Ventilator Weaning Clinical Pathway – PICU – Clinical Signs of a Failed Wean

Ventilator Weaning Clinical Pathway – PICU

Clinical Signs of a Failed Wean

For any of the signs/symptoms below, stop wean and reassess.

  • Increased FiO₂ ≥ 40% for > 6 hrs
  • > 20% increase in HR or RR after respiratory rate, change sustained for > 2 hrs and unexplained by other factors such as fever or under-sedation
  • Asynchrony with ventilator
  • Increased WOB
    • Nasal flaring/accessory muscle use/retractions
  • Increased EtCO₂/paCO₂ on ABG or decreased minute ventilation (MV)

Note: Blood gas not required for every wean. Their use with weans or ERTs based on clinician judgment.

Assessment of Failed Wean

  1. Discuss potential reasons for failure, below
  2. Consider and address reason for failure
  3. Re-evaluate child's ability to tolerate a wean in 6 hrs
Potential Reason for Failure Comments
Level of Sedation
  • With ventilator setting reductions, particularly the respiratory rate, over-sedation may result in a child "riding the ventilator" and not initiating their own spontaneous breaths
  • Consider adjustments to sedative infusions, such as an opioid infusion wean, prior to the next ventilator wean
Hypotension/Hemodynamic Changes
  • Common in children who were in hemodynamically unstable prior to weaning
  • Weans may induce increased work of breathing, decreasing preload and manifesting as hypotension
Fluid Status Consider diuresis
Fever Consider new infection source
New Pneumonia Consider new infiltrate
Neuromuscular Weakness
  • Recent neuromuscular blockade
  • Deconditioning due to duration of mechanical ventilation