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\begin{document}

\title{Effect of implementation of protocol-based weaning practices in medical
Intensive Care Unit of a high burden resource-limited setting}



\author[1]{Anuj Ajay}%
\author[1]{Manasvini Bhatt}%
\author[1]{Manish Soneja}%
\author[1]{Animesh Ray}%
\author[1]{Neeraj Nischal}%
\author[1]{Piyush Ranjan}%
\author[1]{Naveet Wig}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 15, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Introduction: Prolonged mechanical ventilation may be associated with
various complications. Checklists and protocols have been made to
increase the success of weaning from ventilation and reduce the
complications; however, adherence to same and outcomes are not well
documented in resource-limited, high burden settings. This study was
conducted to assess the current weaning practices and impact of
implementation of evidence-based weaning protocol in a high-burden
tertiary care ICU setting. Materials and methods: A quasi experimental
(pre-test, post-test design) study was carried out in the medical ICU of
a tertiary care centre between January 2016 and June 2017.The study was
done in three phases, in which 50 patients were recruited in phase one
and phase three. Phase two involved training and education of residents
in protocol-based weaning. The compliance to various steps of the
protocol-based weaning was assessed and outcome parameters were assessed
and compared between phases one and three. Results: The baseline
demographic profile and comorbidities of the patients in both the groups
were comparable. The compliance to weaning protocol was low in various
steps. There was a significant improvement assessment of readiness
criteria, post-SBT assessment and pre-extubation screening in the
post-intervention as compared to the pre-intervention phase. There was
an increase in the proportion of patients who were successfully
extubated from 50\% to 66\% (p=0.10). There was no significant
difference in duration of mechanical ventilation (10 days vs 7.3 days,
p= 0.61), ICU stay (9.2 vs 8.2 days, p= 0.57), as well as hospital stay
between the two groups (16.1 vs 17.1 days, p= 0.45).Frequency of
re-intubations decreased from 14\% to 6\% and ventilator associated
pneumonia decreased from 34\% to 18\%. Conclusion: The study revealed
low compliance to various parameters assessed as a part of weaning;
however, training of resident doctors was successful in improving
compliance with protocol-based weaning.%
\end{abstract}%



\sloppy


\textbf{Title: Effect of implementation of protocol-based weaning
practices in medical Intensive Care Unit of a high burden
resource-limited setting}

Anuj Ajay\textsuperscript{1}, Manasvini Bhatt \textsuperscript{1},
Manish Soneja\textsuperscript{1*}, Animesh Ray\textsuperscript{1},
Neeraj Nischal\textsuperscript{1}, Piyush
Ranjan\textsuperscript{1}Naveet Wig\textsuperscript{1}

Department of Medicine , All India Institute Of Medical Sciences, New
Delhi

\textbf{Abbreviated Names:}

Anuj A, Soneja M\textsuperscript{*}, Jorwal P, Ray A, Nischal N, Ranjan
P, Wig N, Sharma S

\textbf{* Address correspondence to:}

Dr Manish Soneja

Additional Professor

Department Of Medicine

AIIMS , New Delhi

Phone Number: 9013074717

Email id: manishsoneja@gmail.com

\textbf{Conflict of interest: None}

\textbf{Funding Source: None}

\textbf{Abstract:}

\textbf{Introduction:} Prolonged mechanical ventilation may be
associated with various complications. Checklists and protocols have
been made to increase the success of weaning from ventilation and reduce
the complications; however, adherence to same and outcomes are not well
documented in resource-limited, high burden settings. This study was
conducted to assess the current weaning practices and impact of
implementation of evidence-based weaning protocol in a high-burden
tertiary care ICU setting.

\textbf{Materials and methods:} A quasi experimental (pre-test,
post-test design) study was carried out in the medical ICU of a tertiary
care centre between January 2016 and June 2017.The study was done in
three phases, in which 50 patients were recruited in phase one and phase
three. Phase two involved training and education of residents in
protocol-based weaning. The compliance to various steps of the
protocol-based weaning was assessed and outcome parameters were assessed
and compared between phases one and three.

