Invasive mechanical ventilation is a lifesaving support modality for critically ill children. It is well known that the length of exposure is correlated with morbidity and mortality.1,2 Ventilator liberation strategies must strike an ideal balance of limiting that exposure while also avoiding extubation failure, an outcome likewise associated with poor outcomes. The topic of timing and approach to ventilator liberation in the pediatric cardiac patient is hotly contested as this subspecialty has significant practice variation, just as there is with the general pediatric population. Pediatric patients with cardiac disease who are mechanically ventilated in the ICU can be dichotomized into two categories: postoperative congenital heart surgery patients with minimal lung disease expected to be extubated within the first day of admission and patients with more significant cardiac or respiratory failure requiring prolonged ventilatory support. For the first group, research and quality improvement work have focused on early postoperative extubation, defined as extubation in the operating room or within 6 h postoperatively. Early extubation can generally be safely achieved in patients after low to moderate risk operations and in some, but not all, studies has been shown to be associated with shorter hospital length of stay.3,4

In cardiac patients requiring longer ventilation times, standardized extubation readiness tests (ERTs) and spontaneous breathing trials (SBTs) become more important in the evaluation of a patient’s readiness for extubation. International ventilator liberation practices are highly variable as a function of limited evidence and stylistic preferences.5-7 An international survey of 555 pediatric intensivists in medical/surgical and cardiac pediatric ICUs (PICUs) showed wide variation in both the types of variables and associated thresholds employed in …

Correspondence: Natalie Napolitano MPH RRT RRT-NPS FAARC, Respiratory Therapy Department, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, 7NW148, Philadelphia, PA 19104. E-mail: napolitanonchop.edu