Weaning by gradual pressure support (PS) reduction without an initial spontaneous breathing trial (SBT) versus PS-supported SBT: A pilot study

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Vitacca" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Vitacca" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215911001012?idApp=UINPBA00004E" "url" => "/08732159/0000001700000006/v2_201509041318/S0873215911001012/v2_201509041318/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Weaning by gradual pressure support (PS) reduction without an initial spontaneous breathing trial (SBT) versus PS-supported SBT: A pilot study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "244" "paginaFinal" => "252" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "K. Gnanapandithan, R. Agarwal, A.N. Aggarwal, D. Gupta" "autores" => array:4 [ 0 => array:3 [ "nombre" => "K." "apellidos" => "Gnanapandithan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "R." "apellidos" => "Agarwal" "email" => array:2 [ 0 => "riteshpgi@gmail.com" 1 => "ritesh@indiachest.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "A.N." "apellidos" => "Aggarwal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "D." "apellidos" => "Gupta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Dept of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Dept of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Desmame por redução gradual da pressão de suporte (PS) sem uma prova de respiração espontânea (SBT) inicial versus PS apoiada pela SBT: um estudo piloto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1764 "Ancho" => 2167 "Tamanyo" => 210259 ] ] "descripcion" => array:1 [ "en" => "Algorithm depicting the entire protocol, from randomization of the patient to implementation of the two methods of weaning." ] ] ] "textoCompleto" => "IntroductionWeaning from mechanical ventilation allows patients to resume their spontaneous breathing.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Almost 40–50% of the total duration of mechanical ventilation is spent on the weaning process.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Delayed weaning not only exposes the patient to increased cost of intensive care but also increased risk of complications.<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> Hospital mortality increases with prolonged mechanical ventilation, in part because of complications like ventilator-associated pneumonia (VAP) and airway trauma.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> On the other hand, premature weaning is associated with difficulty in re-establishing artificial airway, compromised gas exchange, high incidence of VAP and increased mortality.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The major factor in successful weaning is resolution of the precipitating illness. Other factors include the comorbid illnesses, cause of acute respiratory failure (ARF), protocol and the method of weaning. Among these, the method of weaning is an important variable because of the potential to intervene. The major weaning studies have been conducted using spontaneous T-piece trials and pressure support (PS) ventilation.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> In these studies, readiness to wean has been assessed by an initial 2h T-piece trial; patients who tolerate this trial are extubated whereas those failing this trial are randomized to different weaning methods. The reintubation rates of the initial spontaneous breathing trials (SBTs) have ranged from 10 to 20%.<a class="elsevierStyleCrossRefs" href="#bib0035">7–11</a>Since the inception of our respiratory intensive care unit (RICU), it has been the practice to wean patients by gradual PS reduction without employing an initial SBT. No study has compared the efficacy and safety of a weaning method without an initial SBT as the initial strategy. We hypothesized that weaning would be more physiological once PS is gradually decreased, and could potentially result in better outcomes than initial SBTs. The aim of this randomized controlled trial (RCT) was to examine the efficacy and safety of two different weaning methods viz. gradual reduction of PS without an initial SBT versus SBTs using low-level PS.Material and methodsThe study was conducted between January 2008 and June 2009 in the RICU of this institute, and was approved by the Ethics Committee (PGIMER Ethics Committee; VS/1353). An informed consent was taken from all the patients or their relatives. All data in the RICU were entered prospectively into a computer program specifically designed for this purpose as previously described.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Inclusion criteriaPatients with ARF requiring mechanical ventilation for more than 24h were included. The severity of the underlying illness and the quantum of the organ dysfunction/failure appearing after RICU admission were scored using SOFA scores.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> New-onset organ dysfunction/failure was computed using ΔSOFA score, by subtracting the SOFA score at admission from the maximum SOFA during the ICU stay.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> All patients received volume-targeted assist control mode ventilation (ACMV) for their initial management. Patients who required ventilatory support for longer periods underwent tracheostomy as indicated. Weaning was attempted when there was significant improvement in the underlying cause. ACMV was stopped and patients were allowed to breathe spontaneously for 5min at continuous positive airway pressure (CPAP) of 5cm H2O, with the FiO2 set at the same level. Patients with respiratory rate ≤35min−1, tidal volume ≥5mL/kg and a rapid shallow breathing index (RSBI) <100breaths per min/L were eligible for randomization into the trial. RSBI was obtained as the ratio of frequency to tidal volume during the first minute of the trial. In addition, most of the following clinical and laboratory criteria had to be satisfied: body temperature <38°C, ability to respond to simple commands, minimal tracheobronchial secretions, hemoglobin ≥7gm/dL, systolic blood pressure (SBP) ≥100mmHg without vasopressor support, PaO2 ≥60mmHg (or pulse oximetric saturation ≥92%) at FiO2 of ≤0.4, PaCO2 ≤45mmHg (≤55mmHg in COPD patients) and PaO2/FiO2 ≥250. Finally, the ICU physician had to agree that the patient was stable and ready to be weaned from the ventilator.Exclusion criteriaPregnancy, age under 12 years, post-operative patients, failure to give informed consent and death prior to weaning from mechanical ventilation were the exclusion criteria.RandomizationPatients meeting the inclusion criteria were randomized to weaning by either gradual reduction of PS without an initial SBT (PS group) or SBT with a fixed PS of 7cm H2O (SBT group). The randomization sequence was computer generated and the assignments (placed in sealed opaque envelopes) were made prior to weaning. Blinding of allocation was not possible.Pressure support groupPS was instituted (equivalent to the plateau pressure of the patient during ACMV) along with CPAP of 5cm of H2O. Thereafter PS was adjusted until the respiratory rate was ≤30breaths/min. The PS was reduced by 2cm H2O every 6h or earlier as clinically indicated. Patients were considered fit for extubation if they tolerated PS of 7cm H2O for at least 1h. If there were signs of intolerance, PS was increased to the preceding level and reassessment for weaning was performed after a period of 6h. If signs of intolerance persisted despite an increase in PS, ACMV was reinstituted.Spontaneous breathing trial groupSBT was administered using a PS of 7cm H2O, and patients were monitored continuously for the first 5min and then every 15min of the trial. Patients who tolerated the SBT for 1h were considered fit for extubation. If there were any signs of intolerance, ACMV was reinstituted. Patients failing the first SBT were reassessed after 24h for the next SBT. The final decision to extubate was left to the intensivist's clinical judgment.Intolerance to the weaning trialWas defined as increase in respiratory frequency by >30% from baseline, heart rate >140beats/min or a rise by >20% from baseline, SBP <90mmHg or >180mmHg, pH <7.32 or decrease by >0.07units, PaO2 <50mmHg, rise in PaCO2 by >20%, presence of confusion, agitation, diaphoresis, cyanosis or evidence of increasing respiratory effort.Post-extubationAll patients were monitored for 48h following extubation. Supplemental oxygen or noninvasive ventilation (NIV) was used as clinically indicated. Patients were followed up till the hospital discharge. The entire protocol is schematically shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>OutcomesThe primary outcomes were the rates of weaning failure and the total duration of weaning. The secondary outcomes were the ICU and hospital length of stay, hospital mortality and the occurrence of VAP. Successful weaning trial was defined as lack of reinstitution of full ventilatory support at any time during the weaning process. Extubation success was considered if there was no requirement of intubation within 48h of extubation. In tracheostomized patients, withdrawal from ventilatory support and its reinstitution were considered equivalents to extubation and reintubation, respectively.Statistical analysisData are presented as mean (SD), median (IQR) or number with percentages. All categorical variables were analysed using the chi-square test. Differences between continuous variables were performed using the Student's t test or Mann Whitney U test. A multivariable logistic regression analysis was performed to study the factors predicting successful extubation.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>ResultsDuring the study period, 184 patients were mechanically ventilated in the RICU. Thirty-two died prior to the onset of weaning, eight patients were ventilated for <24h, and 20 patients did not provide written consent and were not included in the study (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Sixty-four males and 60 females with a median (IQR) age of 35 (24–50) years were included in the trial. The mean (SD) SOFA score at admission was 5.4 (3.8). The causes of respiratory failure requiring ventilatory support were acute respiratory distress syndrome (ARDS) in 58, poisoning (including organophosphate compounds, snake bite, inhalational toxins and others) in 24, chronic obstructive pulmonary disease in 10, neuromuscular disorders (including Guillain–Barre syndrome, myasthenic crisis) in 10 and other causes (interstitial lung disease, acute exacerbation of asthma, bronchogenic carcinoma, diffuse alveolar haemorrhage [3 patients], lung collapse, pneumothorax, congestive cardiac failure [2 patients], acute coronary syndrome and pericardial tamponade) in 14 patients.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Of the 124 patients, 61 were assigned to the PS group and 63 to the SBT group. Four patients (3 PS group, 1 SBT group) developed concomitant events unrelated to the weaning process (cerebrovascular accident [n=2], acute myocardial infarction [n=1] and massive gastrointestinal bleed [n=1]). These were considered as early withdrawals and were not included in the analysis. The baseline characteristics in both the groups were comparable except the PaO2/FiO2 ratio, which was significantly higher in SBT group (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The mean (SD) pressure support in the PS group at the beginning of the weaning procedure was 17.2 (3.6) cm of H2O. The median (IQR) duration of ventilation prior to weaning was 80.2 (50.5–175.6)h.