\textbf{Results} : The baseline demographic profile and comorbidities of
the patients in both the groups were comparable. The compliance to
weaning protocol was low in various steps. There was a significant
improvement assessment of readiness criteria, post-SBT assessment and
pre-extubation screening in the post-intervention as compared to the
pre-intervention phase. There was an increase in the proportion of
patients who were successfully extubated from 50\% to 66\% (p=0.10).
There was no significant difference in duration of mechanical
ventilation (10 days vs 7.3 days, p= 0.61), ICU stay (9.2 vs 8.2 days,
p= 0.57), as well as hospital stay between the two groups (16.1 vs 17.1
days, p= 0.45).Frequency of re-intubations decreased from 14\% to 6\%
and ventilator associated pneumonia decreased from 34\% to 18\%.

\textbf{Conclusion:} The study revealed low compliance to various
parameters assessed as a part of weaning; however, training of resident
doctors was successful in improving compliance with protocol-based
weaning.

\textbf{Key words:} weaning; mechanical ventilation; extubation;
intensive care unit

\textbf{What is known?}

There are a large number of studies comparing protocol based weaning
versus non protocolised weaning in various ICU settings. Although in
general the results of these studies tend to favour protocol based
weaning; a large heterogeneity in the results of these studies with
respect to the various parameters studied is observed. There are very
few studies which have assessed compliance to protocol based weaning
strategies in a critical care setting once the protocol has been
introduced as routine practice.

\textbf{What is new?}

Our aim was to determine gaps in various steps in the weaning process in
first phase, to create awareness among resident doctors in the second
phase to improve weaning practices and increase the compliance to
various steps of the protocol in third phase. Most of the previous
studies mentioned have not assessed the compliance in following in
individual steps of weaning protocol and have assumed the compliance in
following various steps to be 100\%. However our study has tried to
convey a pragmatic view of the scenario that would happen in a typical
ICU in a high burden setting wherein the compliance is affected by the
availability of resources.

\textbf{Introduction}

Mechanical ventilation was a path-breaking intervention in management of
critically ill patients in the 19\textsuperscript{th}century. Over the
years, mechanical ventilation has revolutionised critical care
management and saved many lives. However, prolonged mechanical
ventilation has its own complications.{[}1{]} Weaning from ventilator is
considered to be a blend of art and science. The steps in the process
include assessing the readiness for weaning, giving a spontaneous breath
trial (SBT) and finally the decision to extubate.{[}1,2{]} These steps
constitute 40\% of the time a patient spends on mechanical ventilation,
and delay in any of them will result in an overall delay in the process
of weaning.{[}3{]} Attempts have been made to introduce objectivity in
the process by introduction of protocols in pursuit of hastening the
process of liberation from mechanical ventilation. Most of the studies
have been conducted in resource-rich settings and have shown significant
improvement in adherence to evidence-based protocols after their
introduction and reinforcement via continuous education of the
physicians, which has led to a higher weaning success.{[}4-6{]} There is
a scant literature on adherence to evidence-based protocols of weaning
in resource- limited settings and effect of educational interventions on
the same. Current evidence suggests the need for weaning protocols to
account for the complexities of social and cultural environment in which
they are to be implemented, particularly in resource-limited settings.
{[}7{]} We conducted this study to assess the current weaning practices
and impact of implementation of evidence-based weaning protocol in a
high-burden tertiary care ICU setting.

\textbf{Material and methods}

A quasi experimental (pre-test, post-test design) study was carried out
in the medical ICU of a tertiary care centre between January 2016 and
June 2017.The primary objective was to study the current practices being
followed for weaning of mechanically ventilated patients and the effect
of introduction of evidence-based weaning protocols. Patient outcomes
were assessed as secondary objective.

All mechanically ventilated patients admitted in medical ICU with age
more than 18 years and Glasgow coma scale score greater than 8 were
included in the study. Patients with expected duration of mechanical
ventilation less than 48 hours, who had neuromuscular disorders, a
history of high cervical cord injury and pregnant patients were excluded
from the study.

