Ventilator Weaning Clinical Pathway — PICU | Children's Hospital of Philadelphia

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Invasively Mechanically Ventilated PICU Patient

Procedural/Short Term Intubation

Extubation Readiness Assessment
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 hours
Mean airway pressure (MAP) ≤ 18
Stable FiO₂ ≤ 40% for 6 hours
Tolerating SBS goal of -1 or 0
Spontaneous breathing
Not under neuromuscular blockade
Underlying reason for intubation has resolved/is resolving

Begin Wean: Parameters and Frequency
Perform NIF/Leak daily — consider Dexamethasone when within 12 hours of extubation

Any PICU provider (MD, RN, CRNP, RT) to suggest entry
RT/RN q2 hour assessments of wean tolerance and ability to continue
All ventilator changes require discussion with and FLOC order

Re-evaluate in 6 hours

Volume Control Ventilation (VCV)
Setting	Weaning Parameter	Frequency	Comments	Goals
Respiratory Rate (RR)	2-6 breaths per min	2-4 hours	Wean if normal RR for age (see age-related vital sign reference ranges)	Ventilation: Maintain EtCO₂ similar to prior Maintain Minute Ventilation (V_E) be similar to prior V_E = RR x V_t Minimize work of breathing
Pressure Support (PS)	2-4 cmH₂0	2-4 hours	Wean to maintain target pressure support tidal volume (V_t) > 4 mL/kg
PEEP (positive end expiratory pressure)	2 cmH₂0	4-8 hours	-	Oxygenation: Maintain Fi0₂ ≤ 40% Maintain Sp0₂ ≥ 90%

Tolerate - Continue Wean

Fail Wean

Clinical Signs of a Failed Wean
Pause wean
Return to prior settings
Address failure

Pressure Control Ventilation (PCV)
Setting	Weaning Parameter	Frequency	Comments	Goals
Respiratory Rate (RR)	2-6 breaths per min	2-4 hours	Wean if normal RR for age (see age-related vital sign reference ranges)	Ventilation: Maintain EtCO₂ similar to prior Maintain Minute Ventilation (V_E) be similar to prior V_E = RR x V_t Minimize work of breathing
Pressure Support (PS)	2-4 cmH₂0	2-4 hours	Wean to maintain target pressure support tidal volume (V_t) > 4 mL/kg
PEEP (positive end expiratory pressure) and PIP (peak inspiratory pressure)	2 cmH₂0	4-8 hours	Wean to maintain ΔP such that target tidal volume(V_t) > 6-10 mL/kg	Oxygenation: Maintain Fi0₂ ≤ 40% Maintain Sp0₂ ≥ 90%

Achieve Settings:
RR = 15-20 Pressure Support = 10 PEEP ≤ 8

Ensure NPO status

Perform Extubation Readiness Trial (ERT)

Pass

Fail

Retry
ERT daily

Extubate within 6 hours
per clinical team

Return to Settings
RR 15-20 /PS 10/ PEEP ≤ 8

Pre-extubation:
Ensure completed Airway Bundle
Consider sedation wean

Posted: May 2016
Revised: September 2022
Authors: N. Yehya, MD; N. McGowan, RT; C. Dominick, RT; H. Wolfe, MD; D. Davis, MD

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.