Hrev_master Healthcare in Low-resource Settings 2024; volume 12:13010 The effectiveness of ventilator weaning using a weaning protocol compared to non-protocol: a systematic review Denissa Faradita Aryani, Rr. Tutik Sri Hariyati, Elly Nurachmah Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia Abstract Ventilator use can reduce respiratory function, heighten infec- tion risk, extend ventilator dependence, and, in severe cases, necessitate prolonged mechanical ventilation. Systematic weaning protocols can alleviate these issues, enhance breathing, and aid extubation. This review assesses studies on weaning protocols in ICU patients. Using the PRISMA framework, an extensive search was performed in databases such as ClinicalKey Nursing, ScienceDirect, ProQuest, SAGE, EMBASE, MEDLINE, Scopus, SpringerLink, and PubMed. This search aimed to find studies comparing protocolized and non-protocolized weaning in adult ICU patients. Included were peer-reviewed randomized controlled trials (RCTs) and quantitative studies focusing specifically on adult ICU weaning protocols. Studies involving non-adult popula- tions were excluded. The JBI and CASP tools were used to assess the quality of the studies. Out of 475 identified articles, six met the inclusion criteria. Three types of weaning protocols were identi- fied: nurse-led, respiratory therapy-led, and automatic protocols. These protocols demonstrated effectiveness by reducing ventilator time, increasing extubation success, and shortening ICU stays. Evidence supports that weaning protocols positively impact patient outcomes, particularly by shortening intubation periods, and can enhance inter-professional collaboration in the ICU. Introduction The Intensive Care Unit (ICU) is designed to monitor patients with high levels of dependency, complex health issues, and the need for advanced technology. Worldwide, approximately 80% of primary care needs in the ICU involve the use of mechanical ven- tilation (VM) or ventilators. According to data from the United States, nearly 5.7 million patients are treated in the ICU annually, of which 30% require ventilators.1 Most instances of acute respi- ratory failure require mechanical ventilation, which can be discon- tinued once the underlying cause has been resolved through the process of weaning and extubation. However, 20-30% of ICU patients are considered challenging to wean from mechanical ven- tilation.2 Patients who receive treatment using a ventilator aim to be weaned from the device. The process of weaning, also known as ventilator weaning, is influenced by the patient’s healing and the improvement of lung capacity, which can optimize ventilation and enhance circulatory support. Successful weaning is dependent on several factors, including breathing exercises while using the ven- tilator.3-5 Nurses, particularly those in critical care or ICU settings, play a crucial role in the care of patients with critical conditions.6- 9 The American Nurses Association recognizes critical nursing as a distinct field involving interdisciplinary collaboration and com- prehensive nursing care. Experts also agree that ICU nurses play a central role in developing weaning plans for patients.10 Critical care is a comprehensive healthcare field that encom- passes various specialists and interventions. To enhance the qual- ity of care in the intensive care unit, international organizations have created evidence-based guidelines, protocols, and bundles.11 Ventilator weaning is a significant aspect of ICU management, and nurses have increasingly played a crucial role in this process over the past two decades through the implementation of nurse-led and nurse-driven weaning protocols.12 Studies have demonstrated that involving nurses and therapists in weaning patients from Correspondence: Denissa Faradita Aryani, Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia. E-mail: denissa.fa@ui.ac.id Key word: ICU, systematic review, weaning process, weaning protocol, ventilator. Contributions: all authors contributed to this article. DFA, RR, and EN contributed substantially to the data curation, extraction, analysis (i.e., critical appraisal), and analysis. Furthermore, the DFA made a significant contribution to the study conceptualization, drafted the original review article, and interpreted the data. RR and ET contributed to revise the review by providing advice regarding the content. Availability of data and material: the full list of references and datasets supporting the findings of this study can be accessed in the relevant pub- lished articles included in this review. Conflict of interest: all authors declare that we have no competing interests. Funding: this study was independently funded by the authors Ethics approval and informed consent: not applicable. Conference presentation: this work was presented at the 3rd International Nursing Scholar Congress 2023, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia. Acknowledgement: we would like to thank the scholarship providers, namely the Indonesian Education Scholarship (BPI), The Indonesia Endowment Funds for Education (LPDP), and Education Financing Service Centre (PUSLAPDIK) for their support for one of our investiga- tor (DFA) in carrying out the