The study was carried out in three phases, each of six months duration.
In the first phase (pre-intervention), the existing practices in the ICU
was assessed daily. Patients were weaned on the basis of the judgement
of the physician in-charge and no stringent protocol was applied. In
this phase, compliance to various steps which were later introduced as a
part of evidence-based protocol was assessed. During the second phase,
the physicians posted in the ICU were educated regarding the steps of
weaning and components of evidence-based protocol (Box1). Multiple
modalities like posters, group interactions, didactic lectures, social
media were used to spread awareness and improve the compliance to the
protocol on a regular basis. During the third phase (post-intervention),
compliance to various steps of the protocol-based weaning was assessed
and outcome parameters were assessed and later on compared between
phases one and three. The ethical clearance of the study was obtained
from the Institute ethics committee.

Statistical analysis: Data analysis was done using STATA 12 software.
For discrete variables, the two groups were compared using Fischer's
exact t-test and continuous variables were compared using two sample
t-test.

\textbf{Results}

Fifty patients each were recruited in pre-intervention and
post-intervention phase. The baseline demographic profile and
comorbidities of the patients in both the groups were comparable
(Table1). APACHE II score in the phase 3 was significantly higher than
in phase 1.

\emph{Readiness Assessment}

Out of the five parameters included in readiness screening, only two
were being monitored in more than 80\% of patients at baseline,
including assessment of GCS and haemodynamic stability. Post
intervention the compliance to these parameters continued to remain high
while there was a significant increase in compliance to the remaining
parameters (Figure 1).

\emph{Pre and post-SBT assessment}

Pre-SBT assessment included evaluation of baseline clinical parameters
and an arterial blood gas (ABG) analysis with documentation of baseline
blood gas parameters (Figure 2). All the parameters showed significant
improvement in the post-intervention phase. Amongst the parameters
included in the post-SBT monitoring, only monitoring of post SBT heart
rate and blood pressure were being done in more than 60\% of patients. A
significant improvement was observed in all parameters monitored
post-SBT (Figure 3).

\emph{Extubation Screening}

Among the five parameters in pre-extubation screening, only GCS
assessment (done in 84\%) was being done in significant proportion of
patients. While this continued to remain high, there was a significant
improvement in other four parameters in phase 3 as compared to Phase 1
(Figure 4).

There was an increase in the proportion of patients who were
successfully extubated from 50\% to 66\%; however, this was not
significant (p=0.10). There was no significant difference in duration of
mechanical ventilation although there was a trend towards reduction (10
days vs 7.3 days, p=0.61). There was no significant difference in the
duration of ICU stay (9.2 vs 8.2 days, p=0.57) as well as hospital stay
between the two groups (16.1 vs 17.1 days, p= 0.45). Frequency of
re-intubations decreased from 14\% to 6\% in phase 3. Frequency of
ventilator associated pneumonia decreased from 34\% to 18\%.

\textbf{Discussion}

Mechanical ventilation is a life supportive therapy for critically ill
patients with respiratory failure. Studies report that approximately
40\% of adult patients admitted in an intensive care setting require
invasive mechanical ventilation. Two large seminal clinical trials
(Brochard 1994;Esteban 1995) indicated that the clinical processes
promoting timely recognition of a patient's readiness to wean were more
important in reducing the duration of mechanical ventilation than the
weaning method itself.(2)Over the years, the weaning process has evolved
from being based on education and experience of the treating clinician
to a proper structured protocol-directed approach. This protocol-based
weaning is slowly gaining impetus in critical care units around the
globe because of its success in reducing the prolonged duration of
mechanical ventilation and hence, indirectly reducing the costs related
to health care. A number of factors influence the effectiveness of this
weaning protocol such as ICU organization, available resources, hospital
culture and healthcare professional characteristics. Therefore, the
designing of the weaning protocols should take into consideration the
social and cultural environment in which they are to be implemented to
accommodate the challenges in clinical practices in the concerned ICU
environment for a successful implementation. A study conducted by Rose
et al (11) revealed that the prevalence of implementation of weaning
protocol in European adult ICUs was 56\% to 69\%. However no such study
highlighting the impact of implementation of weaning protocols has been
reported from a resource limiting setting like ours. Hence we conducted
this study for assessment of current weaning practices and determine the
impact of implementation of protocol based weaning in a high burden
setting.

