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Mirzaali J, Vakili M, Khoddam H. The Value of Persian Weaning Tool in Prediction of Patients’ Weaning Outcome Compared with Physician- Directed Approach: A Diagnostic Accuracy Study. J Res Dev Nurs Midw 2020; 17 (1) :1-11
URL: http://nmj.goums.ac.ir/article-1-1181-en.html
1- School of nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran.
2- Department of Biostatistics, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran.
3- Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran. , Khoddam@Goums.ac.ir
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Abstract

Background: One of the important criteria in patients receiving artificial respiration is the time of weaning from the mechanical ventilator. As physician’s decision might be somehow subjective, several tools have been suggested for prediction of the time of weaning more objectively. This study aimed to determine the predictive value of Persian Weaning Tool (PWT) compared with Physician- directed approach as the gold standard.
Methods: This diagnostic accuracy study was done in 2016-2017 in Two Medical and Educational Centers of Gorgan, Iran.  97 admitted patients in intensive care units, under mechanical ventilation were evaluated. The patients were recruited into the study by a convenience sampling method and evaluated for readiness to wean using two approaches (physician’s decision and using PWT). Successful weaning was considered as the ability of patient to breathe spontaneously during the first 48 hours after weaning. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR), as well as the agreement (kappa coefficient) between the two approaches, were calculated. In addition, to compare the differences between variables in two groups, chi-Square, T and man-Whitney tests were used. All analyses were performed using SPSS software ver.16, and MedCalc program ver.13. P<0.05 was considered as statistically significant.
Results: Most patients (64.9%) were men. The mean age, duration of hospital admission, and duration of mechanical ventilation of the participants were 46.49±18.15 years, 67.11±7.14 days, and 31.5±2.5 days, respectively. Weaning was successful in 87.6% of the patients. PWT had a significant agreement with the physician’s choice (kappa coefficient=0.637, P<0.001) with sensitivity, specificity, PPV, NPV, PLR, and NLR of 100%, 50%, 93.4%, 100%, 2, and 0, respectively. The cut-off level of 53 was considered as the best point to improve the diagnostic accuracy to 92.94%, 75%, 96.3%, 60%, 3.72, and 0.094, respectively.
Conclusions: Findings showed that PWT is an accurate tool for predicting the readiness of patients for weaning objectively. This tool can be used as a complementary approach by physicians and other care providers in intensive care units.
Keywords: Mechanical Ventilation weaning; Predictive Value of Tests; Persian, Tool
10.29252/jgbfnm.17.1.1

Introduction

Mechanical  ventilation  is  one  of  the  main  components  of  resuscitation  and  a  fundamental medical  device  for  critically  ill  patients  with  respiratory  insufficiency   requiring  artificial respiration,  especially  in  patients  admitted  to  Intensive  Care  Units  (ICUs) (1).  Mechanical ventilators define and adjust the patient’s breathing pattern using actuators, sensors, and digital electronics and hence increase patients’ survival (2). However, using a mechanical ventilator can cause  several  complications  for  the  patients,  such  as  ventilator-induced  lung  injury,  ventilator-associated pneumonia, poor nutrition, neuromyopathy, and tracheal complications (3). Therefore, it  is  important  to  appropriately  select  patients  for  using  the  mechanical  ventilator  and  for weaning the patients from the ventilator to reduce patients’ costs and complications (4).Weaning  the  patients  from  the  mechanical  ventilator  is  the  gradual  process  of  decreasing ventilator support, which takes about 40%of the duration of mechanical ventilation process (5). The  decision  of  weaning  process  is  mainly  made  and  performed  by  the  physician,  according  to the  suggested  criteria  and  clinical  decision  support  systems (6,  7).  But  physician-directed weaning  requiresfrequent  visits  by  physicians  that  occupy  physicians’  time;  therefore,  some have  suggested  related  protocols  to  be  used  by  nurses  or  respiratory  therapist  in  order  to  save physicians’ time and enable physicians to focus on other duties that cannot be performed by non-physicians (8, 9). Accordingly, different scoring systems have been suggested to predict success and  timely  weaning  of  patients  from  the  ventilator,  such  as  the  Acute  Physiology  and  Chronic Health  Evaluation  II  (APACHE  II)  and  sequential  organfailure  assessment  (SOFA)  scores, Burn’s Wean Assessment Program  (BWAP), and Morganroth’s scale; nonetheless, each of the suggested scores has its own limitations (10). Because of the limitations of the suggested scoring systems, an Iranian assessment tool has been developed by Irajpour and colleagues, entitled “Persian Weaning Tool (PWT)”, in order to be used  for  on  time  weaning  of  the  patient  from  the  mechanical  ventilator (11).  Bazrafshan and colleagues have shown that PWT has acceptable validity and inter-rater reliability, in comparison with BWAP and Morganroth’s scale (12).  Beside  the  validity  and  reliability,  it  is  important  to evaluate  whether  the  diagnostic  power  of  this  tool  is  as  accurate  as  the  physician-directed diagnosis. However, as far as we are concerned, to date, the diagnostic accuracy of this tool has not yet been evaluated.  Therefore,  in  this  study,  we  aimed  to  determine  the  predictive  value  of PWT  and  factors  affecting  patients’  outcomes.  For this purpose, we compared the patients’ outcome of weaning from ventilator between physician-directed and PWT-directed approach.