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Primary outcomesThe numbers of patients with successful weaning trial (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) were significantly higher in the PS group compared to the SBT group (PS group – 52/58 versus SBT group – 43/62). All these patients were extubated; however, five patients in each group who underwent successful weaning trial (5/52 versus 5/43, P=0.75) required reintubation. The median duration of weaning was 66h in the PS group versus 73.5h in the SBT group with trend towards quicker weaning in the PS group. As it is difficult to judge success or failure rates in tracheostomized patients, which could be a major confounding factor, the analysis was repeated after excluding patients with tracheostomy. There was no difference in any of the primary outcomes in patients with and without tracheostomy (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Secondary outcomesThe duration of stay in the RICU was significantly lower in the PS group. However, the duration of hospital stay was similar in the two groups (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). There was no difference in the mortality rates, occurrence of VAP and the need for tracheostomy or post-extubation NIV in the two groups. However, the duration of RICU stay was significantly shorter in the SBT group; compared to the PS group (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The time to failure of a weaning trial was significantly shorter in the SBT group; however, there was no difference between the two groups after excluding patients with tracheostomy (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Six and 19 patients in the PS and SBT group, respectively, failed the weaning trial and required prolonged attempts at weaning (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Of the 25 patients in both the groups who failed the weaning trial, nine patients died prior to further attempts at weaning. Sixteen patients were eventually weaned, and prolonged weaning was encountered in 10 patients. Among those reintubated (n=10), four patients died and the weaning process was prolonged in the remaining six. Three patients who were successfully weaned died during the hospital stay.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Logistic regression analysis was performed to ascertain the variables predicting successful extubation. In the multivariate model, after adjustment, the variables that predicted outcome were duration of ventilation prior to weaning, baseline SOFA score and the weaning strategy (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Once patients with tracheostomy were excluded, the variables that predicted outcome were duration of ventilation prior to weaning and the weaning strategy (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionThe results of the study suggest that weaning by gradual reduction of PS without an initial SBT was associated with better outcomes (in terms of higher weaning trial successes, shorter ICU stay and trend towards quicker time to extubation) than weaning by PS-supported SBTs. This study was conducted in the RICU of a tertiary referral institute manned by intensivists and nursing staff well trained in ventilatory strategies. Our patient profile included medical patients with respiratory failure of various etiologies. Randomization ensured comparability between the two groups. The only significant difference was a higher PaO2/FiO2 ratio in the SBT group, which is unlikely to affect the results as the other parameters were well matched. We also ensured strict adherence to the protocol including the criteria used for altering the level of PS or extubation.In the SBT arm, trials were conducted every 24h as once daily SBTs with a rest period of 24h are associated with best outcomes.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Two trials have shown that once daily SBT is associated with higher weaning success compared to multiple trials.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Esteban et al. showed that 30min SBTs are as effective as 120min trials in achieving successful extubation with similar reintubation and mortality rates.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Also, longer duration of SBTs may delay the recovery of muscle function as reflected by the longer ICU stays in the 120min group in their study.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Most patients who fail an initial SBT do so in the first 20min with the success rate being similar in 30 and 120min trials.<a class="elsevierStyleCrossRefs" href="#bib0045">9,11</a> Hence, the duration of the SBT was limited to 1h in our study to further reduce the monitoring time and the workload on the RICU staff. We used PS of 7cm H2O for SBT as it was shown that the number of successful extubation was 10% higher in SBT performed with PS of 8cm H2O than with T-piece with similar reintubation rates.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Brochard et al. found that a PS of 8cm of H2O was sufficient to compensate for the additional work of breathing caused by the endotracheal tube and demand valve.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Another advantage of SBT with a specified PS over a T-piece trial is that it does not require disconnection from the ventilator, and ensures safety in a resource constrained ICU.Two large studies have investigated gradual withdrawal of ventilatory support.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> However, these studies included patients by an initial 2h SBT with those failing SBT randomized to PS reduction, synchronized intermittent mandatory ventilation (SIMV) or SBTs. These trials established that SIMV was associated with longer duration of weaning than the other two methods. Studies using initial T-piece trials have produced failure rates ranging from 12 to 32%.<a class="elsevierStyleCrossRefs" href="#bib0035">7–11</a> Our study is different from these studies in that we directly randomized patients to gradual PS reduction without initial SBT, and the results suggest that this strategy is as effective as PS-supported SBT. However, a larger RCT is required to confirm the results of our study. The PS group in our study had lesser duration of weaning and shorter ICU stay consistent with earlier results.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> However, one study reported that the duration of weaning was significantly shorter with T-piece trials than PS.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> One possible reason could be the restrained manner in which PS was reduced in this study wherein a respiratory rate cutoff of <25breaths/min was required for reduction of PS whereas intolerance to T-piece trial was considered at 35breaths/min.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Also, prior to extubation, the patients had to tolerate a PS of 5cm of H2O for 2h. This may have led to slower reduction of PS and hence a longer duration of weaning. Further, this study did not consider the failure of T-piece trials requiring reinstitution of ventilation in their outcomes.The failure rate of SBT was 30% in our study similar to previous reports of 26–42%.<a class="elsevierStyleCrossRefs" href="#bib0020">4,7,8,11</a> The reintubation rate of 8% is consistent with earlier reintubation rates of 4–19%.<a class="elsevierStyleCrossRefs" href="#bib0020">4,7–9,17</a> The median time to failure of the first weaning trial was 43 and 25min in the PS and SBT arms, respectively. The time to failure of the weaning trial is shorter in the SBT group because PS effectively assists each spontaneous breath and hence reduces the respiratory workload imposed on the respiratory muscles.<a class="elsevierStyleCrossRefs" href="#bib0090">18–20</a> The short duration of trial failure re-emphasizes that 60min SBTs are as effective as the 120min trials. The PS group also had shorter ICU stay compared to the SBT group consonant to quicker weaning. The occurrence of VAP in reintubated patients was 70% in our study compared to 17% in those without reintubation, which is similar to previous observation.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> In the multivariate model, the baseline SOFA score, the duration of ventilation prior to weaning and the weaning method significantly influenced successful weaning trials. Vallverdu et al. in a study on factors affecting the weaning outcome in diverse cause of mechanically ventilated patients also found duration of ventilation as a significant factor associated with weaning success.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Kollef et al. found that baseline APACHE II score was one of the factors that predicted successful weaning.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Our study has number of limitations. We used an unconventional method to assess the readiness to wean, i.e. CPAP of 5cm H2O. As the study compares the standard SBT method to gradual PS reduction, there was a need for an initial short trial of CPAP to objectively select patients for randomization into the trial. The study has a small sample size and includes diverse causes of respiratory failure. However, our study population was more homogenous than previous studies as we included only medical patients. The absence of blinding is a potential for bias in the study but blinding was not possible as this was an intervention study in critically ill patients that required close monitoring following intervention. Another limitation of the study is the inclusion of patients with tracheostomy (number similar in both arms), and the definitions for extubation and reintubation in this group of patients. Similarly, the use of NIV following extubation is another source of bias although its use was at the discretion of the attending physician and the number in which it was applied was small. The strength of the study is the evaluation of a hitherto uninvestigated method of weaning.In conclusion, weaning by gradual reduction of PS without an initial SBT was associated with higher success rates, quicker weaning, and a shorter ICU stay versus once daily PS-supported SBTs. However, RCTs with a larger sample size are required to confirm the results of our findings.