The weaning protocol was broadly divided into four major steps namely,
assessment of readiness to wean, pre-SBT trial, post-SBT trial and
extubation screen, which were included as quality indicators in our
study. There was a significant improvement with respect to compliance to
these steps of the weaning process as per protocol in the post
intervention phase. Most of the previous studies mentioned have not
assessed the compliance in following these steps of weaning protocol and
have assumed the compliance in following various steps of weaning to be
100\%. However our study has tried to take a more realistic picture of
the scenario that would happen in an ICU in a high burden,
resource-limited setting wherein the compliance is affected by the
availability of resources.In our study, among the readiness criteria
only two, assessment of GCS and hemodynamic instability were being
followed in a large proportion of patients at baseline. However, in the
post intervention phase the compliance to these parameters remained high
while to other components increased. A similar improvement was seen in
the compliance to components of pre SBT and post SBT monitoring phase in
the post intervention phase as compared to pre intervention phase. Among
the secondary outcomes, although there was a trend towards reduction of
duration of mechanical ventilation in the second phase, the results did
not achieve statistical significance. There was an increase in the
proportion of patients who were successfully extubated, although the
results did not reach statistical significance. The frequency of
complications like re-intubation and VAP rates were lower in the post
intervention arm although the difference was not statistically
significant. This result was consistent with study conducted by
Krishan\emph{et al} in which no difference was found in number of
patients requiring reinstitution of mechanical ventilation, ICU length
of stay and hospital mortality in control and protocol weaning
group.{[}9{]} Elly \emph{et al} conducted a study on neurosurgical
patients showed that implementation of weaning protocol based on
traditional respiratory physiologic parameters had practical limitations
in postoperative patients with no significant differences in
complications, mortality and duration of mechanical ventilation in
control and intervention group.{[}8{]} Simeone \emph{et al} conducted a
study on patients undergoing cardiac surgery and reported lesser
duration of mechanical ventilation and length of ICU stay in the
protocol weaning group as compared to usual group.{[}12{]}(Table 2)

This study is first of its kind, conducted in a high-burden,
resource-limited setting for evaluation of effect of implementation of
protocol-based weaning methods in a pragmatic scenario. The study
revealed low compliance to various parameters assessed as a part of
weaning process. Training of resident doctors was successful in
improving compliance with protocol-based weaning process.

There are a number of limitations in the study. This was short duration
study with small number of patients precluding any meaningful
conclusions on the effect on patient outcomes. A larger study population
could have shown a more significant change in the quality indicators of
patient outcomes, which were assessed. Even with a well-organized study,
there was less than 90\% compliance with some parameters in the weaning
protocol. This means that there are many variables involved in the
process improvement. In this study, these barriers to protocol
compliance improvement, including the contributions of physician and
allied staff behaviour, were not measured. Identifying and rectifying
these variables could have led to a better rate of compliance with
weaning protocol in this study.

