PICU Clinical Pathway for Management
of Ventilator Weaning

Goals and Metrics
Provider Resources
Related Pathways
Invasively Mechanically Ventilated Child in the PICU
Procedural/Short-term Intubation
  1. Extubation Readiness Assessment
  2. Turn off sedation and extubate when ready per clinical team
Meets Criteria for Weaning Readiness for Extubation
  • Stable conventional ventilator modes (VCV/PCV)
    non-escalated for 6 hrs
  • Mean airway pressure (MAP) ≤ 18
  • Stable FiO2 ≤ 40% for 6 hrs
  • Tolerating SBS goal of -1 or 0
  • Spontaneous breathing
  • Not under neuromuscular blockade
  • Underlying reason for intubation has resolved/is resolving
Begin Wean: Parameters and Frequency
Perform NIF/Leak upon entry to pathway and daily between 7-11 p.m.
Consider Dexamethasone when within 12 hrs of extubation
  • Any PICU provider (MD, RN, CRNP, RT) to suggest entry
  • RT/RN q2hr assessments of wean tolerance and ability to continue
  • All ventilator changes require discussion with a FLOC order
  • Utilize PICU Ventilator Weaning Pathway Order Set
Re-evaluate in 6 hrs
Volume Control Ventilation (VCV)
Setting Weaning Parameter Frequency Comments Goals
Respiratory Rate (RR) 2-6 breaths per min 2-4 hrs 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 cmH2O 2-4 hrs Wean to maintain target pressure support tidal volume (Vt) > 4 mL/kg
PEEP
(positive end-expiratory pressure)		 2 cmH2O 4-8 hrs -
Oxygenation:
  • Maintain FiO2 ≤ 40%
  • Maintain SpO2 ≥ 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 hrs 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 cmH2O 2-4 hrs Wean to maintain target pressure support tidal volume (Vt) > 4 mL/kg
PEEP (positive end-expiratory pressure)
and
PIP (peak inspiratory pressure)		 2 cmH2O 4-8 hrs Wean to maintain ΔP such that target tidal volume(Vt) > 6-10 mL/kg
Oxygenation:
  • Maintain FiO2 ≤ 40%
  • Maintain SpO2 ≥ 90%
Achieve Settings:
RR = 15-20 Pressure Support = 10 PEEP ≤ 8
Ensure NPO
Perform Extubation Readiness Trial (ERT)
Pass
Fail
Retry
ERT daily
Extubate within 6 hrs
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
Last Revised: March 2024
Editors: Clinical Pathways Team