Sedation and Ventilator Weaning Bundle and Time to Extubation in Infants With Bronchiolitis: Secondary Analysis of the Sedation AND Weaning in Children (SANDWICH) Trial

Rebecca B Mitting; Cliona McDowell; Bronagh Blackwood; Samiran Ray

doi:10.1097/PCC.0000000000003685

Sedation and Ventilator Weaning Bundle and Time to Extubation in Infants With Bronchiolitis: Secondary Analysis of the Sedation AND Weaning in Children (SANDWICH) Trial

Pediatr Crit Care Med. 2025 Feb 23. doi: 10.1097/PCC.0000000000003685. Online ahead of print.

Authors

Rebecca B Mitting^{1

2}, Cliona McDowell³, Bronagh Blackwood³, Samiran Ray^{4

5}

Affiliations

¹ Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom.
² Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom.
³ Northern Ireland Clinical Trials Unit, the Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Ireland.
⁴ Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom.
⁵ Respiratory, Critical Care and Anaesthesia Unit, Infection, Inflammation, and Immunity Division, University College London, London, United Kingdom.

PMID: 39846788
DOI: 10.1097/PCC.0000000000003685

Abstract

Objective: The Sedation and Weaning in Children (SANDWICH) trial of a sedation weaning and ventilator liberation bundle had a primary outcome of time to successful extubation, and showed significant but small difference. We explored the impact of the intervention on infants with bronchiolitis.

Design: Post hoc subgroup analysis of a cluster-randomized trial, 2018 to 2019 (ISRCTN16998143).

Patients: Surviving patients with bronchiolitis under 1 year of age in the SANDWICH trial (n = 784).

Interventions: Nil.

Measurements and main results: Time to successful extubation, and rates of unplanned and failed extubation were compared in patients exposed and not exposed to the intervention. To explore a site-level effect, we tested the correlation between the rate of unplanned and failed extubation at each trial site with the median time to successful extubation at that site. Of 784 patients (48%), 376 were exposed to the intervention. Median (interquartile range [IQR]) time to successful extubation was 69.6 (IQR 50.4-110.4) hours in patients exposed to the intervention and 86.4 (IQR 60-124.8) hours in non-exposed. Exposure to the SANDWICH intervention was associated with a 13% (95% CI, 1%-26%) reduction in time to extubation following adjustment for confounders. Thirty (3.8%) patients experienced unplanned extubation and 112 (14%) failed extubation. Patients who experienced failed extubation had an increased time to successful extubation, which remained significant after adjustment for confounders. At the site level, there was a negative correlation between failed extubation rate and median time to successful extubation (Spearman rho -0.53 [95% CI, -0.8 to -0.08], p = 0.02).

Conclusions: In a secondary analysis of the SANDWICH trial, the subgroup of bronchiolitis patients showed that exposure to the intervention was associated with a clinically significant reduction in time to successful extubation. Although failed extubation was associated with increased duration of ventilation in an individual, sites with higher rates of failed extubation had a lower median duration of ventilation.