\textbf{Box 1: Protocol for weaning of patients from mechanical
ventilation(10,13)}\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\textbf{1. Readiness to wean:} 1.GCS \textgreater{} 8 2. pH
\textgreater{} 7.25 3. PF ratio of \textgreater{}150 4. Systolic blood
pressure \textgreater{} 90 mm Hg without the use of significant dosage
of vasopressors 5. Cause of respiratory failure had
improved\tabularnewline
\midrule
\endhead
\textbf{2. Spontaneous Breath Trial:} a) Baseline blood gas and clinical
parameters to be documented. b) SBT to be performed using either an
incremental reduction of pressure support to a PSV of 5-7 cm or by a
T-piece trial, which was to be carried out for a duration of 30 minutes
to a maximum of 2 hours. c) Assess intolerance to SBT: Rise in
pCO\textsubscript{2}\textgreater{} 8mm Hg or an absolute value
\textgreater{} 50 mm Hg PO\textsubscript{2}\textless{} 50-60 mm Hg or
SpO\textsubscript{2}\textless{} 90\% on FiO2 \textgreater{} 50\% pH
\textless{} 7.32 or decrease more than 0.07 units RR \textgreater{}
35/min or increase of \textgreater{} 50\% New onset hypotension (SBP
\textless{} 90mm Hg),increase in SBP more than 20\% or new onset
arrhythmia Tachycardia with a heart rate \textgreater{} 140 beats/min or
increase more than 20\% Worsening of GCS\tabularnewline
\textbf{3. Extubation screen :} Appropriate alertness and muscle
function (assessed by GCS and head lift-off bed for \textgreater{} 5
seconds) Adequate cough reflex (assessed via suctioning frequency which
should not have been more frequent once every two hours) Adequate airway
patency assessed using a cuff-leak test\tabularnewline
\textbf{Extubation} If the patient satisfied all of the above criteria,
they were extubated to either room air, high flow oxygen or NIV
depending on the underlying condition.\tabularnewline
\bottomrule
\end{longtable}

GCS- Glasgow coma scale , RR- Respiratory rate, Vt -- Tidal volume, PSV-
Pressure support ventilation, pCO2 -- partial pressure of carbon dioxide
, pO2- partial pressure of oxygen, SpO2 -- Saturation of oxygen in
periphery capillary blood , FiO2 -- fraction of oxygen in inspired air,
NIV- Non invasive ventilation, Pf ratio --ratio of arterial oxygen
partial pressure to fractional inspired oxygen

\textbf{Table1: Demographic features, underlying illness and severity of
disease among patients in Phase 1 and 3 (n =100)}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Characteristic} & \textbf{Phase 1 (n=50)} & \textbf{Phase 3
(n=50)} & \textbf{p-value}\tabularnewline
\midrule
\endhead
Male gender & 50 & 46 & 0.68\tabularnewline
Age (years, mean \selectlanguage{ngerman}± SD) & 51.9+19.1 & 48.7+18 & 0.98\tabularnewline
Comorbidities & Comorbidities & Comorbidities &
Comorbidities\tabularnewline
Diabetes Mellitus & 30 & 38 & 0.39\tabularnewline
Hypertension & 34 & 30 & 0.66\tabularnewline
Asthma & 0 & 2 & 1.00\tabularnewline
COPD & 14 & 22 & 0.21\tabularnewline
CKD & 6 & 14 & 0.31\tabularnewline
CAD & 6 & 18 & 0.12\tabularnewline
CVA & 2 & 8 & 0.36\tabularnewline
APACHE II score* & 20.5 \emph{+} 6.9 & 23.5 \emph{+} 6.6 &
0.02\tabularnewline
SOFA score* & 8.1 \emph{+} 3.2 & 8.2 \emph{+} 3.2 & 0.90\tabularnewline
\bottomrule
\end{longtable}