Methods                                                                                                                              

In the present diagnostic accuracy study, 97 patients admitted to ICU under mechanical ventilation were evaluated. The study was performed at 5th Azar and Shahid Sayyad Shirazi Hospitals, the two medical and educational centers of Golestan University of Medical Sciences, Gorgan, Iran with 38 ICU beds (27 and 11 ICU beds, respectively). The study duration was from November 2016 to May 2017.  The study’s protocol was approved by the Ethics Committee of Golestan University of Medical Sciences (code: 940430125).
The sample size was calculated using the below formula. Based on a pilot study on 22 patients admitted to the ICUs of the same hospitals, considering the sensitivity of PWT at 90%, the study’s confidence interval of 95%, and the accuracy of 0.06, 97 patients were studied.
Accordingly, every patient who met the study’s inclusion criteria were included in the study by the convenience sampling method. The inclusion criteria of this study were considered as patients’ age range from 18 to 80 years, being under mechanical ventilation for at least 48 hours and less than 3 weeks, and having Endotracheal Tube (ETT). The patients with a history of chronic respiratory, cardiac, neuromuscular, or mental diseases, signs or history of sinusitis, and having received sedative drugs recently were excluded. Before enrollment of the patients into the study, the design and objectives of the study were explained to their caregivers and written informed consent was obtained from their families for the participation of their patients in the study. Any patient with accidental extubation was excluded from the study.
The ventilators that were used included Extended Air Liquid Medical Systems (made in France) and Hamilton Medical AG, C2 (made in Switzerland). The researcher recorded patients’ age, sex, duration of hospital admission and mechanical ventilation, as well as the results of the physician’s assessment for weaning, the patients’ outcomes, and completed the PWT questionnaire. The patients who were recruited into the study were considered by the physician for weaning preparedness. The physician-based criteria for readiness of the patients for weaning from the mechanical ventilation included (13): resolution or improvement of the underlying disease, for which mechanical ventilation was initiated, no fever, arterial oxygen saturation (O2 Sat.) >90%, while receiving oxygen, Fio2 ≤0.4, positive end-expiratory pressure (PEEP) <8 cmH2O, hemodynamic stability without vasopressor requirement, ability to breathe spontaneously according to the results of the spontaneous breathing test (SBT), being arousable, Glasgow Coma Scale (GCS) ≥13, and PH >7.2. If the patient met these criteria, before initiating the process of weaning from the mechanical ventilator, all the patients were ventilated by pressure support ventilation (PSV) of 8-10 cmH2O and PEEP of 5 cmH2O, and the frequency/tidal volume ratio (f/Vt) was measured in patients before SBT. Then, spontaneous breathing was tested for 2 hours, and the patient’s tolerance was evaluated during this period by the physician. If the patient was stable during this test, he/she was extubated and the weaning was considered as successful. SBT was considered as negative, if any of the following criteria was found during the test: reduced O2 saturation to <95%, reduced arterial O2 pressure. to <60 mmHg, increased carbon dioxide (CO2) to >50 mmHg, reduced PH to <7.33 or reduction of >0.07 units in PH, respiratory rate (RR) >38 per minute or more than 50% increase during 5 minutes, heart rate (HR) >140 beats/min, systolic blood pressure >180 or <90 mmHg, agitation, disorientation, or reduced consciousness. Weaning was considered as unsuccessful, if SBT was negative, the patient required re-intubation, or expired during the first 48 hours after extubating. During this process, the information required by PWT was also recorded by the researcher simultaneously.
