Ventilator Weaning Clinical Pathway – PICU – Extubation Readiness Trial (ERT)

Ventilator Weaning Clinical Pathway – PICU

Extubation Readiness Trial (ERT)

  • Tests the ability to support spontaneous breathing with minimal positive pressure assistance, with the goal of reducing risk for re-intubation.
  • Prior to performing , ensure sedation has been weaned appropriately and there is no residual neuromuscular blockade. PICU Sedation Algorithm.
  • 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.

  1. Ensure settings:
    RR 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 below.
Test Result Recommendations Recommended Dosing
Leak ≥ 30 cmH2O Use pre-extubation dexamethasone with racemic epinephrine if available
  1. Dexamethasone
    • 0.5 mg/kg IV q6hr, 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 follow guidance below.
Assessment Recommended Steps
Pass
  • Document in EHR and notify via secure chat to PHL PICU [Color] hospital provider, fellow and attending and extubate within 6 hrs
  • Maintain NPO
  • Consider stopping dexamethasone if no post-extubation stridor
  • Pre-extubation
    • Completed airway bundle and consider sedation wean
    • Maintain adequate analgesia while weaning sedation
Fail
Clinical Signs of a Failed Wean
  • Return to settings
    • RR 8
    • PS 8 cmH2O
    • PEEP < 8 cmH2O
  • Resume feeds
  • Review, then assess reasons for failure
  • Perform ERT daily until passed