Ventilator Weaning Clinical Pathway — CICU

Meets Criteria for Weaning Readiness for Extubation

This pathway guides the care of children in the CICU who are invasively mechanically ventilated and meet all of the following weaning entry criteria:

Weaning Entry Criteria

Children who meet all of the following:

  • Stable conventional mode of ventilation (PCV/VCV) that has been unchanged/non-escalated for 6 hrs
  • PIP < 25, PEEP < 8
  • Stable FiO2 < 50%
    • FiO2 > 50% sustained for 6 hrs is not appropriate for weaning
  • Tolerating SBS goal of -1 or 0
  • Spontaneous breathing
  • Not under neuromuscular blockade
  • Closed sternum
  • Lactate < 2
  • Vasopressors or inotropes non-escalated for 6 hrs
  • Underlying reason for intubation has resolved/is resolving such that the child will be weaned toward extubation
    • Those who require titration of ventilator settings for over/under ventilation and those with active disease instability (e.g., TBI, seizure activity, hemodynamic and/or cardiac instability.) are not appropriate

Note: Nitric oxide (iNO) should not preclude weaning.

Exclusions

Children who require more critical assessment between weans and are not appropriate include:

  • End-of-life care
  • Neuromuscular disorders
    • e.g., spinal muscular atrophy (SMA), Duchene muscular dystrophy

Note: Children who have been invasively mechanically ventilated for long periods (> 4 wks) and/or mechanically ventilated at baseline may require different approaches to weaning. Consider trial periods in these children at lower levels of support, such as sprinting or CPAP trials.

Children with Procedural/Short-term Intubations < 12-24 hrs

Perform an Extubation Readiness Assessment and extubate if appropriate:

  • Postoperative care
  • Procedural sedation