PWT is a tool that assesses patients’ conditions with 26 items in three domains, including respiratory status (9 items), cardiovascular status (4 items), and general condition (13 items) of the patients. It is scored by 1 (for critical patients’ condition, in which the patient needs immediate intervention), 2 (when the patient needs routine care), 3 or 4 (for appropriate patients’ condition), and not applicable (in some items). The tool has five 2-point items, nineteen 3-point items and two 4-points items, resulting in a total score of 26-75 (11).
Decision about the weaning process was made by a single physician for all the patients included in this study. The researcher assessed all the admitted patients in ICU on a daily basis, irrespective of their weaning process, and the physician was unaware of the results of PWT. Finally, the results of weaning (successful or unsuccessful) were compared with the information collected using PWT to calculate the power of PWT for accurate prediction of the patients’ weaning from the mechanical ventilator.
For describing the data, frequency tables were used. All the statistical analyses were performed using the statistical software IBM SPSS Statistics for Windows, version 16 (SPSS Inc., Chicago, Ill., USA) and MedCalc version 13 software. For the numeric variables between the two groups (with successful or unsuccessful weaning), first the normal distribution of the data was tested by Shapiro Wilk test. The numeric data were described by mean and standard deviation (SD) and compared between the groups using independent samples t test or Mann Whitney U test, whenever the data did not have a normal distribution. P<0.05 was considered as statistically significant. The categorical variables were compared between the groups using the Chi-square test. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of PWT assessment were calculated by comparing the results with the physician’s decision. Also, the agreement (kappa coefficient) between the two approaches was calculated. The area under the curve (AUC) of receiver operating characteristic (ROC) curve was calculated for suggestion of the best cut-off point for PWT.

Results

In this study, 97 patients (63 men) with an age range of 17-78 years, duration of hospitalization between 3-32 days (11.67±7.14) and mechanical ventilation between 3-13 days (5.31±2.5) were studied.
Evaluation of the patients’ consciousness level and physiological measurements during the two-hour period of SBT showed they could tolerate spontaneous breathing and remained stable (table 1).
 
 
Table 1. Description of patients’ clinical parameters before deciding for weaning
Measurements Number Mean (SD) Range
Glasgow Coma Scale 97 14.01 (0.97) 11-15
Respiratory rate (bmp) 97 12.4 (3.63) 7-26
Heart rate (bmp) 97 83.16 (11.68) 55-99
Temperature 9 (°C) 97 37.16 (0.54) 36.0-38.1
Systolic blood pressure (mmHg) 97 111.97 (14.98) 80-130
Diastolic blood pressure (mmHg) 97 66 (6.69) 60-90
O2 saturation (%) 97 97.14 (2.21) 92-100
PH 97 7.40 (0.05) 7.30-7.50
 