All figures in percentages except *mean \emph{+} standard deviation.
COPD-

chronic obstructive pulmonary disease, CKD- chronic kidney disease, CAD-

coronary artery disease, CVA- cerebrovascular accident

\textbf{Table 2. Outcomes parameters in previous studies}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
\begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Study}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Ely{[}8{]}}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Krishnan{[}9{]}}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Kollef {[}10{]}}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Rose {[}11{]}}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Simeone {[}12{]}}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Marelich {[}4{]}}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\textbf{Our Study}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
Median duration of mechanical ventilation\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
Intervention\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
4.5 (2-9)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
60.4 hr (28.6--167.0)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
35hrs (15-114)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
43hrs (6-169)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
6.5\emph{+}3.8hrs\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
68 (33--164)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
7(2-19)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
Control\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
6 (3-11)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
68.0 hr (27.1--169.3)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
44hrs (21-209)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
40hrs (14-87)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
8.6\emph{+}3.5hrs\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
124 (54--334)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
7(2-40)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Control\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
40\%\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
33.1\%\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
23.6\%\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
5.9\%\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
50\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
Duration of ICU stay\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
Intervention\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
8 (4-18)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
115hr (67--259)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
29\emph{+}15.8\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
8(2-21)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
Control\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
9 (5-16)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
146hr (81--291)\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
46.1\emph{+}33.9\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
6.5(2-42)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Duration of hospital stay\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Intervention\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
14 (9-26)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
15(4-70)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Control\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
15.5 (6-30)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
14(2-58)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Acknowledgements:}

We would like to acknowledge the residents, nursing staff and
technicians in medicine department for their participation and support
that facilitated smooth conduct of the study.

\textbf{References} :

\begin{enumerate}
\tightlist
\item
  Pham T, Brochard LJ, Slutsky AS. Mechanical Ventilation: State of the
  Art. Mayo Clin Proc. 2017 Sep;92(9):1382-1400.
\item
  Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al.
  Weaning from mechanical ventilation. Eur Respir J. 2007
  May;29(5):1033-56.
\item
  McConville JF, Kress JP. Weaning patients from the ventilator. N Engl
  J Med. 2012 Dec 6;367(23):2233-9.
\item
  Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M.
  Protocol weaning of mechanical ventilation in medical and surgical
  patients by respiratory care practitioners and nurses: effect on
  weaning time and incidence of ventilator-associated pneumonia. Chest
  2000; 118:459--67.
\item
  McLean SE, Jensen LA, Schroeder DG, Gibney NR, Skjodt NM. Improving
  adherence to a mechanical ventilation weaning protocol for critically
  ill adults: outcomes after an implementation program. Am J Crit Care.
  2006 May;15(3):299-309.
\item
  Borges LGA, Savi A, Teixeira C , de Oliveira RP,De Camillis MLF,
  Wickert R et al. Mechanical ventilation weaning protocol improves
  medical adherence and results.J Crit Care.2017Oct;41:296-302
\item
  Jordan J, Rose L, Dainty KN, Noyes J, Blackwood B. Factors that impact
  on the use of mechanical ventilation weaning protocols in critically
  ill adults and children: a qualitative evidence-synthesis. Cochrane
  Database Syst Rev. 2016 Oct 4;10:CD011812.
\item
  Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, et al.
  Effect on the duration of mechanical ventilation of identifying
  patients capable of breathing spontaneously. N Engl J Med 1996;335
  (25):1864--9.
\item
  Krishnan JA, Moore D, Robeson C, Rand CS, Fessler HE. A prospective,
  controlled trial of a protocol-based strategy to discontinue
  mechanical ventilation. American Journal of Respiratory and Critical
  Care Medicine 2004;169:673--8.
\item
  Kollef MH, Shapiro SD, Silver P, St John RE, Prentice D, Sauer S,
  etal.A randomized, controlled trial of protocoldirected versus
  physician-directed weaning from mechanical ventilation. Critical Care
  Medicine 1997;25(4):567--74.
\item
  Rose L, Presneill JJ, Johnston L, Cade JF. A randomised , controlled
  trial of conventional versus automated weaning fom mechanical
  ventilation using SmartCare/PS.Intensive Care Med.2008
  Oct;34(10);1788-95
\item
  Simeone F, Biagioli B,Scoletta S, Marullo AC, Marchet LT , Carciorgna
  Met al. Optimization of mechanical ventilation support following
  cardiac surgery. J Cardiovasc Surg(Torino).2002 Oct;43(\%):633-41
\item
  Esteban A,Alia l,Gordo Fet al.Extubation outcome after spontaneous
  breathing trials with T-tube or pressure support ventilation: the
  Spanish Lung Failure Collaborative Group.Am J Respir Crit Care Med
  1997;156:59465
\end{enumerate}\selectlanguage{english}
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