Mechanical ventilation (MV) is the main ventilation resource used to treat newborn and children admitted to Pediatric and Neonatal Intensive Care Units (PICUs and NICUs).1–3 Even though MV has saved many lives, it has also been associated with complications such as lung injury, pneumonia, cardiovascular instability due to cardiopulmonary interaction, morbidities in neurodevelopment, and injury to the respiratory tract associated with the endotracheal tube.3,4 Therefore, it is advisable to discontinue ventilation support as soon as possible.4

Weaning is an important stage of MV representing 40% of the ventilation support total time.5 Weaning a patient off MV is a complex process which combines clinical aspects (i.e. guidelines and evidence-based protocols), contextual aspects (i.e. organization, resources and professional team) and healthcare providers’ skills (i.e. education, combination of competence/experience and professional relationships).6

For the clinical aspects, there is a large variability in the clinical application of MV weaning protocols,7 hence, there is no agreement on when weaning procedure should start. Evidence of effective methods for weaning patients off MV as well as guidelines/recommendations of tests which determine the best timing or readiness for extubation, both in pediatrics and neonatology, is still necessary.8,9

For the contextual and professional aspects, MV weaning and extubation procedures may vary according to the structure of the unit, availability of a skilled professional team, the type of patients being assisted, and medical and nursing leadership models. Such factors will influence the definition of professional roles and responsibilities for MV weaning and extubation.6

Previous studies6,10–13 have presented the role of non-medical clinicians in decisions related to MV protocols and the weaning procedure. In Brazil, few studies have assessed the practice related to MV weaning procedures and the characteristics of physical therapists who assist in adult14–16 and neonatal17 Intensive Care Units (ICUs). There is no study to the authors knowledge describing the participation of physical therapists in performing MV weaning and extubation procedures on pediatric or neonatal units. Therefore, the aim of this study was to identify and assess the characteristics associated with the involvement of physical therapists in MV weaning and extubation procedures in pediatric and neonatal ICUs in Brazil.

This is the first study carried out in Brazil that describes the role and characteristics of the work structure for physical therapists taking part in MV weaning and extubation procedures involving pediatric and neonatal patients. Our findings showed that physical therapists would carry out weaning procedures more often when there were MV weaning protocols on the units. In units in which there were dedicated physical therapists 24h/7 days per week, protocols were commonly used. In this case, the extubation decision was predominantly made by the dedicated physical therapist and the extubation procedure was frequently done successfully in the first attempt. Following the extubation, it is important for the physical therapist to follow-up and monitor the patient to assure airway patency and adequate pulmonary ventilation during this period.22

In the NICUs, MV weaning procedure was frequently performed by physical therapists individually or as part of a multi-professional team, while in the PICUs and mixed PICUs this procedure was performed more often by physician with physical therapist. For the extubation procedure, our findings revealed that it was primarily done by physicians in PICUs and mixed PICUs, and that physical therapists independently deciding to perform extubation only occurred in NICUs following set procedures.

A previous Brazilian survey16 carried out in adult ICUs in the country showed that 79.2% of physical therapists interviewed performed the MV weaning procedure. Nevertheless, only 22% of them independently conducted MV weaning. The profile of professional responsibility when making decisions on these procedures varies among countries, however, the establishment of a protocol is often shared by the health professional team.23 That being said, the ultimate decision lies with the physician whose patient is being treated. Involving a team of professionals may avoid delayed identification of when to start the weaning procedure and makes use of other clinicians skills in performing extubation, as well as unnecessary extension of MV.23 Moreover, having a health professional other than the patient's physician decide on MV weaning and extubation procedures may be influenced not only by the existence of MV and weaning protocols,23 but also the availability and involvement of the multiprofessional team of each ICU, in this process.

In pediatrics, decisions to start the MV weaning procedure is usually in the hands of ICU physicians after the assessment of clinical and functional criteria which determine the possibility of a successful weaning procedure.4,24 Previous surveys have shown that the use of MV weaning protocols in NICUs25 and PICUs6,26 are rarely used and have controversial results.8,27 On the other hand, another survey conducted in Canada, described that MV protocols were commonly used in units where there were dedicated physical therapists,10 especially in units where this professional service was available 24h/7 days per week.11 Protocols are useful to standardize MV procedures in ICUs, since they offer opportunities to engage a multi-professional team and encourage actions to be taken when facing doubt about when to initiate the MV weaning procedure.10,11

The results of the current survey showed the predominant use of protocols occurred in private hospitals. Previous studies have shown controversial results regarding the application of MV protocols in different types of hospitals.10,11 Furthermore, it is important to note that physical therapy assistance provided 24h/7 days per week was predominant in ICUs in public teaching hospitals, although a study carried out by Costa et al.,28 showed that physical therapists worked mainly in the private sector (60%) in different levels of health care.

It is important to note that, although the response rate was 48.9%, this survey included all the states of the country and was above the minimal sample required (82 units) to be representative of the total number of ICUs in Brazil. Similar surveys in Brazil actually have achieved lower response rates.29

This survey was important to understand the profile of physical therapists in different types of ICUs with regards to MV weaning and extubation procedures. Furthermore, it was significant to identify the professionals’ working conditions that might impact how these procedures are performed. Finally, it is meaningful to highlight the participation of physical therapists in MV weaning and extubation procedures as well as the involvement of different team members who work in the ICU. Future studies will be needed to assess the impact of physical therapy assistance 24h/7 days per week on the MV weaning process outcomes.

The authors declare no conflicts of interest.