PICU Clinical Pathway for Management of
Ventilator Weaning
Ventilator Weaning
Related Pathways
Invasively Mechanically Ventilated PICU Patient
Procedural/Short Term Intubation
- Extubation Readiness Assessment
- Turn off sedation and extubate when ready per clinical team
- 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
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
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:
Minimize work of breathing
|
Pressure Support (PS) | 2-4 cmH20 | 2-4 hours | Wean to maintain target pressure support tidal volume (Vt) > 4 mL/kg | |
PEEP (positive end expiratory pressure) |
2 cmH20 | 4-8 hours | - |
Oxygenation:
|
Tolerate - Continue Wean
Fail Wean
- Clinical Signs of a Failed Wean
- Pause wean
- Return to prior settings
- Address failure
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:
Minimize work of breathing
|
Pressure Support (PS) | 2-4 cmH20 | 2-4 hours | Wean to maintain target pressure support tidal volume (Vt) > 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(Vt) > 6-10 mL/kg |
Oxygenation:
|
Achieve Settings:
RR = 15-20 Pressure Support = 10 PEEP ≤ 8
RR = 15-20 Pressure Support = 10 PEEP ≤ 8
Ensure NPO status
Perform Extubation Readiness Trial (ERT)
Pass
Fail
Retry
ERT daily
ERT daily
Extubate within 6 hours
per clinical team
per clinical team
Return to Settings
RR 15-20 /PS 10/ PEEP ≤ 8
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
Revised: September 2022
Authors: N. Yehya, MD; N. McGowan, RT; C. Dominick, RT; H. Wolfe, MD; D. Davis, MD