Ventilator Weaning Clinical Pathway – PICU

PICU Clinical Pathway for Management of Ventilator Weaning

Goal and Metrics
Provider Resources
 
 

Procedural/Short-Term Intubation

  1. Assess for residual neuromuscular blockade: Use of Peripheral Nerve Stimulator for Train-of-Four (TOF) Monitoring
  2. Extubation readiness assessment
    • Adequate respiratory drive
    • Spontaneous breathing
    • Cough/gag present
    • Ability to manage secretions
    • Airway bundle completed for potential reintubation
  3. Evaluate for RN/RT extubation eligibility, turn off sedation and extubate per clinical team
Invasively Mechanically Ventilated Child in the PICU > 24 hrs who meets criteria for weaning readiness for extubation
  • Pressure or volume-controlled ventilator modes non-escalated for 6 hrs
  • Mean airway pressure ≤ 18 mmhg
  • FiO2 ≤ 40% for 6 hrs
  • SBS -1 or 0
  • Spontaneous breathing
  • Not under neuromuscular blockade
  • Underlying reason for intubation resolving/resolved
 
 
  • Perform initial NIF/leak
  • Begin wean utilizing parameters and frequency below
    • RN/RT assess q2hr wean tolerance
    • Utilize PICU Ventilator Weaning Pathway Order Set
    • Ventilator changes require an order
    • Daily NIF/leak between 7–11 p.m.
 
 
Clinical Signs of a Failed Wean

Wean Not Tolerated

 
 
Wean to Goal Settings
RR 20
PS 10
PEEP ≤ 8
 
 
 
 
Pass
Fail
Goal
Extubate within 6 hrs of passed ERT

Perform Daily

Weaning Parameters and Frequencies by Ventilation Mode
Volume Control Ventilation (VCV)
Setting Weaning Parameter Weaning Frequency Comments Goals
Respiratory Rate (RR) 2–6 breaths per min 2–4 hrs Wean if normal RR for age
Age RR
< 6 mos 20–60
6 mos – 2 yrs 15–45
2–5 yrs 15–40
> 5 yrs 10–35
  • Ventilation
    • EtCO2 similar to prior
    • Minute ventilation (VE) similar to prior
      • VE = RR × Vt
    • Minimize WOB
Pressure Support (PS) 2–4 cmH2O 2–4 hrs Wean to maintain target pressure support tidal volume (Vt) > 4 mL/kg
Positive End-Expiratory Pressure (PEEP) 2 cmH2O 4–8 hrs  
  • Oxygenation
    • FiO2 ≤ 40%
    • SpO2 ≥ 90%
Pressure Control Ventilation (PCV)
Setting Weaning Parameter Weaning Frequency Comments Goals
Respiratory Rate (RR) 2–6 breaths per min 2–4 hrs Wean if normal RR for age
Age RR
< 6 mos 20–60
6 mos – 2 yrs 15–45
2–5 yrs 15–40
> 5 yrs 10–35
  • Ventilation
    • EtCO2 similar to prior
    • Minute ventilation (VE) similar to prior
      • VE = RR × Vt
    • Minimize WOB
Pressure Support (PS) 2–4 cmH2O 2–4 hrs Wean to maintain target pressure support tidal volume (Vt) > 4 mL/kg
  • Positive End-Expiratory Pressure (PEEP)
  • and
  • Peak Inspiratory Pressure (PIP)
 2 cmH2O 4–8 hrs Wean to maintain ΔP such that target tidal volume (Vt) > 6–10 mL/kg
  • Oxygenation
    • FiO2 ≤ 40%
    • SpO2 ≥ 90%