doctoral program in nursing. Received: 4 September 2024. Accepted: 4 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:13010 doi:10.4081/hls.2024.13010 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 717] [Healthcare in Low-resource Settings 2024;12:13010] Non -co mmerc ial us e o nly mechanical ventilation and extubation leads to better outcomes.3,13- 15 Historically, physicians were primarily responsible for weaning patients and making key decisions during the process. In contem- porary practice, some countries continue to handle the weaning process collaboratively within the ICU, lacking a specific patient weaning protocol. A study by Hirzalah stated that the nurse’s weaning ventilator protocol resulted in a significant reduction in the duration of ventilator use and a significant reduction in wean- ing time.15 A study conducted in the United States in 2013, which examined the weaning protocol by nurses, resulted in a shorter extubating time of 2 h and 13 min compared to protocols from other groups. The study also identified four independent predictors of weaning duration, one of which was the nurses’ weaning proto- col.16 This systematic review aimed to determine the effectiveness of ventilator weaning using a protocol compared to ventilator weaning without the use of a protocol in patients on ventilators in the ICU. In addition, this study will explain the types of protocols that have been proven safe. Materials and Methods The aim of the study was to identify the effectiveness of ven- tilator weaning protocol compared to the non-protocol. We fol- lowed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement. Search strategy and selection criteria To meet the methodological standard of a systematic review, specific keywords were used to conduct a comprehensive literature search and data extraction from Scopus, Medline, SAGE, ProQuest, ClinicalKey Nursing, PubMed, JSTOR, EMBASE, ScienceDirect, and SpringerLink electronic databases, adhering to PRISMA guidelines. The search included quantitative research articles on mechanically ventilated ICU patients, published in English between 2019-2023, using keywords such as “intubated patient”, “ventilated patient”, “mechanical ventilated patient”, “ICU patient”, “weaning protocol”, “Nursing protocol in wean- ing”, “usual care”, “extubation”, “extubation readiness”, and “improving ICU outcome”. Selection of studies An investigator (DFA) independently conducted the initial screening of articles by reviewing the titles, abstracts, and full texts from all databases. The results of candidate articles were saved using EndNote X9 software for the initial screening and identifica- tion of duplicates. In the subsequent step, DFA performed a com- prehensive screening with the aid of Rayyan software to assess eli- gibility. DFA organized and analyzed the literature by label for decisions on inclusion or exclusion. DFA then invited two investi- gators (RR & EN) for collaborative screening, who independently reviewed the articles without seeing each other’s choices until the process was complete, minimizing potential bias. Disagreements were resolved through a consensus-building meeting. Inclusion and exclusion criteria We included full-text articles from 2019-2023 on Randomized Controlled Trials and quantitative methods related to mechanical ventilation weaning protocols in the ICU, excluding studies on pediatric ICUs or those outside the scope. Extraction was primarily carried out by one investigator (DFA). From all databases, 475 arti- cles were obtained: 128 from ClinicalKey Nursing, 21 from ScienceDirect, 22 from ProQuest, 53 from SAGE, 6 from EMBASE, 10 from PubMed, 30 from MEDLINE, 29 from JSTOR, 16 from SCOPUS, and 160 from SpringerLink. DFA grouped each database in EndNote and checked for duplicates. A total of 165 duplicates were identified, leaving 310 articles meet- ing the criteria. Three investigators (DFA, RR, EN) conducted a second round of checks. DFA ensured all tasks were accurately completed, contributing to the project’s successful completion for RR and EN. Data extraction and synthesis The following data were extracted from all studies: i) publica- tion details (English full text, title, publication date, author’s name and country), ii) study design (RCT, Cross-sectional, Quasi-exper- iment, Cohort), iii) setting (sample, adult intensive care unit, mechanically ventilated), iv) model selection (weaning method, ventilator weaning protocol type, usual care, non-protocol ventila- tor weaning, weaning decision maker), v) data specifics (patient characteristics, duration of mechanical ventilation, duration of weaning). DFA conducted the initial screening by reviewing the titles and publication dates of all articles using EndNote and the Rayyan AI Powered Tool for Systematic Review. This process fil- tered out 200 irrelevant articles and 19 articles that were not fully accessible, resulting in 91 articles meeting eligibility criteria. Three investigators (DFA, RR, EN) independently performed a second review, identifying 6 potential articles. Data from eligible studies were then extracted into a specific spreadsheet by DFA, RR, and EN (Figure 1). Quality assessment The methodological quality of selected studies and