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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The process of weaning from invasive mechanical ventilation is one of the central axes of the intensivists&#8217; routine clinical practice&#44; which can account for up to 40&#37; of the overall time on invasive mechanical ventilation &#40;IMV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It consists of 2 main phases&#58; early detection of patients eligible to initiate it &#40;screening&#41;&#44; and confirmation test through the spontaneous breathing trial &#40;SBT&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">In recent years&#44; 2 new aspects have been developed&#58; risk stratification for extubation failure and the application of non-invasive respiratory support after extubation&#46; This new approach requires dealing with 4 aspects simultaneously &#40;stratification&#44; screening&#44; SBT&#44; and post-extubation support&#41;&#44; instead of the traditional approach of just 2 sequential phases&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">To determine the individual risk of failure&#44; multiple described factors exist &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The use of a complex model including all variables<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> allows for better risk sub-stratification and subgroup detection&#44; while a simple model with 3 variables only &#40;age&#44; chronic cardiac or pulmonary disease&#41; &#40;3&#41; is pragmatic and reduces the burden of clinical work&#46; It is still to be determined whether a 4-factor model&#44; adding prolonged mechanical ventilation &#40;&#62;7 days of IMV&#41; could be the optimal strategy in risk stratification&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Non-invasive ventilatory support after extubation&#44; either with facilitative or preventive intent&#44; should be individualized based on individual risk and the presence of specific risk factors&#44; given the differences in efficacy reported&#46; Our recommendation with preventive intent includes the use of a 24-h course of high-flow oxygen therapy &#40;HFOT&#41; in low-risk patients &#40;patients without any of the described risk factors&#41;&#44; in intermediate-risk patients &#40;&#8804;3 risk factors excluding obese&#44; hypercapnic patients after SBT&#41;&#44; the combination of non-invasive mechanical ventilation &#40;NIV&#41; plus HFOT for 48&#8239;h&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and in high-risk patients &#40;&#8805;4 risk factors&#44; obese or hypercapnic after SBT&#41;&#44; optimized NIV with gas conditioning at intermediate temperature &#40;29&#8239;&#176;C&#41; for 48&#8239;h and selection of the appropriate interface for conditioning&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Non-invasive ventilatory support with facilitative intent also requires introducing changes to screening and SBT&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The early detection of patients ready to start weaning from IMV is key to avoid any weaning delays&#46; The screening process requires updating for several reasons&#46; First&#44; current recommendations applied to low or intermediate risk patients may result in unnecessary weaning delays&#44; associated complications &#40;e&#46;g&#46;&#44; acquired delirium at the ICU setting&#41;&#44; and possible higher rate of failed SBT&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Second&#44; predicting SBT success using parameters such as rapid and shallow breathing index should not be confused with extubation success prediction&#46; Third&#44; too demanding non-respiratory screening criteria such as the use of noradrenaline at doses&#8239;&#60;&#8239;0&#46;1&#8239;mcg&#47;kg&#47;min<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a> and inadequate sedation protocols may contribute to delays and increase result heterogeneity&#46; Additionally&#44; regarding the use of inotropes&#44; no specific recommendations have been made despite being drugs that may be useful in transitioning to negative pressure spontaneous ventilation in patients with cardiac dysfunctions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fourth&#44; the assessment of pulmonary function recovery has shown limited advances until recently&#44; transitioning from PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#8239;&#62;&#8239;200 with PEEP&#8239;&#8804;&#8239;5&#8239;cm H2O and FiO<span class="elsevierStyleInf">2</span>&#8239;&#8804;&#8239;40&#37; to PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#8239;&#8805;&#8239;150 with PEEP&#8239;&#8804;&#8239;8 and FiO<span class="elsevierStyleInf">2</span>&#8239;&#8804;&#8239;40&#37; and finally to PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#8239;&#62;&#8239;180 with PEEP 10 and FiO<span class="elsevierStyleInf">2</span> 50&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Additionally&#44; non-invasive therapies after extubation &#40;whether preventive or facilitative&#41; reduce respiratory effort&#44; allowing changes to these screening parameters&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Diagnosis should be confirmed by analyzing performance during SBT&#44; with 30&#8239;min of pressure support application&#44; although the pressure range is still very wide &#40;from 5 to 8&#8239;cm H<span class="elsevierStyleInf">2</span>O&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Therefore&#44; the role of PEEP during SBT is still to be elucidated and is currently under study &#40;Clinicaltrials&#46;gov NCT 05526053&#41;&#46; Also&#44; epidemiological