Scientific Letter
Weaning from mechanical ventilation in COVID-19 patients
Análisis del proceso de desconexión de la ventilación mecánica en pacientes con COVID-19
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Abbreviations: ICU, Intensive Care Unit; COVID-19, Coronavirus disease 2019; ICC, International Consensus Conference; WIND, Weaning according to a New Definition.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Several studies<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> have concluded that patients requiring invasive ventilatory support due to acute respiratory distress syndrome (ARDS) associated with coronavirus disease 2019 (COVID-19) present a course and prognosis different from those seen in other disease conditions.</p><p id="par0010" class="elsevierStylePara elsevierViewall">However, few studies<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> have specifically analyzed the mechanical ventilation (MV) weaning process in COVID-19.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The present scientific letter describes the characteristics of this weaning process in a population of patients with ARDS secondary to COVID-19 in our setting, and analyzes the clinical outcomes according to the WIND (Weaning according to a New Definition)<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and ICC (International Consensus Conference) classifications.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">post hoc</span> analysis was performed of patients enrolled in a prospective clinical trial from March to September 2021. The study, which adhered to the CONSORT criteria,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> was registered in ClinicalTrials.gov (<a href="ctgov:NCT05012267">NCT05012267</a>). Patients over 18 years of age that met the following criteria were included: ARDS secondary to COVID-19 defined according to the Berlin specifications<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and with an indication for prone positioning based on the criteria of the PROSEVA trial.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The patients were randomized to a prolonged (48 h) or short-prone position strategy (>16 h). A retrospective observational study of the aspects related to the weaning process was subsequently carried out.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Continuous variables were reported as the mean and standard deviation (SD) or as the median and interquartile range (IQR), while categorical variables were reported as frequencies and percentages. Normal data distribution was analyzed using the Kolmogorov-Smirnov test, and the differences between the weaning groups were analyzed with the Student <span class="elsevierStyleItalic">t</span>-test or analysis of variance (ANOVA) for continuous variables and Pearson’s chi-square test or the Kruskal-Wallis test for categorical variables. The survival analysis considered mortality as the primary endpoint. The Kaplan-Meier method was used to plot the survival curves, and the log-rank test was applied for comparison of the curves.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Statistical significance was considered for <span class="elsevierStyleItalic">p</span> ≤ 0.05. The SPSS version 25.0 statistical package (IBM Corp., Armonk, NY, USA) was used throughout.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During the study period, 223 patients were admitted to the Intensive Care Unit (ICU), and of these, 118 presented COVID-19 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A total of 60 patients were included in the study.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">All patients were classified according to the WIND criteria as follows: group 0, <span class="elsevierStyleItalic">n</span> = 11 (18%), group 1, <span class="elsevierStyleItalic">n</span> = 30 (50%), group 2, <span class="elsevierStyleItalic">n</span> = 9 (15%) and group 3, <span class="elsevierStyleItalic">n</span> = 10 (17%). Only 37 patients (62%) could be classified according to the ICC criteria (Supplementary Tables 1 and 2): simple weaning, <span class="elsevierStyleItalic">n</span> = 26 patients (70%), difficult weaning, <span class="elsevierStyleItalic">n</span> = 5 patients (14%), and prolonged weaning, <span class="elsevierStyleItalic">n</span> = 6 (16%). The baseline characteristics and initial ventilatory parameters of the global population and of the different WIND groups, as well as the clinical outcomes, are reported in Supplementary Table 3. The concordance analysis of the results between the two classifications is described in Supplementary Table 1. Of the 23 patients not classifiable according to the ICC criteria, 11 (47%) were included in group 0, as no MV weaning attempt was made. In contrast, the remaining 12 (52%) were included in group 1 (<span class="elsevierStyleItalic">n</span> = 4), group 2 (<span class="elsevierStyleItalic">n</span> = 4) and group 3 (<span class="elsevierStyleItalic">n</span> = 4). In these cases, classification according to the ICC criteria was not possible due to death occurring before extubation (<span class="elsevierStyleItalic">n</span> = 5) or tracheotomy performed before starting the weaning process (<span class="elsevierStyleItalic">n</span> = 7).</p><p id="par0045" class="elsevierStylePara elsevierViewall">During the study period, 49 patients (82%) experienced some MV weaning attempt. The first attempt was a spontaneous breathing trial in 35 patients (71%), direct extubation in four (9%), and a spontaneous breathing trial over tracheotomy in 10 (20%). The first weaning attempt proved successful in 35/49 cases (71%).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Among all the included patients, successful weaning occurred in 37 cases (62%), while reintubation during admission to the ICU was recorded in 8 (21%). The mean time to reintubation was one day. The patients requiring reintubation presented a mortality rate of 25%, versus 0% among the patients not requiring reintubation.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Tracheotomy was performed in 22 patients (37%), with a median time from orotracheal intubation to tracheotomy of 11 days (range 8–14). Of the patients subjected to tracheotomy, 9 died (41%), while the rest could be successfully weaned.</p><p id="par0060" class="elsevierStylePara elsevierViewall">On examining the clinical outcomes, both classifications showed increased complexity of the weaning process to be associated with longer ICU and hospital stays, and longer times under sedation and neuromuscular block. However, a correlation to mortality was only observed in the case of the WIND classification (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> and Supplementary Tables 3 and 4).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">This secondary analysis of patients with ARDS as a consequence of COVID-19 offers epidemiological information on the invasive MV weaning process not previously analyzed in our setting. The main findings can be summarized as follows: 1) Almost 20% of the patients did not experience a first MV weaning attempt; 2) Sixty-two percent of the patients were extubated, and one out of every 5 required reintubation; 3) Tracheotomy was performed in 37% of the cases; 4) The ICC classification was unable to analyze almost 40% of the patients, with no differences in mortality between its groups; 5) The WIND classification was able to analyze all the patients in the sample, stratifying them into groups characterized by a gradual increase in morbidity and mortality.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The present study has several limitations, including its single-center design and small sample size. Although the fact that the study was carried out in a single center limits the heterogeneity of the weaning process, the latter was not carried out following a strict protocol. Lastly, given the objectives of the study, no search was made for independent factors associated with the clinical outcomes.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">The present study has received no financial support.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Statement on generative AI and AI assisted technologies in the drafting process</span><p id="par0080" class="elsevierStylePara elsevierViewall">No artificial intelligence tool was used in the preparation of this work.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Statement on generative AI and AI assisted technologies in the drafting process" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:2 [ "identificador" => "xack741405" "titulo" => "Acknowledgements" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0100" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0025" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1522 "Ancho" => 2925 "Tamanyo" => 264700 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Study flow chart according to the CONSORT criteria. Abbreviations: ICU, Intensive Care Unit; COVID-19, Coronavirus disease 2019; ICC, International Consensus Conference; WIND, Weaning according to a New Definition.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1009 "Ancho" => 1675 "Tamanyo" => 47098 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Kaplan-Meier survival curves for the different weaning groups according to the WIND classification. Comparison with the log-rank test (<span class="elsevierStyleItalic">p</span> < 0.001).</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.doc" "ficheroTamanyo" => 135680 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics and outcomes of invasively ventilated patients with COVID-19 in Argentina (SATICOVID): a prospective, multi-center cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Estenssoro" 1 => "C.I. Loudet" 2 => "F.G. Rios" 3 => "V.S. Kanoore Edul" 4 => "G. Plotnikow" 5 => "M. 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