We propose a two-year project to pilot test and evaluate an intervention to change sedation management in pediatric patients supported on mechanical ventilation for acute respiratory failure in the PICU. Rather than seeking an elusive ideal drug, this unique nurse-led pilot study focuses on optimizing clinical decision making by: (a) multidisciplinary team education and consensus building; (b) multidisciplinary team identification of the patient's trajectory of illness and daily prescribing of a sedation goal; (c) a nurse-implemented sedation algorithm to guide titration of comfort medications; and(d)team feedback on clinical performance. This intervention models the most recent sedation clinical practice guideline published by the Society of Critical Care Medicine and addresses the only potentially manipulable factor influencing extubation failures rates in the Pediatric Intensive Care Unit.