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres547599" "titulo" => array:5 [ 0 => "Abstract" 1 => "Background and aim" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec565479" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres547598" "titulo" => array:5 [ 0 => "Resumo" 1 => "Antecedentes e objetivo" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusões" ] ] 3 => array:2 [ "identificador" => "xpalclavsec565478" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Inclusion criteria" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Exclusion criteria" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Randomization" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Pressure support group" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Spontaneous breathing trial group" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Intolerance to the weaning trial" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Post-extubation" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Outcomes" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0060" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Primary outcomes" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Secondary outcomes" ] ] ] 7 => array:2 [ "identificador" => "sec0075" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-12-24" "fechaAceptado" => "2011-06-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565479" "palabras" => array:6 [ 0 => "Mechanical ventilation" 1 => "Weaning" 2 => "Extubation" 3 => "Respiratory failure" 4 => "ICU" 5 => "ARDS" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565478" "palabras" => array:6 [ 0 => "Ventilação mecânica" 1 => "Desmame" 2 => "Extubação" 3 => "Falha respiratória" 4 => "UCI" 5 => "ARDS" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Background and aimStudies on weaning strategies have yielded conflicting results regarding the superiority of different methods. The aim of this RCT was to compare the efficacy of gradual pressure support (PS) reduction without an initial spontaneous breathing trial (SBT) with PS-supported SBT. MethodsPatients mechanically ventilated for >24h were randomized to weaning by gradual reduction of PS without an initial SBT versus once daily SBT (PS 7cm H2O). The primary outcomes were the rates of successful weaning trial and time to successful extubation. The secondary outcomes were the ICU and hospital length of stay, hospital mortality and the occurrence of ventilator-associated pneumonia (VAP). ResultsOf the 120 patients (61 males, median age 35 years), 58 were assigned to PS and 62 to the SBT group. The median (IQR) duration of ventilation prior to weaning was 80.2 (50.5–175.6)h. The baseline characteristics were similar in the two groups except the PaO2/FiO2 ratio, which was significantly higher in SBT group. The rates of successful weaning trial (89.7% versus 69.4%) were significantly higher in the PS group. The median duration of weaning (66h versus 81.5h, P=0.05) and the median duration of ICU stay (8 days versus 9.4 days, P=0.027) were lower in the PS group. There was no difference in hospital stay, mortality rates or occurrence of VAP in the two arms. On multivariate analysis, the duration of ventilation prior to weaning, baseline SOFA score and the weaning method were predictors of successful extubation. ConclusionsGradual reduction of PS without an initial SBT was found to be associated with better outcomes compared to once daily PS-supported SBT." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "Antecedentes e objetivoOs estudos sobre estratégias de desmame tiveram resultados controversos em relação à superioridade de métodos diferentes. O objetivo deste RCT foi comparar a eficácia da redução gradual da pressão de suporte (PS) sem uma prova de respiração espontânea (SBT) inicial com a PS apoiada pela SBT. MétodosOs pacientes ventilados mecanicamente por >24 horas foram aleatorizados para desmame por redução gradual da PS sem uma SBT inicial versus a SBT uma vez por dia (PS-7cm H2O). Os principais resultados foram as taxas de sucesso do teste de desmame e o tempo até a extubação bem sucedida. Os resultados secundários foram o tempo em que estiveram na UCI e no hospital, mortalidade hospitalar e ocorrência de pneumonia associada ao ventilador (VAP). ResultadosDos 120 pacientes (61 homens, média de idade de 35 anos), 58 foram atribuídos ao grupo de PS e 62 ao grupo de SBT. A duração média (IQR) da ventilação antes do desmame foi de 80,2 (50,5–175,6)horas. Os parâmetros basais foram semelhantes nos dois grupos, exceto a taxa PaO2/FiO2, que foi significativamente superior no grupo de SBT. As taxas de testes de desmame bem-sucedido (89,7% versus 69,4%) foram significativamente superiores no grupo de PS. A duração média de desmame (66 versus 81,5 horas, p=0.05) e a duração média de tempo na UCI (8 versus 9,4 dias, p=0,027) foi inferior no grupo PS. Não se registaram diferenças no tempo em que estiveram no hospital, taxas de mortalidade ou ocorrência de VAP nos dois grupos. Numa análise multivariada, a duração de ventilação antes do desmame, o índice SOFA basal e o método de desmame foram preditores de uma extubação bem sucedida. ConclusõesDescobriu-se que a redução gradual da PS sem uma SBT inicial estava associada com melhores resultados comparados com PS apoiada pela SBT uma vez por dia." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1764 "Ancho" => 2167 "Tamanyo" => 210259 ] ] "descripcion" => array:1 [ "en" => "Algorithm depicting the entire protocol, from randomization of the patient to implementation of the two methods of weaning." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1924 "Ancho" => 2181 "Tamanyo" => 225319 ] ] "descripcion" => array:1 [ "en" => "CONSORT diagram demonstrating the flow of participants through each stage of the trial." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "All values are expressed as mean (SD) unless otherwise stated. Italics: significant p value <0.05.ARDS, acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; SOFA, sequential organ failure assessment." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PS group (n=58) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SBT group (n=62) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age in years, median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34.5 (22.8–50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 (25–50.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male gender, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (55.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (46.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SOFA score on admission, median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (2–6.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (2.5–8.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Duration of ventilation in hours, median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80.5 (51.3–203.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 (49.75–149.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Type I respiratory failure, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 (69) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 (67.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Endotracheal tube size, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">7mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (5.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">7.5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (55.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 (43.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">8mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (34.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (46.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">8.5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (5.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Indication for ventilation, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.44 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ARDS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (44.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Poisons and toxins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (16.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (8.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (8.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Neuromuscular disorders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other causes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (18.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (14.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Respiratory parameters at onset of weaning</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Respiratory rate, breaths/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.28±2.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.37±2.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tidal volume, mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">383.5±51.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">382.1±39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.77 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Rapid shallow breathing index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64±8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64±5.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Minute volume, L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.4±1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.4±1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.41±0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.41±0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PaO2, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.5±11.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83.5±15.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">FiO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.29±0.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.29±0.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PaO2/FiO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">273.1±24.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">284.8±27.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884566.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of the patients in the two groups." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "All values are expressed as median (IQR) unless otherwise stated. Bold italics: significant p value <0.05.NIV, noninvasive ventilation; VAP, ventilator associated pneumonia." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Outcome \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">With tracheostomy</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Without tracheostomy</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PS group (n=58) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SBT group (n=62) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P value \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PS group (n=44) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SBT group (n=46) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top">Primary outcomes</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Weaning trial success, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 (89.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (69.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (95.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (80.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Time to extubation in successful weaning, h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (27.8–98.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73.5 (25–133) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.8 (25.3–96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.4 (11.5–122) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.57 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top">Secondary outcomes</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hospital mortality, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (13.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (12.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (6.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (13.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">VAP, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (13.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">RICU stay, days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (6–18.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 (4–14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.027 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (6–10.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hospital stay, days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.5 (8–20.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.5 (7–15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (8–15.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 (7–14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top">Others</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Time to weaning trial failure, min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.5 (32.5–51.