Neuromuscular Compromise and Respiratory Failure — Invasive Ventilation: Weaning Strategies — Clinical Pathway: Inpatient and PICU

Neuromuscular Compromise and Respiratory Failure Clinical Pathway — Inpatient and PICU

Invasive Ventilation: Weaning Strategies

Weaning Ventilator Settings

Wean ventilator settings with a goal of maintaining a normal or baseline:

  • PaCO2
  • SpO2 ≥ 92% in room air
  • Tidal volume goal of 8-10 mL/kg unless the patient meets criteria for the ALI/ARDS guideline
  • Baseline PEEP on NIV support
  • Keep RR increased above normal per age range (no need to wean to rate of 5 or pressure support of 5)

Wean toward the settings that approximate the NIV settings that the patient will be extubated to (goal of PIP/PEEP 1-2 cm H2O lower than non-invasive settings).

Invasive Ventilation Weaning Requirements

Parameter Guidance
Leak Testing
  • Leak should be tested 24 hr prior to anticipated extubation.
  • Consider dexamethasone based on leak.
Leak
≥ 30 cmH2O Recommend the use of pre-extubation dexamethasone with racemic epinephrine available
  1. Dexamethasone: 0.5 mg/kg IV q6 hours (max 4 mg/dose). First dose at least 12 hours prior to planned extubation.
  2. Racemic epinephrine (one dose available at bedside): 0.25-0.5 mL of 2.25% racemic epinephrine solution diluted in 3 mL normal saline.
20-30 cmH2O Consider peri-extubation dexamethasone and racemic epinephrine.
NIF
  • Not indicated prior to extubation.
CPAP +/- Pressure Support (Sprinting) Trials
  • Not indicated — sprinting off of invasive ventilation or on sub-therapeutic ventilation to “recondition” the respiratory muscles often results in atelectasis and fatigue.
Excessive Oral Secretions
  • If excessive oral secretions:
    • Consider medical management of saliva control prior to extubation.
    • Glycopyrrolate may be considered at a low dose when indicated; thickening of secretions must be monitored.

Discussing a Tracheostomy with Family