studies warn of the frequency of direct extubation without any confirmation tests being performed&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although this practice may shorten time on IMV&#44; its use should be limited to very patients at very low risk of experiencing extubation failure until this practice is standardized or times are shortened by optimizing screening and SBT&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It seems imperative to individualize SBT based on each patient&#8217;s individual risk&#44; screening&#44; and therapy after extubation&#44; rather than extubating without individualizing SBT or extubating specific subgroups after failed SBT to facilitative NIV&#44; such as selected patients with hypoxemic failure<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> or patients with COPD and hypercapnic failure&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We face the need for redefining the weaning process&#46; The application of non-invasive ventilatory support after extubation implies redefining terms such as reintubation&#44; as it may delay the onset of respiratory failure after extubation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> At the other end of the spectrum&#44; the problem of accelerating extubation is raised&#46; This is an excessively broad concept&#44; as it includes various scenarios&#58; aggressive screening without performing SBT&#44; risk stratification&#44; or prevention<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; aggressive screening with intolerable SBT and application of facilitative NIV<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#59; aggressive screening without performing SBT and application of facilitative NIV<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#59; aggressive screening&#44; tolerated conservative SBT with risk stratification and preventive HFOT&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> To date&#44; the latter is the only one of these approaches tested with a design that reduces subjectivity with demonstrated clinical benefits&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In medicine&#44; most diagnostic processes include screening and a confirmation test&#44; and weaning should comply to the usual rules of medical diagnostic practice&#46; Additionally&#44; the evolution of medicine towards personalization should include weaning with the detection of subgroups with different clinical behavior&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">Gonzalo Hern&#225;ndez declares personal fees and travel expenses from Fisher &#38; Paykel&#46;</p></span></span>"
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            2 => "Screening"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Proposal to individualize weaning considering individual risk stratification and post-extubation support application&#46; BMI&#44; body mass index&#59; HFOT&#44; high-flow oxygen therapy&#59; NIV&#44; non-invasive ventilation&#59; PEEP&#44; positive end-expiratory pressure&#59; PS&#44; pressure support&#59; SBT&#44; spontaneous breathing trial&#46; &#42;Aggressive screening<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#42;&#42;Conservative screening&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">FiO<span class="elsevierStyleInf">2</span>&#44; fraction of inspired oxygen&#59; MIP&#44; maximal inspiratory pressure&#59; P0&#46;1&#44; airway occlusion pressure in the first 0&#46;1&#8239;s&#59; PaO<span class="elsevierStyleInf">2</span>&#44; arterial oxygen pressure&#44; PEEP&#44; positive end-expiratory pressure&#59; RR&#44; respiratory rate&#59; RSBI&#44; Rapid Shallow Breathing Index&#59; TV&#44; tidal volume&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Current standard of screening</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#46; Subjective criteria&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Resolution or stabilization of the condition that prompted IMV&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Minimum level of continuous sedation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Respiratory rate&#8239;&#62;&#8239;6&#8239;bpm and &#8804;&#8239;35&#8239;bpm&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2&#46; Objective criteria&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Cardiovascular stability with a maximum of 0&#46;1&#8239;mcg&#47;kg&#47;min of noradrenaline&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Hemoglobin&#8239;&#62;&#8239;7&#8239;g&#47;dL&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Ion levels within range&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Temperature within the range of 36&#8211;38&#46;5&#8239;&#176;C&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Early predictive criteria of tolerance to SBT &#40;RSBI&#44; P0&#46;1&#44; MIP&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#8239;&#8805;&#8239;150 with PEEP&#8239;&#8804;&#8239;8&#8239;cm H<span class="elsevierStyleInf">2</span>O&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Intolerance to SBT</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#46; Subjective criteria&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Decreased level of consciousness&#44; profuse sweating&#44; cyanosis&#44; increased respiratory effort&#44; and dyspnea&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2&#46; Objective criteria&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; PO<span class="elsevierStyleInf">2</span>&#8239;&#8804;&#8239;50&#8211;60&#8239;mm Hg with FiO<span class="elsevierStyleInf">2</span>&#8239;&#8805;&#8239;0&#46;5 or SpO<span