PICU Ventilator Weaning — Extubation Readiness Trial — Clinical Pathway: ICU

Ventilator Weaning Clinical Pathway — PICU

Extubation Readiness Trial (ERT)

This is a test of the child’s ability to support spontaneous breathing with minimal positive pressure assistance, with the goal of reducing risk for re-intubation. Prior to performing the ERT, ensure that the child’s sedation has been weaned appropriately and that the SBS = 0. Please see PICU Sedation Weaning for guidance.

ERT typically performed on CPAP/PS. Providers may individualize settings based on clinical situation

Performing the ERT

Perform leak check upon entry to the pathway and daily between 7-11 p.m.
Dexamethasone should be initiated if indicated 12 hrs prior to planned extubation.

  1. Ensure settings of frequency (RR) 15-20 / PS 10 cmH2O / PEEP ≤ 8 cmH2O
  2. Make child NPO at start of ERT
  3. Assess cough +/- gag
    Note: There is minimal evidence in pediatrics to support the need for a negative inspiratory force (NIF) test. Provider discretion should guide performance of the NIF and Leak test. Recommended guidance is below:
Test Result Recommendations Recommended Dosing
Leak ≥ 30 cmH2O Recommend the use of pre-extubation Dexamethasone with racemic epinephrine available
  1. Dexamethasone:  0.5 mg/kg IV q6 hrs
    (max 4 mg/dose). First dose at least 12 hrs 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

If no leak, leave cuff down and inform the PHL PICU [Color] Provider Team via secure chat
NIF 0 to -20 mmHg Consider extubation to non-invasive positive pressure ventilation (NIPPV)  
  1. Reduce settings to PS 5/PEEP 5 for 2 hrs and evaluate if child passes or fails this time test and follow guidance below:
Assessment Recommended Steps
Pass
  • Notify via Epic secure chat to PHL PICU [Color] Provider Team and extubate within 6 hrs
    • Keep child NPO
    • Consider stopping Dexamethasone if child does not exhibit post-extubation stridor
    • Ensure pre-extubation: Completed Airway bundle and SBS = 0 (consider Sedation Wean)
      Maintain adequate analgesia while weaning sedation
Fail
  • See Clinical Signs of a Failed Wean
  • Return child to (RR) 15-20 / PS 10 cmH2O / PEEP ≤ 8 cmH2O settings and resume feeds
  • Discuss reasons for failure. Consider and address:
    • Level of sedation — With ventilator setting reductions, particularly the respiratory rate, over-sedation may result in a child “riding the ventilator” and not initiating their own spontaneous breaths. Consider adjustments to sedative infusions, such as an opioid infusion wean, prior to the next ventilator wean.
    • Hypotension/hemodynamic changes — This is common in children who were in hemodynamically unstable prior to weaning. Weans may induce increased work of breathing, decreasing preload and manifesting as hypotension.
    • Fluid Status — Consider diuresis
    • Fever — Consider new infection source
    • New pneumonia — Consider that the child may have a new infiltrate
  • Retry the ERT daily until the child can pass