the correct- ness of data extraction were reviewed by two independent investi- gators (DFA, RR). One investigator were asked for the expert judg- ment (EN). In general, articles or studies are assessed for quality based on: i) clear research questions, ii) concepts or terminology can be explained operationally, iii) clear inclusion and exclusion Article Figure 1. PRISMA Table. [Healthcare in Low-resource Settings 2024;12:13010] [page 718] Non -co mmerc ial us e o nly criteria, iv) methods which answer research questions, v) precise data analysis, vi) relevant results and discussion, vii) minimal risk of bias, viii) relevant implications, and ix) described research lim- itations. The author uses measuring instruments according to the characteristics of the study, namely, The Critical Appraisal Skills Program (CASP) for RCT research and the Joanna Briggs Institute (JBI) for cross-sectional, quasi-experiment and cohort research (Tables 1 and 2). Results Study selection The outcome of the literature search was 475 studies sourced from all electronic databases. Of these, only 91 articles were deemed eligible for further consideration after 200 articles were determined to be irrelevant, and 19 articles were not provided in full text. Following a second stage screening conducted by all investigators (DFA, RR, EN), only six potential articles remained. A total of 41 articles were excluded due to various reasons, such as incorrect outcome, incorrect publication type, incorrect study design, use of a foreign language, and lack of full text. Study characteristics All six studies incorporated in the review follow a quantitative research methodology, comprising one cross-sectional study, one quasi-experimental study, two cohort studies, and two Randomized Controlled Trials (RCTs). Each article is in English, accessible in full text, and published between 2019 and 2023. The studies share a common population, which consists of adult ICU patients aged over 18 years and ventilated for at least 24 hours. The systematic review features studies from a range of sources, with a total of 5,380 participants taking part in the studies. To ensure accurate and relevant results, the review includes adult ICU patients from Sweden, Iran, Brazil, Japan, and the United Kingdom. All articles feature structured weaning intervention protocols in contrast to conventional weaning procedures (Table 3). Primary outcome Type of weaning protocol This Systematic Review assesses six articles that examine var- ious aspects of ventilator weaning protocols. Five of the six articles under consideration focus on comparing weaning protocols with conventional care. These include the works of Ghanbari et al.,17 Lago et al.,18 Vahedian-Azimi et al.,19 and Vizcaychipi et al.20 In contrast, the study by Caderwall et al. examines weaning protocols and accompanying practices in patients who require ventilator sup- port in the ICU.21 A study conducted by Ghanbari et al. evaluated the effectiveness of the Nurse-Led Weaning Protocol, which dif- fers from physician-based protocols for weaning patients from mechanical ventilation.17 The Nurse-Led Weaning Protocol utilizes the Burn’s Weaning Scale (BWS), containing 40 items, and employs a combination of ventilation methods, including CPAP, PCV, BIPAP, SIMV, and PSIMV. The study revealed that the nurs- ing protocol involved monitoring several laboratory values on a daily basis. Lago et al. compared the International Consensus Conference (ICC) guideline protocols with the WIND classification, which categorizes patients’ weaning types as no weaning, short weaning, difficult weaning, and prolonged weaning.18 However, the specific weaning method employed in this study remains indeterminate. Nitta et al. conducted research on the development of weaning and extubation protocols, encompassing an evaluation checklist with four components: Spontaneous Breathing Trial (SBT), extubating eligibility, non-invasive positive pressure (NPPV) prophylaxis, and post-extubation assessment.22 The study revealed that the weaning method utilized was SBT for 30 minutes, with a flow trig- ger set at 0, PSV 0, Positive End Expiratory Pressure (PEEP) established at 5 cmH2O, or through the use of a T-tube. The RCT conducted by Vahedian-Azimi et al., found that weaning from RT was preceded by a checklist of weaning criteria. The method used was continuous positive airway pressure (CPAP) set at 5 cmH2O, fraction of inspired oxygen (FiO2) set at 0.4, arte- rial oxygen saturation value greater than or equal to 92%, and a Rapid Shallow Breathing Index (RSBI) less than 105 times per Article [page 719] [Healthcare in Low-resource Settings 2024;12:13010] Table 1. JBI critical appraisal for cross-sectional, quasi experiment, and cohort research. Researcher Design Question Overall appraisal and year 1 2 3 4 5 6 7 8 9 10 11 Cederwall, et al.21 Cross Sectional Y Y Y Y N N Y Y INCLUDE Ghanbari, et al.17 Quasi Experiment Y Y N N Y Y Y Y Y INCLUDE Lago et al.18 Cohort Y Y Y N N Y Y Y Y Y Y INCLUDE Nitta et al.22 Cohort Y Y Y Y N Y Y Y Y Y Y INCLUDE Table 2. CASP critical appraisal for RCT research. Researcher Design Section Question DECISION and year 1 2 3 4 5 Vahedian-Azimi et al.19 RCT Section A Y Y Y INCLUDE Section B Y Y Y