Protocolized Weaning From Mechanical Ventilation in the PICU: A Systematic Review and Meta-Analysis.

Abstract / Summary

The use of standardized weaning protocols for invasive mechanical ventilation (IMV) is well established in adult critical care, but evidence in pediatric populations remains limited and heterogeneous. To evaluate the impact of protocolized weaning compared to usual care on clinical outcomes in pediatric intensive care units (PICUs). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized interventional studies comparing protocolized weaning with usual care in critically ill children. Databases searched included PubMed, Embase, Cochrane Library, and ClinicalTrials.gov, through July 2025, without language or date restrictions. Two reviewers independently extracted data and assessed risk of bias using RoB 2 and ROBINS-I tools. Seventeen studies were included (seven RCTs and ten non-randomized studies), involving 16,805 pediatric patients. Among RCTs, protocolized weaning showed a non-significant trend toward reduced IMV duration (mean difference [MD]: -9.68 h; 95% CI: -19.62 to 0.26; p = 0.06). Non-randomized studies showed a significant reduction (MD: -30.30 h; 95% CI: -59.42 to -1.18; p = 0.04). In the combined analysis, protocolized weaning was associated with a statistically significant reduction in IMV duration (MD: -20.86 h; 95% CI: -33.31 to -8.40; p = 0.001). PICU length of stay was also reduced in the overall analysis, though not in RCTs alone. No significant differences were observed for hospital length of stay, extubation failure, or mortality. Trial Sequential Analysis showed that current RCT evidence remains inconclusive. Protocolized weaning was associated with shorter mechanical ventilation duration in some analyses, although the certainty of this evidence is low due to high risk of bias and heterogeneity.

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