PICU Ventilator Weaning Pathway
Invasively Mechanically Ventilated PICU Patient
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Procedural/Short Term Intubation
  1. Extubation Readiness Assessment
  2. Turn off sedation and extubate when ready per clinical team
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  • 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
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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
  • (VE) be similar to prior
    • VE = RR x Vt
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:
  • Maintain Fi02 ≤ 40%
  • Maintain Sp02 ≥ 90%
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 hours Wean if normal RR for age (see age-related vital sign reference ranges)
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 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:
  • Maintain Fi02 ≤ 40%
  • Maintain Sp02 ≥ 90%
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Achieve Settings:
RR = 15-20 Pressure Support = 10 PEEP ≤ 8
Ensure NPO status
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Pass
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Fail
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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: May 2018
Authors: N. Yehya, MD, N. Craig, RT, C. Dominick, RT, H. Wolfe, MD, D. Davis, MD