Pediatric Post-Extubation Noninvasive Respiratory Support: A Multi-Institutional Analysis

Introduction: Non-invasive respiratory support (NRS) is increasingly used in pediatric critical care to avoid invasive mechanical ventilation (IMV). Practices related to post-extubation NRS use and its effects on outcomes is a key evidence gap. This study aimed to describe risk factors associated with NRS liberation failure ≤48 hours post-extubation and associations with patient-centered outcomes.


Methods: This is a retrospective cohort study of pediatric patients ≤18 years exposed to IMV via endotracheal tube for ≥24 hours between January 1, 2013, and December 31, 2022, in the Virtual Pediatric Systems, LLC database. NRS liberation failure ≤48 hours post-extubation was the primary outcome. Mixed-effects logistic regression models were developed for patient-centered outcomes.


Results: 132,712 encounters from 158 institutions were included. High flow nasal cannula (HFNC) was the most common NRS modality (20%) followed by bilevel positive airway pressure (BiPAP) (8.1%) and continuous positive airway pressure (CPAP) (4.3%) with rescue deployment more common than planned. Later study year (2021-2022 OR 1.93 [1.82-2.04]), high risk primary diagnostic category (OR 1.9 [1.84-1.97]), planned HFNC use (OR 2.80 [2.66-2.94]), planned CPAP use (OR 5.95 [5.28-6.71]), planned BiPAP use (OR 11.76, [10.72-12.90]), and IMV duration ≥7 days prior to the first extubation attempt (OR 2.25 [2.18-2.33]) were associated with higher odds of NRS liberation failure. While younger age was associated with lower odds of NRS liberation failure; < 28 days (OR 0.89 [0.83-0.95]), 28 days to < 12 months (OR 0.95 [0.90-0.99]), 12 months to < 6 years (OR 0.90 [0.86-0.95]). Patients with NRS liberation failure had longer total NRS duration (3.8 vs 1.0 days), longer PICU (14.1 vs 8.6 days) and hospital (24.4 vs 15.9 days) length of stay, and PICU all-cause mortality (3.4% vs 2.5%). Younger age, high risk primary diagnostic category, use of rescue CPAP, use of planned as well as rescue BiPAP, and duration IMV duration ≥7 days were associated with higher odds of extubation failure ≤48 hours and 7 days.


Conclusions: Post-extubation NRS use is highly prevalent and most commonly deployed as a rescue strategy. Failure to liberate from NRS ≤48 hours post-extubation is associated with worse patient-centered outcomes.