurse practitioners in the pediatric intensive care unit.
        AACN Clin Issues. 2005; 16 ([published Online First: 2005/05/07]): 172-177
        • Richards C.A.
        • Starks H.
        • O’Connor M.R.
        • Doorenbos A.Z.
        Elements of family-centered care in the pediatric intensive care unit: an integrative review.
        J Hospice Palliat Nurs. 2017; 19 ([published Online First: 2017/05/13]): 238-246
        • Lincoln Y.S.
        • Guba E.G.
        But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation.
        N Dir Progr Eval. 1986; 1986: 73-84