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (15–40) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.023 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.5 (10.6–32.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (15.4–25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tracheostomy, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (24.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (25.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884565.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Primary and secondary outcomes in the two groups with and without tracheostomy." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "All values are expressed as median (IQR) unless otherwise stated.VAP, ventilator associated pneumonia." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PS group (n=6) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SBT group (n=19) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Time to extubation, h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 (26.5–90.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 (8–102) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hospital mortality, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (31.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">VAP, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (31.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ICU stay, days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (10.3–21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (10–26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.88 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hospital stay, days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.5 (12.5–22.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (14–19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.64 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tracheostomy, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (52.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884564.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of patients with weaning failure." ] ] 5 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "All values are expressed as median (IQR) unless otherwise stated." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">With tracheostomy</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extubation success (n=85) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extubation failure (n=35) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Crude OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Adjusted OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ARDS as etiology of respiratory failure, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (45.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (65.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.44 (0.2–1)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.91 (0.31–2.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Duration of ventilation prior to weaning in hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (46.5–98.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">172 (100–249) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.993 (0.989–0.997)<a class="elsevierStyleCrossRef" href="#tblfn0015">¶</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.99 (0.989–0.998)<a class="elsevierStyleCrossRef" href="#tblfn0015">¶</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Baseline SOFA score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (2–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (3–11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 (0.7–0.9)<a class="elsevierStyleCrossRef" href="#tblfn0015">¶</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.77 (0.66–0.91)<a class="elsevierStyleCrossRef" href="#tblfn0015">¶</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Delta SOFA score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0–4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (0–4.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.96 (0.82–1.13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.86 (0.67–1.09) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gradual Pressure Support reduction, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 (55.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (31.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.7 (1.2–6.2)<a class="elsevierStyleCrossRef" href="#tblfn0010">§</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.83 (1.59–14.7)<a class="elsevierStyleCrossRef" href="#tblfn0015">¶</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884563.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Without tracheostomy</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extubation success (n=77) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extubation failure (n=13) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Crude OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Adjusted OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ARDS as etiology of respiratory failure, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (48.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (92.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 (0.01–0.62)<a class="elsevierStyleCrossRef" href="#tblfn0010">§</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 (0.02–2.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Duration of ventilation prior to weaning in hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.5 (45.5–80.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">128 (98.5–174.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.98 (0.97–0.99)<a class="elsevierStyleCrossRef" href="#tblfn0015">¶</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.98 (0.97–0.99)<a class="elsevierStyleCrossRef" href="#tblfn0010">§</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Baseline SOFA score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (2–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (3–8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.81 (0.65–1.01)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.86 (0.64–1.16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Delta SOFA score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0–4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.96 (0.75–1.22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.03 (0.73–1.46) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gradual Pressure Support reduction, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (53.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (23.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.79 (0.97–14.88)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.09 (1.02–64.05)<a class="elsevierStyleCrossRef" href="#tblfn0010">§</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884567.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "P value <0.1." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "§" "nota" => "P value <0.05." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "¶" "nota" => "P value <0.01." ] ] ] "descripcion" => array:1 [ "en" => "Predictors of successful extubation—multivariate analysis in patients with and without tracheostomy." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Weaning from mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false 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Weaning by gradual pressure support (PS) reduction without an initial spontaneous breathing trial (SBT) versus PS-supported SBT: A pilot study

Desmame por redução gradual da pressão de suporte (PS) sem uma prova de respiração espontânea (SBT) inicial versus PS apoiada pela SBT: um estudo piloto

K. Gnanapandithana, R. Agarwalb,

Corresponding author

riteshpgi@gmail.com
ritesh@indiachest.org

Corresponding author.

, A.N. Aggarwalb, D. Guptab

a Dept of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

b Dept of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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and airway trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> On the other hand&#44; premature weaning is associated with difficulty in re-establishing artificial airway&#44; compromised gas exchange&#44; high incidence of VAP and increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The major factor in successful weaning is resolution of the precipitating illness&#46; Other factors include the comorbid illnesses&#44; cause of acute respiratory failure &#40;ARF&#41;&#44; protocol and the method of weaning&#46; Among these&#44; the method of weaning is an important variable because of the potential to intervene&#46; The major weaning studies have been conducted using spontaneous T-piece trials and pressure support &#40;PS&#41; ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> In these studies&#44; readiness to wean has been assessed by an initial 2<span class="elsevierStyleHsp" style=""></span>h T-piece trial&#59; patients who tolerate this trial are extubated whereas those failing this trial are randomized to different weaning methods&#46; The reintubation rates of the initial spontaneous breathing trials &#40;SBTs&#41; have ranged from 10 to 20&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Since the inception of our respiratory intensive care unit &#40;RICU&#41;&#44; it has been the practice to wean patients by gradual PS reduction without employing an initial SBT&#46; No study has compared the efficacy and safety of a weaning method without an initial SBT as the initial strategy&#46; We hypothesized that weaning would be more physiological once PS is gradually decreased&#44; and could potentially result in better outcomes than initial SBTs&#46; The aim of this randomized controlled trial &#40;RCT&#41; was to examine the efficacy and safety of two different weaning methods viz&#46; gradual reduction of PS without an initial SBT versus SBTs using low-level PS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">The study was conducted between January 2008 and June 2009 in the RICU of this institute&#44; and was approved by the Ethics Committee &#40;PGIMER Ethics Committee&#59; VS&#47;1353&#41;&#46; An informed consent was taken from all the patients or their relatives&#46; All data in the RICU were entered prospectively into a computer program specifically designed for this purpose as previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Inclusion criteria</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patients with ARF requiring mechanical ventilation for more than 24<span class="elsevierStyleHsp" style=""></span>h were included&#46; The severity of the underlying illness and the quantum of the organ dysfunction&#47;failure appearing after RICU admission were scored using SOFA scores&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> New-onset organ dysfunction&#47;failure was computed using &#916;SOFA score&#44; by subtracting the SOFA score at admission from the maximum SOFA during the ICU stay&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> All patients received volume-targeted assist control mode ventilation &#40;ACMV&#41; for their initial management&#46; Patients who required ventilatory support for longer periods underwent tracheostomy as indicated&#46; Weaning was attempted when there was significant improvement in the underlying cause&#46; ACMV was stopped and patients were allowed to breathe spontaneously for 5<span class="elsevierStyleHsp" style=""></span>min at continuous positive airway pressure &#40;CPAP&#41; of 5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#44; with the FiO<span class="elsevierStyleInf">2</span> set at the same level&#46; Patients with respiratory rate &#8804;35<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">&#8722;1</span>&#44; tidal