class="elsevierStyleInf">2</span>&#8239;&#60;&#8239;90&#37;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; PCO<span class="elsevierStyleInf">2</span>&#8239;&#8805;&#8239;50&#8239;mm Hg or increase&#8239;&#8805;&#8239;8&#8239;mm Hg from baseline&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; pH&#8239;&#60;&#8239;7&#46;32 or decrease of &#8805;0&#46;07&#8239;pH units from baseline&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; RR&#47;TV &#40;RSBI&#41;&#8239;&#62;&#8239;105 breaths&#47;min&#47;L&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Respiratory rate&#8239;&#8805;&#8239;35&#8239;bpm or 50&#37; increase from previous&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Heart rate&#8239;&#8805;&#8239;140&#8239;bpm&#44; 20&#37; increase&#44; or arrhythmia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Systolic blood pressure &#60; 90&#8239;mm Hg or &#8805;180&#8239;mm Hg or 20&#37; increase&#46;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">APACHE II&#44; Acute Physiology and Chronic Health Evaluation&#59; BMI&#44; body mass index&#59; COPD&#44; chronic obstructive pulmonary disease&#59; IMV&#44; invasive mechanical ventilation&#46; SBT&#44; spontaneous breathing trial&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3-factor model&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">11-factor model&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Age&#8239;&#62;&#8239;65 years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Age&#8239;&#62;&#8239;65 years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Chronic heart disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Heart failure as the reason for intubation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Chronic respiratory disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Moderate-to-severe COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">APACHE II score&#8239;&#62;&#8239;12 on extubation day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">BMI&#8239;&#62;&#8239;30&#8239;kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Secretion aspiration&#8239;&#62;&#8239;2 times within the 8&#8239;h prior to extubation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Charlson comorbidity index&#8239;&#62;&#8239;1 &#40;includes respiratory and cardiac comorbidities&#41;&nbsp;\t\t\t\t\t\t\n
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Weaning from mechanical ventilation: Speed it up and make it safe
Desconexión de la ventilación mecánica invasiva: búscala antes, extuba mejor
Patricia Rodrigueza, Gonzalo Hernándeza,b,c,
Corresponding author
ghernandezm@telefonica.net

Corresponding author.
a Complejo Hospitalario Universitario de Toledo, Toledo, Spain
b Grupo de Investigación en Disfunción y Fallo Orgánico en la Agresión (IdiPAZ), Madrid, Spain
c Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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This new approach requires dealing with 4 aspects simultaneously &#40;stratification&#44; screening&#44; SBT&#44; and post-extubation support&#41;&#44; instead of the traditional approach of just 2 sequential phases&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">To determine the individual risk of failure&#44; multiple described factors exist &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The use of a complex model including all variables<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> allows for better risk sub-stratification and subgroup detection&#44; while a simple model with 3 variables only &#40;age&#44; chronic cardiac or pulmonary disease&#41; &#40;3&#41; is pragmatic and reduces the burden of clinical work&#46; It is still to be determined whether a 4-factor model&#44; adding prolonged mechanical ventilation &#40;&#62;7 days of IMV&#41; could be the optimal strategy in risk stratification&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Non-invasive ventilatory support after extubation&#44; either with facilitative or preventive intent&#44; should be individualized based on individual risk and the presence of specific risk factors&#44; given the differences in efficacy reported&#46; Our recommendation with preventive intent includes the use of a 24-h course of high-flow oxygen therapy &#40;HFOT&#41; in low-risk patients &#40;patients without any of the described risk factors&#41;&#44; in intermediate-risk patients &#40;&#8804;3 risk factors excluding obese&#44; hypercapnic patients after SBT&#41;&#44; the combination of non-invasive mechanical ventilation &#40;NIV&#41; plus HFOT for 48&#8239;h&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and in high-risk patients &#40;&#8805;4 risk factors&#44; obese or hypercapnic after SBT&#41;&#44; optimized NIV with gas conditioning at intermediate temperature &#40;29&#8239;&#176;C&#41; for 48&#8239;h and selection of the appropriate interface for conditioning&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Non-invasive ventilatory support with facilitative intent also requires introducing changes to screening and SBT&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The early detection of patients ready to start weaning from IMV is key to avoid any weaning delays&#46; The screening process requires updating for several reasons&#46; First&#44; current recommendations applied to low or intermediate risk patients may result in unnecessary weaning delays&#44; associated complications &#40;e&#46;g&#46;&#44; acquired delirium at the ICU setting&#41;&#44; and possible higher rate of failed SBT&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Second&#44; predicting SBT success using parameters such