Based on the findings, 86 (87.6%) patients had a successful weaning and 12 patients (12.4%) had an unsuccessful weaning. Demographic and clinical variables were compared between the groups with successful and unsuccessful weaning, the results of which are presented in table 1. As shown in the table, weaning rate was not different according to the patients’ sex (P value=0.60), the underlying disease (for which mechanical ventilation was initiated) (P value=0.37), and the cause of admission (including multiple trauma), P value =0.97; (table 1). Comparing the values of variables between the groups with successful and unsuccessful weaning showed a significant difference in the median of GCS (P value=0.008), duration of hospital admission (P value=0.040), ventilation (P value =0.008), and the mean of PWT score (P value=0.001) (table 2).
Table 2. The weaning success rate based on patients’ demographic and clinical characteristics
Variable Category Total Successful Unsuccessful
Sex, No. (%) Female 34 (35.05) 29 (34.1) 5 (41.7)
Male 63 (64.95) 56 (65.9) 7 (58.3)
Underlying disease, No. (%) Cardiopulmonary 9 (9.3) 7 (8.2) 2 (16.7)
Reduced consciousness 10 (10.3) 8 (9.4) 2 (16.7)
Multiple trauma 48 (49.5) 42 (49.4) 6 (50)
Other (cancer, surgery, etc.) 30 (30.9) 28 (32.9) 2 (16.7)
Reason for admission, No. (%) Multiple trauma 48 (49.5) 42 (43.3) 6 (6.2)
Other diagnoses 49 (50.5) 43 (44.3) 6 (6.2)
Age (years), Mean ± SD 48.42 ± 18.61 56.83 ±12.66
Duration of hospital admission (days), Mean ± SD 11.23±6.73 14.75±6.89
Duration of ventilation (days), Mean ± SD 7.08±2.71 5.07±2.41
Glasgow coma Scale, Mean ± SD 14.10±0.90 13.33±0.88
Oxygen saturation (%), Mean ± SD 97.17±2.20 96.91±2.31
Systolic blood pressure (mmHg), Mean ± SD 111.75±15.03 113.50±15.15
Diastolic blood pressure (mmHg), Mean ± SD 66.02±6.73 65.83±6.68
Serum hemoglobin level (mg/dl), Mean ± SD 12.43±1.05 12.79±1.70
PWT score, Mean ± SD 48.42±18.61 50.58 ±2.90
In addition, the percentage of successful weaning cases predicted using the physician-directed method (87.6%) and PWT (93.8%) were significantly different (P value=0.001). Comparing the results of the PWT assessment with the patients’ outcomes showed that using PWT could lead to diagnosis of all successful cases accurately with a sensitivity of 100%, but it could lead to diagnosis of only half of the cases with unsuccessful weaning, which showed a specificity of 50% for PWT. Six of the patients considered as might have successfully weaned by PWT, had unsuccessful results, indicating PPV of 93.4% and all of the patients evaluated as unsuccessful by PWT had ultimately unsuccessful weaning, indicating NPV of 100%. PLR and NLR of PWT were 2 and 9. Kappa statistic of PWT was 0.637 (P<0.001). All in all, PWT had a diagnostic accuracy of 93.8%. Based on the results of ROC curve, the best cut-off was considered at 53, which increases the sensitivity, specificity, PPV, NPV, PLR, and NLR to 92.94%, 75%, 96.3%, 60%, 3.72 and 0.094, respectively (figure 1).