volume &#8805;5<span class="elsevierStyleHsp" style=""></span>mL&#47;kg and a rapid shallow breathing index &#40;RSBI&#41; &#60;100<span class="elsevierStyleHsp" style=""></span>breaths per min&#47;L were eligible for randomization into the trial&#46; RSBI was obtained as the ratio of frequency to tidal volume during the first minute of the trial&#46; In addition&#44; most of the following clinical and laboratory criteria had to be satisfied&#58; body temperature &#60;38<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; ability to respond to simple commands&#44; minimal tracheobronchial secretions&#44; hemoglobin &#8805;7<span class="elsevierStyleHsp" style=""></span>gm&#47;dL&#44; systolic blood pressure &#40;SBP&#41; &#8805;100<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg without vasopressor support&#44; PaO<span class="elsevierStyleInf">2</span> &#8805;60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg &#40;or pulse oximetric saturation &#8805;92&#37;&#41; at FiO<span class="elsevierStyleInf">2</span> of &#8804;0&#46;4&#44; PaCO<span class="elsevierStyleInf">2</span> &#8804;45<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg &#40;&#8804;55<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg in COPD patients&#41; and PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#8805;250&#46; Finally&#44; the ICU physician had to agree that the patient was stable and ready to be weaned from the ventilator&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Exclusion criteria</span><p id="par0025" class="elsevierStylePara elsevierViewall">Pregnancy&#44; age under 12 years&#44; post-operative patients&#44; failure to give informed consent and death prior to weaning from mechanical ventilation were the exclusion criteria&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Randomization</span><p id="par0030" class="elsevierStylePara elsevierViewall">Patients meeting the inclusion criteria were randomized to weaning by either gradual reduction of PS without an initial SBT &#40;PS group&#41; or SBT with a fixed PS of 7<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O &#40;SBT group&#41;&#46; The randomization sequence was computer generated and the assignments &#40;placed in sealed opaque envelopes&#41; were made prior to weaning&#46; Blinding of allocation was not possible&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pressure support group</span><p id="par0035" class="elsevierStylePara elsevierViewall">PS was instituted &#40;equivalent to the plateau pressure of the patient during ACMV&#41; along with CPAP of 5<span class="elsevierStyleHsp" style=""></span>cm of H<span class="elsevierStyleInf">2</span>O&#46; Thereafter PS was adjusted until the respiratory rate was &#8804;30<span class="elsevierStyleHsp" style=""></span>breaths&#47;min&#46; The PS was reduced by 2<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O every 6<span class="elsevierStyleHsp" style=""></span>h or earlier as clinically indicated&#46; Patients were considered fit for extubation if they tolerated PS of 7<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O for at least 1<span class="elsevierStyleHsp" style=""></span>h&#46; If there were signs of intolerance&#44; PS was increased to the preceding level and reassessment for weaning was performed after a period of 6<span class="elsevierStyleHsp" style=""></span>h&#46; If signs of intolerance persisted despite an increase in PS&#44; ACMV was reinstituted&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Spontaneous breathing trial group</span><p id="par0040" class="elsevierStylePara elsevierViewall">SBT was administered using a PS of 7<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#44; and patients were monitored continuously for the first 5<span class="elsevierStyleHsp" style=""></span>min and then every 15<span class="elsevierStyleHsp" style=""></span>min of the trial&#46; Patients who tolerated the SBT for 1<span class="elsevierStyleHsp" style=""></span>h were considered fit for extubation&#46; If there were any signs of intolerance&#44; ACMV was reinstituted&#46; Patients failing the first SBT were reassessed after 24<span class="elsevierStyleHsp" style=""></span>h for the next SBT&#46; The final decision to extubate was left to the intensivist&#39;s clinical judgment&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Intolerance to the weaning trial</span><p id="par0045" class="elsevierStylePara elsevierViewall">Was defined as increase in respiratory frequency by &#62;30&#37; from baseline&#44; heart rate &#62;140<span class="elsevierStyleHsp" style=""></span>beats&#47;min or a rise by &#62;20&#37; from baseline&#44; SBP &#60;90<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg or &#62;180<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#44; pH &#60;7&#46;32 or decrease by &#62;0&#46;07<span class="elsevierStyleHsp" style=""></span>units&#44; PaO<span class="elsevierStyleInf">2</span> &#60;50<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#44; rise in PaCO<span class="elsevierStyleInf">2</span> by &#62;20&#37;&#44; presence of confusion&#44; agitation&#44; diaphoresis&#44; cyanosis or evidence of increasing respiratory effort&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Post-extubation</span><p id="par0050" class="elsevierStylePara elsevierViewall">All patients were monitored for 48<span class="elsevierStyleHsp" style=""></span>h following extubation&#46; Supplemental oxygen or noninvasive ventilation &#40;NIV&#41; was used as clinically indicated&#46; Patients were followed up till the hospital discharge&#46; The entire protocol is schematically shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Outcomes</span><p id="par0055" class="elsevierStylePara elsevierViewall">The primary outcomes were the rates of weaning failure and the total duration of weaning&#46; The secondary outcomes were the ICU and hospital length of stay&#44; hospital mortality and the occurrence of VAP&#46; <span class="elsevierStyleItalic">Successful weaning trial</span> was defined as lack of reinstitution of full ventilatory support at any time during the weaning process&#46; <span class="elsevierStyleItalic">Extubation success</span> was considered if there was no requirement of intubation within 48<span class="elsevierStyleHsp" style=""></span>h of extubation&#46; In tracheostomized patients&#44; withdrawal from ventilatory support and its reinstitution were considered equivalents to extubation and reintubation&#44; respectively&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Data are presented as mean &#40;SD&#41;&#44; median &#40;IQR&#41; or number with percentages&#46; All categorical variables were analysed using the chi-square test&#46; Differences between continuous variables were performed using the Student&#39;s t test or Mann Whitney <span class="elsevierStyleItalic">U</span> test&#46; A multivariable logistic regression analysis was performed to study the factors predicting successful extubation&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">During the study period&#44; 184 patients were mechanically ventilated in the RICU&#46; Thirty-two died prior to the onset of weaning&#44; eight patients were ventilated for &#60;24<span class="elsevierStyleHsp" style=""></span>h&#44; and 20 patients did not provide written consent and were not included in the study &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Sixty-four males and 60 females with a median &#40;IQR&#41; age of 35 &#40;24&#8211;50&#41; years were included in the trial&#46; The mean &#40;SD&#41; SOFA score at admission was 5&#46;4 &#40;3&#46;8&#41;&#46; The causes of respiratory failure requiring ventilatory support were acute respiratory distress syndrome &#40;ARDS&#41; in 58&#44; poisoning &#40;including organophosphate compounds&#44; snake bite&#44; inhalational toxins and others&#41; in 24&#44; chronic obstructive pulmonary disease in 10&#44; neuromuscular disorders &#40;including Guillain&#8211;Barre syndrome&#44; myasthenic crisis&#41; in 10 and other causes &#40;interstitial lung disease&#44; acute exacerbation of asthma&#44; bronchogenic carcinoma&#44; diffuse alveolar haemorrhage &#91;3 patients&#93;&#44; lung collapse&#44; pneumothorax&#44; congestive cardiac failure &#91;2 patients&#93;&#44; acute coronary syndrome and pericardial tamponade&#41; in 14 patients&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 124 patients&#44; 61 were assigned to the PS group and 63 to the SBT group&#46; Four patients &#40;3 PS group&#44; 1 SBT group&#41; developed concomitant events unrelated to the weaning process &#40;cerebrovascular accident &#91;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#93;&#44; acute myocardial infarction &#91;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#93; and massive gastrointestinal bleed &#91;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#93;&#41;&#46; These were considered as early withdrawals and were not included in the analysis&#46; The baseline characteristics in both the groups were comparable except the PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio&#44; which was significantly higher in SBT group &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The mean &#40;SD&#41; pressure support in the PS group at the beginning of the weaning procedure was 17&#46;2 &#40;3&#46;6&#41; cm of H<span class="elsevierStyleInf">2</span>O&#46; The median &#40;IQR&#41; duration of ventilation prior to weaning was 80&#46;2 &#40;50&#46;5&#8211;175&#46;6&#41;<span class="elsevierStyleHsp" style=""></span>h&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Primary outcomes</span><p id="par0075" class="elsevierStylePara elsevierViewall">The numbers of patients with successful weaning trial &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; were significantly higher in the PS group compared to the SBT group &#40;PS group &#8211; 52&#47;58 versus SBT group &#8211; 43&#47;62&#41;&#46; All these patients were extubated&#59; however&#44; five patients in each group who underwent successful weaning trial &#40;5&#47;52 versus 5&#47;43&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;75&#41; required reintubation&#46; The median duration of weaning was 66<span class="elsevierStyleHsp" style=""></span>h in the PS group versus 73&#46;5<span class="elsevierStyleHsp" style=""></span>h in the SBT group with trend towards quicker weaning in the PS group&#46; As it is difficult to judge success or failure rates in tracheostomized patients&#44; which could be a major confounding factor&#44; the analysis was repeated after excluding patients with tracheostomy&#46; There was no difference in any of the primary outcomes in patients with and without tracheostomy &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Secondary outcomes</span><p id="par0080" class="elsevierStylePara elsevierViewall">The duration of stay in the RICU was significantly lower in the PS group&#46; However&#44; the duration of hospital stay was similar in the two groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There was no difference in the mortality rates&#44; occurrence of VAP and the need for tracheostomy or post-extubation NIV in the two groups&#46; However&#44; the duration of RICU stay was significantly shorter in the SBT group&#59; compared to the PS group &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The time to failure of a weaning trial was significantly shorter in the SBT group&#59; however&#44; there was no difference between the two groups after excluding patients with tracheostomy &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Six and 19 patients in the PS and SBT group&#44; respectively&#44; failed the weaning trial and