The document outlines the clinical process for weaning a 7-year-old child with prior cardiac and respiratory issues from mechanical ventilation after complications during extubation. It emphasizes key factors to consider, including the patient's overall condition, lung health, and ventilatory settings, and discusses different weaning strategies like SIMV and CPAP. Ultimately, the child required a tracheostomy after multiple failed extubation attempts, demonstrating the complexity and challenges involved in managing pediatric ventilation weaning.

1. Weaning

2. • A 7 year old child
• VSD with patch closure, had moderate PAH(pre-op)
• Repeat ECHO done showed no residual shunt with
normal Pulmonary pressure
• On Ceftriaxone
What factors are considered for a patient before
extubation?

3. Important overall planning for weaning:
•Plan weaning when you intubate
•Wean from ventilator vs. wean from airway.
•Primary reason for mechanical ventilation must be
resolved.

4. Important factors to consider for weaning
• General conditions of the patient:
Anemia, Nutritional status, conscious level and
respiratory drive.
• Condition of the lungs :
Resolution of the primary pathology, now new
pathology
• Condition of the respiratory muscles:
Conditioning of respiratory muscles after prolonged
paralysis; recovery of neuromuscular diseases 4

5. • Ventilatory factors:
Dangerous parameters to be weaned first:
- high peak pressure/volume and FiO2
- periodic monitoring of the lungs to see
whether it is improving
• Airway factors:
presence of a leak,
size/type of endotracheal tube
secretions, Upper airway obstruction.
5

6. Other system consideration
• CNS : off sedation/analagesia, awake
• CVS: any cardiac pathology should have resolved.
HEMODYNAMICALLY STABLE
• Abdomen: No distension
• Nutrition wise should at least be in good shape
• METABOLIC: Sodium, potassium, calcium- normal
Magnesium- corrected
Phosphate – normalized.
6

7. In the previous hospital
•Tried extubation and failed for two episodes
•Aminophylline and Terbutaline - extensive wheezing
•Ventilatory settings increased as secretions increased
•Antibiotics escalated to Pipercillin-tazobactum X 2 days
•CVL in the neck now day 10.
Hemodynamically stable on Dopamine @10mcg/kg/min
•Transferred to your unit on day 10 post-operative day

8. In our hospital
•Investigated for Sepsis & VAP
•CVL re-sited, dopamine piggy-backed and could
reduce to 5mcg/kg/min
(possible due to source control)
•Aminophylline discontinued
•Ventilator parameters optimized.
PIP=25, PEEP= 9, FiO2 =60%, VR=25/min.
•TC =28,000, CRP=300, Neutrophils =78%, spiking high
grade fever ,
•Antibiotics escalated to Meropenem + Vancomycin
•Feeds started and graded up as tolerated.

9. 9

10. • Source of infection:
CRBSI vs VAP
10
Difficult to pinpoint
Empiric therapy needs broad coverage
ESBL – Klebsiella pneumonia identified on day 2 after
admission in BAL culture.(? How is it done)
VAP – Criteriae for diagnosing VAP
- CPIS score

11. • Vancomycin was stopped and Meropenem
continued, no further fever spikes
• Off Dopamine, CVL - removed
• On full feeds tolerating well
• On Morphine - 40mcg/kg/hr
• Current Ventilator settings on Day 4 of PICU stay
PIP = 22, PEEP=6, FiO2=55%, VR= 20/min
(PIP=25, PEEP= 9, FiO2 =60%, VR=25/min- day1 )
ABG – good gas exchange and normal pH
Some weaning of ventilator parameters has occurred
11

12. What mode will you use to wean this child.
Child improving on major aspects.
12
Day 5

13. SIMV :
Ventilator performs work during mandatory breathes
And the patient does all work during spontaneous
breathes.
SIMV +PS:
Pressure support is added for the patient breathes so
that it aids in the patient’s work of breathing

14. Methods of weaning:
SIMV:
•Reduce SIMV breaths frequency 2-5 breaths at a
time.
•Assess for hypoxemia/hypercarbia.
•Reduce pressure support in gradual decrements.
PS=6-8 provide minimal extra support. If higher
support is required to maintain tidal volume than do
not wean.
•When SIMV rate is reduced to about 5-8 then can
extubate the patient. 14

15. Methods of weaning:
SIMV to CPAP:
•Used in neonates.
•When SIMV rate is <5/min then the child is put on
CPAP of 5-6cm of H20 with zero rate.
•Small size tube may add resistance to the breathing
and so this mode alone is not advisable. PS should be
added.
•Prong CPAP is advisable
15