 Figure 1. AUC of ROC curve for the best cut-off point of Persian Weaning Tool

Discussion

Based  on  the  findings,  87.6%  of  the  patients  weaned  by  physician  decision  had  successful outcome. Nemer and colleagues used the same criteria, entitled integrative weaning index (IWI) for  evaluation  of  patients  as  that  used  in  our  study  and  reported  a  success  rate  of  84.7%  for physician-based weaning from mechanical ventilation (14), which is close to that of the present study.  This indicates the appropriateness of physician-based decision in our study.  Boniatti  and others  modified  IWI  based  on  the  1st  and  30thminute  of  the  spontaneous  breathing  trials  and compared  their  differences  and  reported  a  success  rate  of  85% (15),  which  is  close  to  what reported  by  Nemer  and  colleagues,  as  well  as  ours.  The slight difference between the success rates of the studies could be resulted from the different patients’ characteristics. According to the evidence, several demographic, and clinical parameters can influence the patients’ success rates of weaning (16).  The weaning method used can also affect the failure rate (17).  Boniatti  and others  suggested  positive  fluid  balance  and  serum  levels  of  hemoglobin  and  bicarbonate  as predictors of weaning failure and re-intubation (15), which is contrary to the results of our study, as we found no significant difference between the patients with successful and failed weaning in terms of Sat.O2, blood pressure, serum levels of hemoglobin, and PH, while the only significant variables  were  presented  as  mean  GCS,  duration  of hospital  admission,  ventilation,  and  PWT score,  and  the  patients  with  unsuccessful  results  had  a  lower  GCS,  higher  duration  of  hospital stay  and  ventilation,  as  well  as  lower  scores  of  PWT.  In  the  study  by  Wu  and  colleagues,  the duration  of hospital  admissionand  higher  modified  GCS  score  were  reported  as  the  significant predictors  of  weaning  failure (18),  which  confirm  the  results  of  the  present  study,  while  they reported success rate of weaning at 56%, which is much lower than that in the present study (18). In the meantime, the patients’ condition is an important factor for the weaning outcome. Not only  the  physical  parameters (19),  but  also  the  psychological  parameters,  such  as  patients’ confidence  and  subjective  perception  of  autonomous  breathing  can  also  affect  the  weaning success  rate (20).  Therefore,  the  numerous  factors  affecting  weaning  success  can  be  the  main reason underlying the different weaning failure/success rates among the results of studies.As  reported,  about  40%  of  patients  under  mechanical  ventilation  experience  difficult  weaning, and  weaning  process  decided  by  the  physician  is  considered  as  a  time-consuming  process, subject  to  inter-rater  and  other  types  of  biases (21).  Accordingly,  several  protocols  and  scoring systems have been suggested for prediction of successful weaning from the mechanical ventilator to be used by non-physician technicians to save the physicians’ time (10, 22); however, they fail to predict successful weaning, especially in patients with prolonged ventilation who display poor compliance (23,  24).  Several  studies  have  compared  the  success  rate  of  weaning  based  on physician-based decision with automated Smart Care™ (DrägerMedical, Lübeck, Germany). The results suggest that this automated system reduced the total duration of ventilation, weaning, and hospital stay, but did not influence mortality or adverse events, specifically re-intubation (25-27). In this method, the ventilator is switched to Smart Care, and the ventilator adjusts the pressure, uses automatic weaning strategy, and executes an automatic weaning test (28); however, this tool is not available in all centers.  