required prolonged attempts at weaning &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Of the 25 patients in both the groups who failed the weaning trial&#44; nine patients died prior to further attempts at weaning&#46; Sixteen patients were eventually weaned&#44; and prolonged weaning was encountered in 10 patients&#46; Among those reintubated &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#44; four patients died and the weaning process was prolonged in the remaining six&#46; Three patients who were successfully weaned died during the hospital stay&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Logistic regression analysis was performed to ascertain the variables predicting successful extubation&#46; In the multivariate model&#44; after adjustment&#44; the variables that predicted outcome were duration of ventilation prior to weaning&#44; baseline SOFA score and the weaning strategy &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Once patients with tracheostomy were excluded&#44; the variables that predicted outcome were duration of ventilation prior to weaning and the weaning strategy &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">The results of the study suggest that weaning by gradual reduction of PS without an initial SBT was associated with better outcomes &#40;in terms of higher weaning trial successes&#44; shorter ICU stay and trend towards quicker time to extubation&#41; than weaning by PS-supported SBTs&#46; This study was conducted in the RICU of a tertiary referral institute manned by intensivists and nursing staff well trained in ventilatory strategies&#46; Our patient profile included medical patients with respiratory failure of various etiologies&#46; Randomization ensured comparability between the two groups&#46; The only significant difference was a higher PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio in the SBT group&#44; which is unlikely to affect the results as the other parameters were well matched&#46; We also ensured strict adherence to the protocol including the criteria used for altering the level of PS or extubation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In the SBT arm&#44; trials were conducted every 24<span class="elsevierStyleHsp" style=""></span>h as once daily SBTs with a rest period of 24<span class="elsevierStyleHsp" style=""></span>h are associated with best outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Two trials have shown that once daily SBT is associated with higher weaning success compared to multiple trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Esteban et al&#46; showed that 30<span class="elsevierStyleHsp" style=""></span>min SBTs are as effective as 120<span class="elsevierStyleHsp" style=""></span>min trials in achieving successful extubation with similar reintubation and mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Also&#44; longer duration of SBTs may delay the recovery of muscle function as reflected by the longer ICU stays in the 120<span class="elsevierStyleHsp" style=""></span>min group in their study&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Most patients who fail an initial SBT do so in the first 20<span class="elsevierStyleHsp" style=""></span>min with the success rate being similar in 30 and 120<span class="elsevierStyleHsp" style=""></span>min trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;11</span></a> Hence&#44; the duration of the SBT was limited to 1<span class="elsevierStyleHsp" style=""></span>h in our study to further reduce the monitoring time and the workload on the RICU staff&#46; We used PS of 7<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O for SBT as it was shown that the number of successful extubation was 10&#37; higher in SBT performed with PS of 8<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O than with T-piece with similar reintubation rates&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Brochard et al&#46; found that a PS of 8<span class="elsevierStyleHsp" style=""></span>cm of H<span class="elsevierStyleInf">2</span>O was sufficient to compensate for the additional work of breathing caused by the endotracheal tube and demand valve&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Another advantage of SBT with a specified PS over a T-piece trial is that it does not require disconnection from the ventilator&#44; and ensures safety in a resource constrained ICU&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Two large studies have investigated gradual withdrawal of ventilatory support&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> However&#44; these studies included patients by an initial 2<span class="elsevierStyleHsp" style=""></span>h SBT with those failing SBT randomized to PS reduction&#44; synchronized intermittent mandatory ventilation &#40;SIMV&#41; or SBTs&#46; These trials established that SIMV was associated with longer duration of weaning than the other two methods&#46; Studies using initial T-piece trials have produced failure rates ranging from 12 to 32&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;11</span></a> Our study is different from these studies in that we directly randomized patients to gradual PS reduction without initial SBT&#44; and the results suggest that this strategy is as effective as PS-supported SBT&#46; However&#44; a larger RCT is required to confirm the results of our study&#46; The PS group in our study had lesser duration of weaning and shorter ICU stay consistent with earlier results&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; one study reported that the duration of weaning was significantly shorter with T-piece trials than PS&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> One possible reason could be the restrained manner in which PS was reduced in this study wherein a respiratory rate cutoff of &#60;25<span class="elsevierStyleHsp" style=""></span>breaths&#47;min was required for reduction of PS whereas intolerance to T-piece trial was considered at 35<span class="elsevierStyleHsp" style=""></span>breaths&#47;min&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Also&#44; prior to extubation&#44; the patients had to tolerate a PS of 5<span class="elsevierStyleHsp" style=""></span>cm of H<span class="elsevierStyleInf">2</span>O for 2<span class="elsevierStyleHsp" style=""></span>h&#46; This may have led to slower reduction of PS and hence a longer duration of weaning&#46; Further&#44; this study did not consider the failure of T-piece trials requiring reinstitution of ventilation in their outcomes&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The failure rate of SBT was 30&#37; in our study similar to previous reports of 26&#8211;42&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#44;8&#44;11</span></a> The reintubation rate of 8&#37; is consistent with earlier reintubation rates of 4&#8211;19&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#8211;9&#44;17</span></a> The median time to failure of the first weaning trial was 43 and 25<span class="elsevierStyleHsp" style=""></span>min in the PS and SBT arms&#44; respectively&#46; The time to failure of the weaning trial is shorter in the SBT group because PS effectively assists each spontaneous breath and hence reduces the respiratory workload imposed on the respiratory muscles&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a> The short duration of trial failure re-emphasizes that 60<span class="elsevierStyleHsp" style=""></span>min SBTs are as effective as the 120<span class="elsevierStyleHsp" style=""></span>min trials&#46; The PS group also had shorter ICU stay compared to the SBT group consonant to quicker weaning&#46; The occurrence of VAP in reintubated patients was 70&#37; in our study compared to 17&#37; in those without reintubation&#44; which is similar to previous observation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In the multivariate model&#44; the baseline SOFA score&#44; the duration of ventilation prior to weaning and the weaning method significantly influenced successful weaning trials&#46; Vallverdu et al&#46; in a study on factors affecting the weaning outcome in diverse cause of mechanically ventilated patients also found duration of ventilation as a significant factor associated with weaning success&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Kollef et al&#46; found that baseline APACHE II score was one of the factors that predicted successful weaning&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Our study has number of limitations&#46; We used an unconventional method to assess the readiness to wean&#44; i&#46;e&#46; CPAP of 5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#46; As the study compares the standard SBT method to gradual PS reduction&#44; there was a need for an initial short trial of CPAP to objectively select patients for randomization into the trial&#46; The study has a small sample size and includes diverse causes of respiratory failure&#46; However&#44; our study population was more homogenous than previous studies as we included only medical patients&#46; The absence of blinding is a potential for bias in the study but blinding was not possible as this was an intervention study in critically ill patients that required close monitoring following intervention&#46; Another limitation of the study is the inclusion of patients with tracheostomy &#40;number similar in both arms&#41;&#44; and the definitions for extubation and reintubation in this group of patients&#46; Similarly&#44; the use of NIV following extubation is another source of bias although its use was at the discretion of the attending physician and the number in which it was applied was small&#46; The strength of the study is the evaluation of a hitherto uninvestigated method of weaning&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; weaning by gradual reduction of PS without an initial SBT was associated with higher success rates&#44; quicker weaning&#44; and a shorter ICU stay versus once daily PS-supported SBTs&#46; However&#44; RCTs with a larger sample size are required to confirm the results of our findings&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xpalclavsec565478"
          "titulo" => "Palavras-chave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Material and methods"
          "secciones" => array:9 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Inclusion criteria"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Exclusion criteria"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Randomization"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Pressure support group"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Spontaneous breathing trial group"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Intolerance to the weaning trial"
            ]
            6 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Post-extubation"
            ]
            7 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Outcomes"
            ]
            8 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Statistical analysis"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0060"
          "titulo" => "Results"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Primary outcomes"
            ]
            1 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Secondary outcomes"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conflicts of interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-12-24"
    "fechaAceptado" => "2011-06-11"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec565479"
          "palabras" => array:6 [
            0 => "Mechanical ventilation"
            1 => "Weaning"
            2 => "Extubation"