as rapid and shallow breathing index should not be confused with extubation success prediction&#46; Third&#44; too demanding non-respiratory screening criteria such as the use of noradrenaline at doses&#8239;&#60;&#8239;0&#46;1&#8239;mcg&#47;kg&#47;min<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a> and inadequate sedation protocols may contribute to delays and increase result heterogeneity&#46; Additionally&#44; regarding the use of inotropes&#44; no specific recommendations have been made despite being drugs that may be useful in transitioning to negative pressure spontaneous ventilation in patients with cardiac dysfunctions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fourth&#44; the assessment of pulmonary function recovery has shown limited advances until recently&#44; transitioning from PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#8239;&#62;&#8239;200 with PEEP&#8239;&#8804;&#8239;5&#8239;cm H2O and FiO<span class="elsevierStyleInf">2</span>&#8239;&#8804;&#8239;40&#37; to PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#8239;&#8805;&#8239;150 with PEEP&#8239;&#8804;&#8239;8 and FiO<span class="elsevierStyleInf">2</span>&#8239;&#8804;&#8239;40&#37; and finally to PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#8239;&#62;&#8239;180 with PEEP 10 and FiO<span class="elsevierStyleInf">2</span> 50&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Additionally&#44; non-invasive therapies after extubation &#40;whether preventive or facilitative&#41; reduce respiratory effort&#44; allowing changes to these screening parameters&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Diagnosis should be confirmed by analyzing performance during SBT&#44; with 30&#8239;min of pressure support application&#44; although the pressure range is still very wide &#40;from 5 to 8&#8239;cm H<span class="elsevierStyleInf">2</span>O&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Therefore&#44; the role of PEEP during SBT is still to be elucidated and is currently under study &#40;Clinicaltrials&#46;gov NCT 05526053&#41;&#46; Also&#44; epidemiological studies warn of the frequency of direct extubation without any confirmation tests being performed&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although this practice may shorten time on IMV&#44; its use should be limited to very patients at very low risk of experiencing extubation failure until this practice is standardized or times are shortened by optimizing screening and SBT&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It seems imperative to individualize SBT based on each patient&#8217;s individual risk&#44; screening&#44; and therapy after extubation&#44; rather than extubating without individualizing SBT or extubating specific subgroups after failed SBT to facilitative NIV&#44; such as selected patients with hypoxemic failure<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> or patients with COPD and hypercapnic failure&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We face the need for redefining the weaning process&#46; The application of non-invasive ventilatory support after extubation implies redefining terms such as reintubation&#44; as it may delay the onset of respiratory failure after extubation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> At the other end of the spectrum&#44; the problem of accelerating extubation is raised&#46; This is an excessively broad concept&#44; as it includes various scenarios&#58; aggressive screening without performing SBT&#44; risk stratification&#44; or prevention<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; aggressive screening with intolerable SBT and application of facilitative NIV<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#59; aggressive screening without performing SBT and application of facilitative NIV<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#59; aggressive screening&#44; tolerated conservative SBT with risk stratification and preventive HFOT&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> To date&#44; the latter is the only one of these approaches tested with a design that reduces subjectivity with demonstrated clinical benefits&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In medicine&#44; most diagnostic processes include screening and a confirmation test&#44; and weaning should comply to the usual rules of medical diagnostic practice&#46; Additionally&#44; the evolution of medicine towards personalization should include weaning with the detection of subgroups with different clinical behavior&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">Gonzalo Hern&#225;ndez declares personal fees and travel expenses from Fisher &#38; 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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Resolution or stabilization of the condition that prompted IMV&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Minimum level of continuous sedation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Respiratory rate&#8239;&#62;&#8239;6&#8239;bpm and &#8804;&#8239;35&#8239;bpm&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2&#46; Objective criteria&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Cardiovascular stability with a maximum of 0&#46;1&#8239;mcg&#47;kg&#47;min of noradrenaline&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Hemoglobin&#8239;&#62;&#8239;7&#8239;g&#47;dL&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Ion levels within range&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Temperature within the range of 36&#8211;38&#46;5&#8239;&#176;C&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Early