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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

Exclusion Criteria

Eligibility Criteria

  • 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
 
 

Wean Process

  • Perform initial leak/NIF test
  • Utilize parameters and frequency below to achieve goal settings
    • RN/RT assess q2hr wean tolerance
    • Utilize PICU Ventilator Weaning Pathway Order Set
    • Ventilator changes require an order
 
 
Clinical Signs of a Failed Wean

Wean Not Tolerated

 
 

Goal Settings Achieved for Extubation Readiness Trial (ERT)

RR 20
PS 10
PEEP ≤ 8
 
 
 
 
Pass
Fail
Goal: Extubate within 6 hrs of ERT

Perform Daily
Leak/NIF test, consider dexamethasone
ERT until pass

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%