            3 => "Respiratory failure"
            4 => "ICU"
            5 => "ARDS"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec565478"
          "palabras" => array:6 [
            0 => "Ventila&#231;&#227;o mec&#226;nica"
            1 => "Desmame"
            2 => "Extuba&#231;&#227;o"
            3 => "Falha respirat&#243;ria"
            4 => "UCI"
            5 => "ARDS"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span><span class="elsevierStyleSectionTitle">Background and aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Studies on weaning strategies have yielded conflicting results regarding the superiority of different methods&#46; The aim of this RCT was to compare the efficacy of gradual pressure support &#40;PS&#41; reduction without an initial spontaneous breathing trial &#40;SBT&#41; with PS-supported SBT&#46;</p></span> <span><span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients mechanically ventilated for &#62;24<span class="elsevierStyleHsp" style=""></span>h were randomized to weaning by gradual reduction of PS without an initial SBT versus once daily SBT &#40;PS 7<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41;&#46; The primary outcomes were the rates of successful weaning trial and time to successful extubation&#46; The secondary outcomes were the ICU and hospital length of stay&#44; hospital mortality and the occurrence of ventilator-associated pneumonia &#40;VAP&#41;&#46;</p></span> <span><span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 120 patients &#40;61 males&#44; median age 35 years&#41;&#44; 58 were assigned to PS and 62 to the SBT group&#46; The median &#40;IQR&#41; duration of ventilation prior to weaning was 80&#46;2 &#40;50&#46;5&#8211;175&#46;6&#41;<span class="elsevierStyleHsp" style=""></span>h&#46; The baseline characteristics were similar in the two groups except the PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio&#44; which was significantly higher in SBT group&#46; The rates of successful weaning trial &#40;89&#46;7&#37; versus 69&#46;4&#37;&#41; were significantly higher in the PS group&#46; The median duration of weaning &#40;66<span class="elsevierStyleHsp" style=""></span>h versus 81&#46;5<span class="elsevierStyleHsp" style=""></span>h&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and the median duration of ICU stay &#40;8 days versus 9&#46;4 days&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;027&#41; were lower in the PS group&#46; There was no difference in hospital stay&#44; mortality rates or occurrence of VAP in the two arms&#46; On multivariate analysis&#44; the duration of ventilation prior to weaning&#44; baseline SOFA score and the weaning method were predictors of successful extubation&#46;</p></span> <span><span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Gradual reduction of PS without an initial SBT was found to be associated with better outcomes compared to once daily PS-supported SBT&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span><span class="elsevierStyleSectionTitle">Antecedentes e objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Os estudos sobre estrat&#233;gias de desmame tiveram resultados controversos em rela&#231;&#227;o &#224; superioridade de m&#233;todos diferentes&#46; O objetivo deste RCT foi comparar a efic&#225;cia da redu&#231;&#227;o gradual da press&#227;o de suporte &#40;PS&#41; sem uma prova de respira&#231;&#227;o espont&#226;nea &#40;SBT&#41; inicial com a PS apoiada pela SBT&#46;</p></span> <span><span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Os pacientes ventilados mecanicamente por &#62;24 horas foram aleatorizados para desmame por redu&#231;&#227;o gradual da PS sem uma SBT inicial versus a SBT uma vez por dia &#40;PS-7<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41;&#46; Os principais resultados foram as taxas de sucesso do teste de desmame e o tempo at&#233; a extuba&#231;&#227;o bem sucedida&#46; Os resultados secund&#225;rios foram o tempo em que estiveram na UCI e no hospital&#44; mortalidade hospitalar e ocorr&#234;ncia de pneumonia associada ao ventilador &#40;VAP&#41;&#46;</p></span> <span><span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Dos 120 pacientes &#40;61 homens&#44; m&#233;dia de idade de 35 anos&#41;&#44; 58 foram atribu&#237;dos ao grupo de PS e 62 ao grupo de SBT&#46; A dura&#231;&#227;o m&#233;dia &#40;IQR&#41; da ventila&#231;&#227;o antes do desmame foi de 80&#44;2 &#40;50&#44;5&#8211;175&#44;6&#41;<span class="elsevierStyleHsp" style=""></span>horas&#46; Os par&#226;metros basais foram semelhantes nos dois grupos&#44; exceto a taxa PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#44; que foi significativamente superior no grupo de SBT&#46; As taxas de testes de desmame bem-sucedido &#40;89&#44;7&#37; versus 69&#44;4&#37;&#41; foram significativamente superiores no grupo de PS&#46; A dura&#231;&#227;o m&#233;dia de desmame &#40;66 versus 81&#44;5 horas&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; e a dura&#231;&#227;o m&#233;dia de tempo na UCI &#40;8 versus 9&#44;4 dias&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;027&#41; foi inferior no grupo PS&#46; N&#227;o se registaram diferen&#231;as no tempo em que estiveram no hospital&#44; taxas de mortalidade ou ocorr&#234;ncia de VAP nos dois grupos&#46; Numa an&#225;lise multivariada&#44; a dura&#231;&#227;o de ventila&#231;&#227;o antes do desmame&#44; o &#237;ndice SOFA basal e o m&#233;todo de desmame foram preditores de uma extuba&#231;&#227;o bem sucedida&#46;</p></span> <span><span class="elsevierStyleSectionTitle">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Descobriu-se que a redu&#231;&#227;o gradual da PS sem uma SBT inicial estava associada com melhores resultados comparados com PS apoiada pela SBT uma vez por dia&#46;</p></span>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1764
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Algorithm depicting the entire protocol&#44; from randomization of the patient to implementation of the two methods of weaning&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CONSORT diagram demonstrating the flow of participants through each stage of the trial&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">All values are expressed as mean &#40;SD&#41; unless otherwise stated&#46; Italics&#58; significant p value &#60;0&#46;05&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ARDS&#44; acute respiratory distress syndrome&#59; COPD&#44; chronic obstructive pulmonary disease&#59; SOFA&#44; sequential organ failure assessment&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PS group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SBT group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age in years&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#46;5 &#40;22&#46;8&#8211;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37 &#40;25&#8211;50&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male gender&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;55&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;46&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SOFA score on admission&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;2&#8211;6&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;2&#46;5&#8211;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of ventilation in hours&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#46;5 &#40;51&#46;3&#8211;203&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77 &#40;49&#46;75&#8211;149&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Type I respiratory failure&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40 &#40;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42 &#40;67&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Endotracheal tube size&#44; n</span> &#40;<span class="elsevierStyleItalic">&#37;</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#46;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;55&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;43&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;34&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;46&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8&#46;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Indication for ventilation&#44; n</span> &#40;<span class="elsevierStyleItalic">&#37;</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ARDS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;44&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Poisons and toxins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;16&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;8&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neuromuscular disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other causes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;18&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;14&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Respiratory parameters at onset of weaning</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory rate&#44; breaths&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tidal volume&#44; mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">383&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>51&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">382&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rapid shallow breathing index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Minute volume&#44; L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>pH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PaO<span class="elsevierStyleInf">2</span>&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">273&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">284&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleItalic">0&#46;01</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of the patients in the two groups&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">All values are expressed as median &#40;IQR&#41; unless otherwise stated&#46; Bold italics&#58; significant p value &#60;0&#46;05&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">NIV&#44; noninvasive ventilation&#59; VAP&#44; ventilator associated pneumonia&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">With tracheostomy</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Without tracheostomy</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PS group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SBT group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PS group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SBT group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">Primary outcomes</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Weaning trial success&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52 &#40;89&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;69&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">0&#46;006</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;95&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;80&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">0&#46;03</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Time to extubation in successful weaning&#44; h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;27&#46;8&#8211;98&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;5 &#40;25&#8211;133&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;8 &#40;25&#46;3&#8211;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#46;4 &#40;11&#46;5&#8211;122&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">Secondary outcomes</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hospital