Therefore,  scoring  systems  have  been  designed  to  calculate  and predictthe risk of successful weaning from mechanical ventilator by a non-physician staff.In  the  present  study,  the  results  of  physician-based  decision  for  weaning  from  the  mechanical ventilation were evaluated with the scoring system of PWT, and the results showed a diagnostic accuracy  of  93.4%,  a  Kappa  coefficient  of  0.637,  which  means  that  PWT  was  compatible  with the  conventional  method  in  64%  of  cases  with  a  significant  difference  between  the  results  of these  two  methods.  Calculation  of  diagnostic  accuracy  of  PWT  showed  sensitivity,  specificity, PPV,  NPV,  PLR,  and  NLR  of  100%,  50%,  93.4%,  100%,  2,  and  0,  respectively,  for  this  scale. PWT  is  an  Iranian  scale  designed  by  Irajpour  and  colleagues  to  facilitate  weaning  of  patients from mechanical ventilator (11). By reviewing the available literature about the scoring systems, Irajpour and colleagues suggested that each of the suggested scores had several limitations, and thus developed PWT for precise determination of the weaning process and claimed that this toolwas a comprehensive tool for this purpose, while its preciseness had to be compared with other tools (11). Following their study, Bazrafshan and colleagues compared the results of PWT with BWAP and Morgan Roth’sscale and suggested that PWT had acceptablevalidity and inter-rater reliability (12).  In  their  study,  they  suggested  cut-off  point  of  57  as  the  minimum  acceptable PWT (12),  while  in  our  study,  we  calculated  53  as  the  most  appropriate  cut-off  based  on  the ROC  curve.  Also,  Bazrafshan  and  colleagues reported  a  sensitivity  of  67.9%  and  specificity  of  8J Res Dev Nurs Midw,Volume 17, Number 1, January, 200280.4%  for  PWT (12),  while  we  reported  sensitivity  and  specificity  of  PWT  at  100%  and  50%, respectively, which changed to 92.94% and 75%, respectively, by considering the cut-off point at 53.  This  difference  between  the  results  of  our  study  and  that  reported  by  Bazrafshan  and colleagues could be resulted from the fact that we compared the results of PWT evaluation with physician-based  decision,  while  Bazrafshan  and  colleagues  compared  the  results  of  PWT  withBWAP  and Morgan Roth’sscale,  which  we  consider  as  a  limitation  of  this  study,  as  none  of these  scores  are  considered  as  the  gold  standard,  and  they  also  have  several  limitations  and problems,  which  can  affect  the  results,  while  we  compared  the  results  with  the  physician’s decision,  which  is  the  routine  care  suggested  by  guidelines.  We further investigated the PPV, NPV, PLR, and NLR of the test. PLR of 2 showed that PWT can predict the successful results of weaning twice more accurate in patients with final successful results, compared with those with ultimate  failed  results  of  weaning,  and  NLR  of  0  showed  that  the  prediction  power  of  failed weaning in patients with ultimate results of successful weaning was 0. The extent at which PLR is more than 1 and theextent at which NLR approaches 0 and is below 0.1 shows the superiority of the tool for the diagnosis of positive cases. Changing the cut-off point to 53 can even increase the diagnostic accuracy of the test more. Although the validity and diagnostic accuracy of other indices,  such  as  IWI  has  been  proven  in  Iranian  population (29).  The diagnostic accuracy of PWT has not been evaluated previously.  Therefore,  further  studies  are  required  to  indicate  the superiority of PWT to other tools and scoring systems.The  present  study  was  the  first  to  evaluate  PWT’s  diagnostic  accuracy,  compared  with  the physician-based  protocol,  considered  as  the  gold  standard.  Nevertheless, this study had some limitations, including non-randomized patients’ recruitments into the study, as well as the small sample size, and lack of follow-up.  Furthermore,  we  considered  several  inclusion  criteria  to specify  the  results  in  that  population  and  reduce  the  effect  of  confounders  on  the  results; therefore,  the  results  of  the  study  cannot  easily  be  generalized  to  other  subgroups  of  patients, such as patients with prolonged artificial respiration.

