Multi-Disciplinary Team Ventilator Optimisation, PICU

Objectives

To support the bedside nurse, physiotherapist and other capable MDT member in undertaking the process of Multi-Disciplinary Ventilator Optimisation.

This guideline will support effective, clear communication and documentation of the team decision regarding appropriate patients and the target parameters for these individual patients.

This guideline does not seek to be a ventilator weaning protocol in itself, the decisions around which settings to adjust and to what final “end point” continue to be open to MDT discussion.

Mechanical ventilation is one of the key interventions provided in PICU. Optimising ventilator settings is key in trying to find the “sweet spot” in which intubated patients have adequate gas exchange while minimising their degree of ventilator-associated lung injury. Nurses, physiotherapists and other members of the MDT are often in a position to recognise changes in their patient’s physiology far sooner than clinicians, who may have several hours between reviews of each patient, and are thus well placed to make timely, real-time adjustments which can keep patients in this “sweet spot” for a higher proportion of their PICU stay. A further potential benefit of multi-disciplinary ventilator optimisation, is that patients can move towards extubatable settings as soon as physiologically appropriate, rather than waiting for medical team reviews. The enhanced MDT engagement with ventilator optimisation that this guideline could lead to may also improve early recognition of deterioration, or lack of expected progress in critically ill children, as well as improving MDT understanding of providing ventilation.

While there is good evidence that in adult ITU mechanical ventilator weaning protocols shorten duration of ventilation^[1], in children the evidence is more mixed. Some RCTs have shown that children requiring mechanical ventilation for acute respiratory failure of any cause do not have their duration of ventilation shortened by introduction of protocolized weaning^[2,3], while in other cases the introduction of protocolized ventilator weaning for children with ARDS (who we may expect to have a longer need for ventilation), has led to a reduction in duration of ventilation^[4]. This guideline does not seek to be a ventilator weaning protocol in itself, it instead provides a framework for clear communication within the MDT of goals for ventilator titration over the next 24 hours, and empowers bedside nurses, physiotherapists and other capable MDT members to titrate ventilator settings with more autonomy, to work towards that agreed goal.

Process

Patient Identification:

Suitable patients for multi-disciplinary ventilator optimisation should be identified by appropriate MDT members. Consideration should be given to their overall stability and expected clinical trajectory. The overall goal for the next 24 hours should be agreed and documented (eg maintain stability, wean mean airway pressure, possible extubation etc), and the ongoing suitability of a patient for continued multi-disciplinary ventilator optimisation reviewed daily at the morning ward round.

Ventilation Target Parameters:

The parameters to be targeted should be agreed, and the numerical target for each of these parameters defined. Parameters which can be included are FiO2, PIP and controlled rate. There is no requirement for every one of these parameters to be included.

Documentation:

The decision to assign a patient to multi-disciplinary team ventilator optimisation, and the parameters to be targeted should be documented in the CIS “medical notes”. A Template for documentation of this discussion is below. Note that it is NOT necessary to define targets for every parameter:

Overall goal(s) for next 24 hours:………………………………………………………………………………
Perform routine………………..blood gases every………..…..hours (only if indicated)
Confirm that PEEP, inspiratory time and trigger have been reviewed at the ward round

FiO2:

Titrate FiO2 to maintain SpO2 between…………and………..%

Peak inspiratory pressure (PIP):

Titrate PIP by…… cmH20 up to every………hours to maintain a tidal volume between……and…….ml.
Do not reduce PIP below……..cm H20 or increase PIP above……cm H20. Update the clinician responsible for patient when either this lower or upper PIP value is reached.
When adjusting PIP, ensure the “Pressure Support” is not set at a higher value than PIP
If FiO2 or etCO2 rise significantly after a reduction in PIP, consider reversing the wean

Controlled rate – select etCO2, paCO2 or H+ guided:

etCO2 guided - titrate controlled rate by …….. up to every ……. hours to maintain etCO2 between……and…….
paCO2 guided – titrate controlled rate by …….. up to every …….. hours to maintain a paCO2 between ……. and …….
H+ guided – titrate controlled rate by ….. up to every …….. hours to maintain H+ between …… and …….
Do not reduced controlled rate to below ……….or increase to above ………
If the patient’s measured resp rate is above the age-appropriate normal range do not wean controlled rate, may be appropriate to increase controlled rate in this scenario – see table below for reference.

If a hard copy of this discussion and these target parameters is desired, a printable one-page proforma is available in the appendix section.

These target parameters should be reviewed at least once daily (often this will occur at morning ward round) and adjusted if necessary.

Clinical changes that may require further clinical review:

If any of the below changes occur after a change in ventilatory support, discuss with the clinician responsible for the patient as clinical review may be required:

Significant increase in FiO2 required
A rise in measured resp rate of >20% that lasts >1 hour and that is not explained by fever, pain or undersedation
A rise in measured heart rate of >20% that lasts >1 hour and that is not explained by fever, pain or undersedation
New asynchrony with the ventilator
Increase in etCO2 or paCO2 above the target ranges for that patient

Appendix/supporting material

Normal Respiratory Rates

Age	Normal resp rate
Term baby- 3 months	25-60
3-6 months	25-60
6-12 months	20-55
1 year	20-40
2 years	20-30
3 years	20-25
4 years	18-25
5-10 years	15-25
>10 years	12-25

Note: Printable paper copy of parameter targets if bedside copy is desired are included in the two documents below.

Multi-Disciplinary Team Ventilator Optimisation – Target Parameters Pressure Control Modes (PDF for printing)

Multi-Disciplinary Team Ventilator Optimisation – Target Parameters Volume Control Modes (PDF for printing)

Last reviewed: 07/10/2025

Next review date: 31/10/2028

Author(s): Kieran Bannerman, Locum Consultant in Paediatric Intensive Care Medicine , Emma Harley, Paediatric Intensive Care Medicine subspecialty trainee.

Author email(s): kieran.bannerman2@nhs.scot.

Approved By: PICU Ventilator Optimisation Group

References

Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014(11):CD006904.
Randolph AG, Wypij D, Venkataraman ST, et al. Effect of Mechanical Ventilator Weaning Protocols on Respiratory Outcomes in Infants and Children: A Randomized Controlled Trial. JAMA. 2002;288(20):2561–2568. doi:10.1001/jama.288.20.2561
Duyndam A, Houmes RJ, van Rosmalen J, Tibboel D, van Dijk M, Ista E. Implementation of a nurse-driven ventilation weaning protocol in critically ill children: Can it improve patient outcome? Aust Crit Care. 2020 Jan;33(1):80-88. doi: 10.1016/j.aucc.2019.01.005. Epub 2019 Mar 13. PMID: 30876696.
Mehta SD, Martin K, McGowan N, Dominick CL, Madu C, Denkin BK, Yehya N. Ventilator-Weaning Pathway Associated With Decreased Ventilator Days in Pediatric Acute Respiratory Distress Syndrome. Crit Care Med. 2021 Feb 1;49(2):302-310. doi: 10.1097/CCM.0000000000004704. PMID: 33156123; PMCID: PMC7854887.