mortality&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;13&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;6&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;13&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>VAP&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;13&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RICU stay&#44; days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;6&#8211;18&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5 &#40;4&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">0&#46;027</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;6&#8211;10&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#8211;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">0&#46;003</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hospital stay&#44; days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;5 &#40;8&#8211;20&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;5 &#40;7&#8211;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;8&#8211;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5 &#40;7&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">Others</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Time to weaning trial failure&#44; min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;5 &#40;32&#46;5&#8211;51&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;15&#8211;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">0&#46;023</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;5 &#40;10&#46;6&#8211;32&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;15&#46;4&#8211;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tracheostomy&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;24&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;25&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab884565.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Primary and secondary outcomes in the two groups with and without tracheostomy&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">All values are expressed as median &#40;IQR&#41; unless otherwise stated&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">VAP&#44; ventilator associated pneumonia&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PS group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SBT group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Time to extubation&#44; h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;26&#46;5&#8211;90&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74 &#40;8&#8211;102&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hospital mortality&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;31&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">VAP&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;31&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ICU stay&#44; days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;10&#46;3&#8211;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;10&#8211;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hospital stay&#44; days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;5 &#40;12&#46;5&#8211;22&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;14&#8211;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tracheostomy&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;52&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab884564.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Characteristics of patients with weaning failure&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">All values are expressed as median &#40;IQR&#41; unless otherwise stated&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">With tracheostomy</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extubation success &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extubation failure &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Crude OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Adjusted OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ARDS as etiology of respiratory failure&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;45&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;65&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;44 &#40;0&#46;2&#8211;1&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;91 &#40;0&#46;31&#8211;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of ventilation prior to weaning in hours&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;46&#46;5&#8211;98&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">172 &#40;100&#8211;249&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;993 &#40;0&#46;989&#8211;0&#46;997&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#182;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;99 &#40;0&#46;989&#8211;0&#46;998&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#182;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Baseline SOFA score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;2&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;3&#8211;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;8 &#40;0&#46;7&#8211;0&#46;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#182;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;77 &#40;0&#46;66&#8211;0&#46;91&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#182;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Delta SOFA score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;0&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;0&#8211;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;96 &#40;0&#46;82&#8211;1&#46;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86 &#40;0&#46;67&#8211;1&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gradual Pressure Support reduction&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47 &#40;55&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;31&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;7 &#40;1&#46;2&#8211;6&#46;2&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#167;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;83 &#40;1&#46;59&#8211;14&#46;7&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#182;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab884563.png"
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Without tracheostomy</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extubation success &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extubation failure &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Crude OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Adjusted OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ARDS as etiology of respiratory failure&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;48&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;92&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08 &#40;0&#46;01&#8211;0&#46;62&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#167;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;23 &#40;0&#46;02&#8211;2&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of ventilation prior to weaning in hours&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;5 &#40;45&#46;5&#8211;80&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">128 &#40;98&#46;5&#8211;174&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;98 &#40;0&#46;97&#8211;0&#46;99&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#182;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;98 &#40;0&#46;97&#8211;0&#46;99&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#167;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Baseline SOFA score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;2&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;3&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;81 &#40;0&#46;65&#8211;1&#46;01&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86 &#40;0&#46;64&#8211;1&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Delta SOFA score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;0&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;96 &#40;0&#46;75&#8211;1&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;03 &#40;0&#46;73&#8211;1&#46;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gradual Pressure Support reduction&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 08732159
Original language: English

DOI:10.1016/j.rppneu.2011.06.015

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	16	11	27
2024 October	119	44	163
2024 September	119	26	145
2024 August	164	34	198
2024 July	148	37	185
2024 June	182	43	225
2024 May	153	41	194
2024 April	126	38	164
2024 March	138	37	175
2024 February	86	94	180
2024 January	90	16	106
2023 December	73	36	109
2023 November	93	35	128
2023 October	87	39	126
2023 September	91	36	127
2023 August	89	15	104
2023 July	84	40	124
2023 June	111	22	133
2023 May	113	28	141
2023 April	94	25	119
2023 March	157	37	194
2023 February	123	30	153
2023 January	96	25	121
2022 December	86	22	108
2022 November	152	39	191
2022 October	118	34	152
2022 September	113	45	158
2022 August	122	58	180
2022 July	112	50	162
2022 June	111	40	151
2022 May	108	53	161
2022 April	91	29	120
2022 March	95	46	141
2022 February	75	35	110
2022 January	76	30	106
2021 December	67	40	107
2021 November	89	38	127
2021 October	67	44	111
2021 September	85	32	117
2021 August	77	25	102
2021 July	41	32	73
2021 June	80	24	104
2021 May	123	25	148
2021 April	231	79	310
2021 March	219	16	235
2021 February	143	23	166
2021 January	114	33	147
2020 December	127	8	135
2020 November	106	29	135
2020 October	87	19	106
2020 September	129	40	169
2020 August	114	19	133
2020 July	149	27	176
2020 June	150	22	172
2020 May	156	39	195
2020 April	129	15	144
2020 March	102	22	124
2020 February	109	23	132
2020 January	128	29	157
2019 December	118	28	146
2019 November	126	22	148
2019 October	130	34	164
2019 September	130	35	165
2019 August	234	32	266
2019 July	263	29	292
2019 June	300	34	334
2019 May	305	26	331
2019 April	351	59	410
2019 March	361	27	388
2019 February	317	12	329
2019 January	317	24	341
2018 December	179	8	187
2018 November	65	0	65
2018 October	104	11	115
2018 September	101	12	113
2018 August	143	37	180
2018 July	186	20	206
2018 June	89	18	107
2018 May	88	24	112
2018 April	119	29	148
2018 March	120	21	141
2018 February	73	10	83
2018 January	106	27	133
2017 December	161	16	177
2017 November	72	26	98
2017 October	38	25	63
2017 September	35	22	57
2017 August	38	17	55
2017 July	36	14	50
2017 June	56	25	81
2017 May	229	16	245
2017 April	91	25	116
2017 March	14	18	32
2017 February	18	11	29
2017 January	21	3	24
2016 December	26	15	41
2016 November	38	18	56
2016 October	56	20	76
2016 September	103	9	112
2016 August	48	7	55
2016 July	10	12	22
2016 June	3	9	12
2016 May	22	13	35
2016 April	121	2	123
2016 March	173	20	193
2016 February	171	27	198
2016 January	171	18	189
2015 December	156	14	170
2015 November	149	20	169
2015 October	179	17	196
2015 September	147	11	158
2015 August	185	8	193
2015 July	222	7	229
2015 June	149	6	155
2015 May	178	8	186
2015 April	213	11	224
2015 March	267	7	274
2015 February	246	9	255
2015 January	168	11	179
2014 December	208	9	217
2014 November	174	5	179
2014 October	254	8	262
2014 September	210	16	226
2014 August	198	9	207
2014 July	169	12	181
2014 June	142	8	150
2014 May	148	10	158
2014 April	169	10	179
2014 March	257	12	269
2014 February	198	10	208
2014 January	207	10	217
2013 December	187	10	197
2013 November	146	14	160
2013 October	172	15	187
2013 September	118	16	134
2013 August	127	28	155
2013 July	134	22	156
2013 June	114	13	127
2013 May	104	12	116
2013 April	117	31	148
2013 March	96	36	132
2013 February	102	33	135
2013 January	91	19	110
2012 December	77	18	95
2012 November	82	19	101
2012 October	55	26	81
2012 September	23	22	45
2012 January	481	0	481

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