16. Methods of weaning:
T-piece/SBT(Spontaneous breathing trial):
•Most adult ICUs practice T-piece weaning
•Ventilation and oxygenation criteriae may be
assessed during this period.
•Muscle conditioning is also helped.
•Higher flow rates to be given
•Needs strict supervision
•SBT is for 2 hours vs 20mins.
16

17. RSBI
Normal Rapid shallow breathing Index
•Calculated by dividing respiratory frequency(f) by the
tidal volume
•Discontinuing from ventilator
•Weaning is likely if RSBI <105 (60-105) - adults
•Values >105 suggest that pt will fail weaning
•RSBI <8 breaths/ml/kg- children.
CROP index
(Compliance, Resistance, Oxygenation Pressure)index
0.15ml/kg/breathes/min
- lower than this failed extubation17

18. Checklist:
a. CNS: off sedation/analgesia, more awake
b. Hemodynamically stable – no inotropes
c. Tolerating feeds well and now off feeds.
d. All electrolytes, potassium, calcium,
magnesium, phosphate has been corrected
and is in perfect milieu
e. Chest x-ray : good lungs, ECHO – normal
f. Ventilator: PS=8,CPAP=6, FiO2=30%,
average work of breathing, SpO2=94%
HR=110, good pulses
g. Plan to extubate him to NIV
18
Day 8 of PICU: late night your fellow makes a
check list to decide whether he can extubate

19. •How useful is NIV in Pediatric ICU.
•How useful is it in extubation process.
•Indications
•Contraindications.

20. Recap
•A 10 month old child –day20
•VSD with patch closure, had moderate PAH
•Failed extubation twice.
•Optimized all aspects as per the checklist
•Failed 3rd trial of extubation

21. X-ray showing entire left lobe collapsed

22. • What went wrong with this child who had breezed
through all your weaning criteria on the ventilator
has now failed.
• Parents extremely worried, want everything to be
done, angry as well as upset.
• Option of Tracheostomy offered but wanted to
consider it later
How will you proceed?
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23. Look for other causes of failure to extubate
a.Review the check list look for any correctable
factors
b.Repeat Echo cardiography
c.Bronchoscopy
d.Ultrasound of the diaphargm
e.Fluroscopy
f.CT Chest

24. • Repeat Echo showed good contractility, good
function and no PAH
• Bronchoscopy showed no major findings other
than secretion filled bronchus which were
suctioned out.
• Ultrasound diaphragm showed poorly motile
bilateral diaphragm which was confirmed by the
Fluroscopy
• CT Chest : showed no major malformation, only
atlectasis.

25. Poorly motile bilateral diaphargmatic movements
with small volume lungs

26. Small volume lungs on positive pressure with right upper- lobe collapse
• Not on any antibiotics
post intubation
• X-ray showed upper lobe
collapse
• Rest of the lung clear
• CRP=4mg/dl
• TC=5600/cumm
• No fever spikes
• PS=10; PEEP =5;
FiO2=35%
• Minimal secretions

27. Essential points during this procedures
•Never paralyze the child during bronchoscopy. Vital
findings like bronchomalacia/ tracheomalacia can be
missed if paralyzed /positive pressure
•Fluroscopy/ Ultrasound – to assess diaphargmatic
paralysis should be done off positive pressure to rule
out diaphargmatic paralysis.

28. • Diaphragmatic palsy – causes
• Will bilateral diaphragmatic palsy benefit from
plication of the diaphragm
• What are the other measures to be taken? .
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29. Further course:
• Option of tracheostomy
•Parents wanted another trial of extubation which
was done after optimizing the condition yet failed.
•Tracheostomy done.

30. • When is tracheostomy offered as an option in
children.
• Advantages of tracheostomy

31. On tracheostomy
Fever – 102o
C
Total counts high normal – 16,000/cumm
Neutrophils -50%, CRP=158mg/dl
Platelets - normal
Hemodynamically stable
Secretions – not increased
No increase in the ventilator parameters:
PS=10 PEEP=5 , no desaturations,
He is not on any antibiotics, feeding well, playful
except during fever spikes, has a single peripheral
access. What would you do.

32. BAL done : insignificant growth
Procalcitonin was negative – (0.05)
IV line site checked – redness and so removed.
Fever settled

33. A month in the PICU .
•Parents counseled regarding taking the child home
on several occasions.
•Child slowly weaned off the oxygen and put on
humidivent
•He required PS+CPAP initially (8 weeks into PICU)
and then weaned to just CPAP at night(10 weeks
later)

34. • Completely off oxygen and ventilator after 12
weeks.
• How do wean or decannulate in
tracheostomy.
34

35. Down size the tube and ensure good leak around the
tube.
When on lowest size good leak and good excursions
of breathe through nares decannulate
Child transferred home with just 1 liter oxygen
requirement and another