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Ventilator Weaning Clinical Pathway – CICU

CICU Clinical Pathway for Management of Ventilator Weaning

Goal and Metrics
Provider Resources
 
 

Procedural/Short-Term Intubation 12–24 hrs

  1. Assess for residual neuromuscular blockade
  2. Extubation Readiness Assessment
    • Adequate respiratory drive
    • Spontaneous breathing
    • Cough/gag present
    • Airway bundle completed
      (for potential reintubation)
    • Ability to manage secretions
  3. Turn off sedation and extubate when ready per clinical team

Invasively Mechanically Ventilated Child in the CICU > 24 hrs who meets criteria for weaning readiness for extubation

Exclusion Criteria

Eligibility Criteria

  • Pressure or volume-controlled ventilator modes non-escalated for 6 hrs
  • Peak Inspiratory Pressure (PIP) < 25
  • Positive End-Expiratory Pressure (PEEP) < 8
  • FiO2 < 50% for 6 hrs
  • 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
 
 

Wean Process

 
 
Clinical Signs of a Failed Wean

Wean Not Tolerated

 
 

Goal Settings Achieved for Extubation Readiness Trial (ERT)

RR 10–15
PS 8–10
PEEP ≤ 6
 
 
 
 
Pass
Fail

Extubate within 6 Hrs of ERT
Completed Airway bundle
Consider sedation wean

Perform Daily
Leak test, consider dexamethasone
ERT until pass

Weaning Parameters and Frequencies by Ventilation Mode
Volume Control Ventilation (VCV)
Setting Weaning Parameter Weaning Frequency Comments Goals
Respiratory Rate (RR) 2–6 breaths per min 2–4 hrs Wean if normal RR for age
Age RR
< 6 mos 20–60
6 mos – 2 yrs 15–45
2–5 yrs 15–40
> 5 yrs 10–35
  • Ventilation
    • EtCO2 similar to prior
    • Minute ventilation (VE) similar to prior
      • VE = RR × Vt
    • Minimize WOB
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
    • FiO2 ≤ 50%
    • SpO2 within 5% of baseline
Pressure Control Ventilation (PCV)
Setting Weaning Parameter Weaning Frequency Comments Goals
Respiratory Rate (RR) 2–6 breaths per min 2–4 hrs Wean if normal RR for age
Age RR
< 6 mos 20–60
6 mos – 2 yrs 15–45
2–5 yrs 15–40
> 5 yrs 10–35
  • Ventilation
    • EtCO2 similar to prior
    • Minute ventilation (VE) similar to prior
      • VE = RR × Vt
    • Minimize WOB
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
    • FiO2 ≤ 50%
    • SpO2 within 5%
      of baseline