predictive criteria of tolerance to SBT &#40;RSBI&#44; P0&#46;1&#44; MIP&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#8239;&#8805;&#8239;150 with PEEP&#8239;&#8804;&#8239;8&#8239;cm H<span class="elsevierStyleInf">2</span>O&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Intolerance to SBT</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#46; Subjective criteria&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Decreased level of consciousness&#44; profuse sweating&#44; cyanosis&#44; increased respiratory effort&#44; and dyspnea&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2&#46; Objective criteria&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; PO<span class="elsevierStyleInf">2</span>&#8239;&#8804;&#8239;50&#8211;60&#8239;mm Hg with FiO<span class="elsevierStyleInf">2</span>&#8239;&#8805;&#8239;0&#46;5 or SpO<span class="elsevierStyleInf">2</span>&#8239;&#60;&#8239;90&#37;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; PCO<span class="elsevierStyleInf">2</span>&#8239;&#8805;&#8239;50&#8239;mm Hg or increase&#8239;&#8805;&#8239;8&#8239;mm Hg from baseline&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; pH&#8239;&#60;&#8239;7&#46;32 or decrease of &#8805;0&#46;07&#8239;pH units from baseline&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; RR&#47;TV &#40;RSBI&#41;&#8239;&#62;&#8239;105 breaths&#47;min&#47;L&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Respiratory rate&#8239;&#8805;&#8239;35&#8239;bpm or 50&#37; increase from previous&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Heart rate&#8239;&#8805;&#8239;140&#8239;bpm&#44; 20&#37; increase&#44; or arrhythmia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Systolic blood pressure &#60; 90&#8239;mm Hg or &#8805;180&#8239;mm Hg or 20&#37; increase&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Current standard of the weaning process&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">APACHE II&#44; Acute Physiology and Chronic Health Evaluation&#59; BMI&#44; body mass index&#59; COPD&#44; chronic obstructive pulmonary disease&#59; IMV&#44; invasive mechanical ventilation&#46; SBT&#44; spontaneous breathing trial&#46;</p>"
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                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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3-factor model&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">11-factor model&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&#8239;&#62;&#8239;65 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&#8239;&#62;&#8239;65 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart failure as the reason for intubation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic respiratory disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate-to-severe COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">APACHE II score&#8239;&#62;&#8239;12 on extubation day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI&#8239;&#62;&#8239;30&#8239;kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secretion aspiration&#8239;&#62;&#8239;2 times within the 8&#8239;h prior to extubation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Charlson comorbidity index&#8239;&#62;&#8239;1 &#40;includes respiratory and cardiac comorbidities&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Upper airway-related risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;1 failed SBT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Development of hypercapnia at the end of SBT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;7 days on IMV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Risk factors associated with failed extubation procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilaci&#243;n mec&#225;nica en Espa&#241;a&#44; 1998-2016&#58; cambios en la desconexi&#243;n de la ventilaci&#243;n mec&#225;nica"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "O&#46;P&#46; Frutos-Vivar"
                            1 => "A&#46; Muriel"
                            2 => "J&#46; Mancebo"
                            3 => "A&#46; Garc&#237;a-Jim&#233;nez"
                            4 => "R&#46; de Pablo"
                            5 => "M&#46; Valledor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medine.2022.04.009"
                      "Revista" => array:7 [
                        "tituloSerie" => "Med Intensiva&#46;"
                        "fecha" => "2022"
                        "volumen" => "46"
                        "numero" => "7"
                        "paginaInicial" => "363"
                        "paginaFinal" => "371"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35570188"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            1 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of postextubation noninvasive ventilation with active humidification vs high-flow nasal cannula on reintubation in patients at very high risk for extubation failure&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Herna&#769;ndez"
                            1 => "I&#46; Paredes"
                            2 => "F&#46; Moran"
                            3 => "M&#46; Buj"
                            4 => "L&#46; Colinas"
                            5 => "M&#46;L&#46; Rodr&#237;guez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-022-06919-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med&#46;"
                        "fecha" => "2022"
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Original language: English
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