SCCMPod-559 PCCM: Optimizing Time to Extubation in the PICU

In this episode of the Society of Critical Care Medicine (SCCM) Podcast, host Elizabeth H. Mack, MD, MS, FCCM, speaks with Rebecca Mitting, MD, MRCPCH, consultant pediatric intensivist and clinical lead for the PICU at Imperial College Healthcare NHS Trust in London. They discuss Dr. Mitting’s article, “Sedation and Ventilator Weaning Bundle and Time to Extubation in Infants With Bronchiolitis: Secondary Analysis of the Sedation AND Weaning in Children (SANDWICH) Trial,” published in the April 2025 issue of Pediatric Critical Care Medicine. The SANDWICH trial, conducted in the United Kingdom, evaluated a nurse-led intervention of sedation scoring, goal-based sedation weaning, and protocolized extubation readiness testing. While the original trial demonstrated only a modest reduction in ventilation duration, Dr. Mitting’s subgroup analysis of infants with bronchiolitis found a reduction of median time to successful extubation by approximately 16 to 17 hours. Dr. Mitting highlights the importance of these findings during the winter season when bronchiolitis drives up PICU occupancy and strain. The critical trade-off between minimizing ventilator days and avoiding extubation failure is discussed, as well as implementation challenges after the COVID-19 pandemic, the importance of protocolized care under resource strain, and future directions for predictive models and personalized strategies to optimize extubation timing. Listeners will gain practical insights into evidence-based approaches for improving outcomes in infants with bronchiolitis and the broader implications for PICU workflow and patient safety. Resources referenced in this episode: Sedation and Ventilator Weaning Bundle and Time to Extubation in Infants With Bronchiolitis: Secondary Analysis of the Sedation AND Weaning in Children (SANDWICH) Trial (Mitting RB, et al. Pediatr Crit Care Med. 2025;26:e423-e431). Effect of a Sedation and Ventilator Liberation Protocol vs Usual Care on Duration of Invasive Mechanical Ventilation in Pediatric Intensive Care Units: A Randomized Clinical Trial (Blackwood B, et al. JAMA. 2021;326:401-410).