Scenario

An 8-year-old boy, with a medical history of congenital myotonic dystrophy (CMD) and scoliosis, was admitted to the paediatric intensive care unit (PICU) with a lower respiratory tract infection. He was intubated and received antibiotics. After a prolonged intubation, he tolerated a spontaneous breathing trial (SBT) and received ‘pre-extubation steroids’. He was extubated to non-invasive ventilation (NIV), but quickly was re-intubated. The reason for extubation failure was determined to be secondary to respiratory muscle insufficiency. Would diaphragmatic ultrasound (DU) assessment of function have predicted extubation failure?

Structured clinical question

In an 8-year-old boy with CMD, can DU (intervention) be used to predict extubation failure (outcome)?

Search

This search was undertaken using PubMed (MeSH) and SumSearch. The descriptive terms of ‘diaphragm’, ‘ultrasound’, ‘mechanical ventilation’ and ‘paediatric’ were combined and generated 56 ‘hits’, of which 6 were relevant. The excluded hits occurred for the following reasons:

• Duplicates: 4

• Preterm: 2

• Not relevant: 38

• No abstract: 3

• Not English language: 2

Summary of included studies

A summary of the selected articles is provided in table 1.

Commentary

The decision to extubate should be cautiously and judiciously undertaken. Extubation from positive pressure mechanical ventilation (MV) to negative pressure patient ventilation results in physiological changes for the patient. A recent paediatric study demonstrated 8.3% of mechanically ventilated patients had extubation failure within 48 hours.1 Desirable criteria for extubation include intact airway reflexes, …