Discussion

The results of the present study showed that PWT had a high diagnostic accuracy in predicting the readiness of patients for weaning from the mechanical ventilation and had a high compatibility with the physician-based decisions for predicting the outcome of weaning. Using this method can successfully diagnose patients with successful/failed weaning results with a high sensitivity and its use can prevent the unnecessary prolongation of artificial respiration and reduce its complications. Therefore, we suggest this tool to be used by non-physicians, as an alternative or beside the physician’s decision, in order to indicate the preparedness of patients for weaning from the mechanical ventilator, facilitate weaning process, reduce the duration of artificial respiration, and improve the patients’ outcome. It has to be considered that PWT was scored by the study’s researcher in the present study; therefore, it is necessary to investigate the diagnostic accuracy of PWT, when assessed by non-physicians, such as nurses, study the patients’ long-term outcomes, and evaluate the diagnostic accuracy of PWT compared with other scoring systems.

Acknowledgements

 
The present study was extracted from the results of a thesis conducted for the fulfillment of Master of Science in intensive care nursing at the school of nursing and midwifery of Golestan University of Medical Science with grant number 940714174. It was financially supported by the Research and Technology Deputy of Golestan University of Medical Sciences, Gorgan, Iran. The authors of the present study sincerely thank the Deputy of Research and Technology of Golestan University of Medical Sciences for supporting this research.

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19. Savi A, Teixeira C, Silva JM, Borges LG, Pereira PA, Pinto KB, et al. weaning predictors do not predict extubation failure in simple-to-wean patients. J Crit Care. 2012; 27(2):221. E1-. e8. [DOI:10.1016/j.jcrc.2011.07.079]
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21. Penuelas O, Frutos-Vivar F, Fernandez C, Anzueto A, Epstein SK, Apezteguia C, et al. Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med. 2011; 184(4):430-7. [DOI:10.1164/rccm.201011-1887OC]
22. Blackwood B, Alderdice F, Burns KE, Cardwell CR, Lavery G, O'Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2010; (5):Cd006904. [DOI:10.1002/14651858.CD006904.pub2]
23. Rojek-Jarmuła A, Hombach R, Krzych ŁJ. APACHE II score cannot predict successful weaning from prolonged mechanical ventilation. Chronic respiratory disease. 2017; 14(13):270-5. [DOI: 10.1177/1479972316687100]
24. West RR, Saidi M, Dawson D. Protocol-driven weaning from mechanical ventilation: a study into adherence and outcomes. Critical Care. 2009; 13(1):P24. [DOI: 10.1186/cc7188]
25. Turan Inal M, Memiş D, Yildirim İ. Comparıson of extubatıon tımes between protocolızed versus automated weanıng systems after major surgery ın the ıntensıve care unıt. Signa vitae: journal for intesive care and emergency medicine. 2012; 7(1):23-7. [DOI:10.22514/SV71.042012.4]
26. Rose L,Schultz MJ, Cardwell CR, Jouvet P, McAuley DF, Blackwood B. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: a cochrane systematic review and meta-analysis. Crit Care. 2015; 19:48. [DOI: 10.1186/s13054-015-0755-6]
27. Burns KE, Lellouche F, Nisenbaum R, Lessard MR, Friedrich JO. Automated weaning and SBT systems versus non‐automated weaning strategies for weaning time in invasively ventilated critically ill adults. Cochrane Database of Systematic Reviews. 2014. [DOI:10.1002/14651858.CD008638.pub2]
28. Kataoka G, Murai N, Kodera K, Sasaki A, Asano R, Ikeda M, et al. Clinical experience with Smart Care after off-pump coronary artery bypass for early extubation. J Artif Organs. 2007; 10(4):218-22. [DOI: 10.1007/s10047-007-0392-1]
29. Madani SJ, Saghafinia M, Nezhad HS, Ebadi A, Ghochani A, Tavasoli AF, et al. Validity of integrative weaning index of discontinuation from mechanical ventilation in Iranian ICUs. Thrita. 2013; 2:62-8. [DOI:10.5812/thrita.12827]
Bibliographic information of this paper for citing:
Mirzaali J, Vakili MA, Khoddam H. The value of Persian Weaning Tool in Prediction of patients’ weaning outcome compared with Physician- directed approach: A Diagnostic Accuracy Study. J Res Dev Nurs Midw, 2020; 17(1): 1-11.
Type of Study: Original Article | Subject: Nursing

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25. Turan Inal M, Memiş D, Yildirim İ. Comparıson of extubatıon tımes between protocolızed versus automated weanıng systems after major surgery ın the ıntensıve care unıt. Signa vitae: journal for intesive care and emergency medicine. 2012; 7(1):23-7. [View at paplisher] [DOI] [Google Scholar]
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29. Madani SJ, Saghafinia M, Nezhad HS, Ebadi A, Ghochani A, Tavasoli AF, et al. Validity of integrative weaning index of discontinuation from mechanical ventilation in Iranian ICUs. Thrita. 2013; 2:62-8. [View at paplisher] [DOI] [Google Scholar]

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