CICU Clinical Pathway for Management
of Ventilator Weaning

Goals and Metrics
Provider Resources
Related Pathways
Invasively Mechanically Ventilated Child in the CICU
Procedural/Short-term Intubation
< 12-24 hrs
  1. Extubation Readiness Assessment
  2. Turn off sedation and extubate when ready per clinical team
Meets Criteria for Weaning Readiness for Extubation
  • Stable conventional ventilator modes (VCV/PCV)
    non-escalated for 6 hrs
  • Peak Inspiratory Pressure (PIP) < 25, PEEP < 8
  • Stable FiO2 ≤ 50% for 6 hrs
  • Tolerating SBS goal of -1 or 0
  • Spontaneous breathing
  • Not under neuromuscular blockade
  • Underlying reason for intubation has resolved/is resolving
  • Closed sternum
  • Lactate < 2
  • Vasopressors or inotropes non-escalated for 6 hrs
Begin Wean: Parameters and Frequency
Perform leak and consider NIF upon entry to pathway and daily between 7-11 p.m.
Consider Dexamethasone when within 12 hrs of extubation
  • Any CICU provider (MD, RN, APP, RT) to suggest entry
  • RT/RN q2hr assessments of wean tolerance and ability to continue
  • All ventilator changes require discussion with a FLOC order
  • Utilize CICU Ventilator Weaning Pathway Order Set
Re-evaluate in 6 hrs
Volume Control Ventilation (VCV)
Setting Weaning Parameter Frequency Comments Goals
Respiratory Rate (RR) 2-6 breaths per min 2-4 hrs
  • Ventilation
    • Maintain EtCO2 similar
      to prior
    • Maintain minute ventilation
    • (VE) be similar to prior
      • VE = RR x Vt
  • Minimize work of breathing
Pressure Support (PS) 2-4 cmH2O 2-4 hrs Wean to maintain target pressure support tidal volume (Vt) > 4 mL/kg
Positive End-expiratory Pressure (PEEP) 2 cmH2O 4-8 hrs
  • Oxygenation
    • Maintain FiO2 ≤ 50%
    • Maintain SpO2 within 5%
      of baseline
Tolerate - Continue Wean
Fail Wean
Pressure Control Ventilation (PCV)
Setting Weaning Parameter Frequency Comments Goals
Respiratory Rate (RR) 2-6 breaths per min 2-4 hrs
  • Ventilation
    • Maintain EtCO2 similar
      to prior
    • Maintain minute ventilation
    • (VE) be similar to prior
      • VE = RR x Vt
  • Minimize work of breathing
Pressure Support (PS) 2-4 cmH2O 2-4 hrs Wean to maintain target pressure support tidal volume (Vt) > 4 mL/kg
Positive End-expiratory Pressure (PEEP)
and
Peak Inspiratory Pressure (PIP)		 2 cmH2O 4-8 hrs Wean to maintain ΔP such that target tidal volume(Vt) > 6-10 mL/kg
  • Oxygenation
    • Maintain FiO2 ≤ 50%
    • Maintain SpO2 within 5%
      of baseline
Achieve Settings:
RR = 10-15 Pressure Support = 8-10 PEEP ≤ 6
Discuss NPO status
Perform Extubation Readiness Trial (ERT)
when settings reached or at 3 a.m.
Pass
Fail
Retry
ERT daily
Extubate within 6 hrs
per clinical team
Return to prior settings
  • Pre-extubation:
  • Ensure completed Airway Bundle
  • Consider Sedation Wean
Posted: April 2024
Editors: Clinical Pathways Team