Ventilator management protocols in pediatrics.

Management of mechanical ventilation is a complex process with outcomes affected by multiple patient and caregiver variable. Well-constructed protocols represent the synthesis of best available evidence regarding ventilator management. In adults, protocols improve important outcomes such as duration of mechanical ventilation, length of stay, and complication rates; however, protocols are not uniformly successful. In pediatrics, the available evidence does not suggest that ventilator management protocols should be adopted routinely, which may be due to pediatric-specific attributes such as a generally shorter weaning duration. Evidence suggests support for protocols to carefully titrate sedation. In addition, daily assessment of SBTs improves patient outcomes and should be more uniformly adopted in pediatrics. Ventilator-related outcomes may be affected by other confounding factors such as nutrition and fluid balance. Specific subpopulations, such as children who have congenital heart disease, may present opportunities for focused use of ventilator management protocols. Protocolized ventilation has an important place in trials of new therapeutic strategies such as surfactant or proning. It is hoped that future research will further define the appropriate use of protocols in the general PICU population. Although specific protocols cannot be routinely recommended, a multidisciplinary team approach to synthesizing available literature and determining best practice is a useful model. This approach will foster "team ownership" of ventilator management by all involved, thus engendering the best possible outcomes for critically ill children who require mechanical ventilation.