Section C Y Y Y Y Y Vizcaychipi et al.20 RCT Section A Y Y Y INCLUDE Section B CNT Y Y Section C Y CNT Y CNT Y Non -co mmerc ial us e o nly minute per liter.19 Spontaneous Breathing Trials (SBT) were per- formed for 120 minutes. Typical care, which is usually provided, is based on the clinical decisions of the intensivist, considering the patient’s clinical status, airway conditions, and RSBI or NIF respi- ration indicators. Another RCT study compared weaning protocols with a mathematical system (iCareWean) in a special healthcare system called BEACON with standard weaning or routine care. In the intervention protocol, systematic charts compiled by the research team were used.20 Weaning interventions encompassed Blood Gas Analysis (GBA) parameters, automatic lung parameter estimators, ventilator setting adjustments, consultations, sedation types, and SBT. This study utilized the BEACON Care system monitor to track Pressure Support (PS) and positive end-expiratory pressure (PEEP) values during SBT conditions. A national survey in Sweden showed that about 55% of Intensive Care Units (ICUs) utilized a weaning protocol compris- ing individualized and collaborative plans for ICU nurses and doc- tors.21 Additionally, 65% of ICUs used a collaborative approach for weaning, while 27% relied on the decision of the doctor. Common methods for weaning include pressure support reduction, Low Flow Oxygen (LFO2), High Flow Oxygen (HFO2), Continuous Positive Airway Pressure (CPAP), and Volume Support (VS). The study identified three main features of the weaning protocol used: i) a nurse’s weaning protocol using the Burn’s Weaning Scale and controlling daily laboratory results; ii) a therapist weaning protocol using predefined criteria and Spontaneous Breathing Trials (SBT) results; iii) a comprehensive protocol that includes the nurse’s decisions in collaboration with intensivists. The review under- scores the importance of structured weaning protocols, whether nurse-led, therapist-led, or collaborative, in enhancing patient out- comes during the weaning process. Each protocol type offers dis- tinct advantages, depending on the clinical setting and the specific needs of the patient population. The effectiveness of weaning protocol According to A. Ghanbari et al., the weaning protocol employed by nurses, specifically the use of BWS, yielded safer and more effective outcomes compared to the clinical judgment of physicians.17 The average duration of mechanical ventilation for the intubated patient group using BWS was 111.75 ± 33.46 hours, while the physician group had a duration of 125.12 ± 43.43 hours, with a significant difference observed in the duration of mechani- cal ventilation between the two groups (P = 0.000). Lago et al. sug- gested that the WIND classification is more suitable for use in the intensive care unit, particularly in patients with severe conditions and prolonged weaning.18 The study found that not all patients could be fully classified as receiving usual care (ICC). In the WIND classification category, all groups exhibited better out- comes with shorter mechanical ventilation time compared to the ICC classification (P = 0.0001). A study from Nitta reported that the weaning protocol demon- strated effectiveness, as 213 patients were successfully extubated following 30 minutes of SBT.22 A comprehensive protocol for weaning and extubation can prevent post-extubation respiratory failure, with a PERF incidence of 9.7% and a reintubation rate of 5.2%.22 Extubation failure is a major risk in mechanical ventila- tion, but a standardized protocol can significantly reduce post- extubation respiratory failure rates. Vahedian-Azimi’s research also indicates that the weaning process can be effectively managed by Respiratory Therapy.19 The results are safe, effective, and asso- ciated with reduced reintubation rates. The protocol’s effectiveness is demonstrated by increases in minute ventilation (P<0.001), Cs and Cdyn (P<0.05), P0.1 (P<0.001), NIF (P<0.001), and RSBI Article Ta ble 3. Stu dy ch ara cte ris tic s. No . T itl e Y ea r D esi gn Pa rti cip an t I nt er ve nt ion 1 C are pr ac tic es for pa tie nts re qu iri ng m ec ha nic al 2 02 3 C ros s S ec tio na l 77 A du lt I CU s W ea nin g p rot oc ol in pa tie nts w ith > 7 d ay s V M in sta lle d v en tila tio n m ore th an se ve n d ay s i n S we dis h in ten siv e c are un its : A na tio na l s urv ey 2 C om pa ris on be tw ee n a nu rse -le d w ea nin g p rot oc ol 2 02 0 Qu asi E xp eri me nt 65 IC U pa tie nts Nu rse W ea nin g P rot oc ol: B urn ’s W ea nin g S ca le (B W S) a nd a we an ing pr oto co l b ase d o n p hy sic ian ’s cli nic al ju dg me nt in IC U pa tie nts 3 C om pa ris on of In ter na tio na l C on sen su s C on fer en ce 2 01 9 C oh ort 32 7 I CU pa tie nts M ult ice nte r m ult ina tio na l p ros pe cti ve ob ser va tio na l s tud y, g uid eli ne s a nd W IN D cla ssi fic ati on fo r w ea nin g f rom th e w ea nin g a cc ord ing to N ew D efi nit ion (W IN D Pr oto co l) m ec ha nic al ve nti lat ion in B raz ilia n c rit ica lly ill pa tie nts : A re tro sp ec tiv e c oh ort st ud y 4 A co mp reh en siv e p rot oc ol for ve nti lat or we an ing an d e xtu ba tio n: 2 01 9 C oh ort 46 4 I CU pa tie nts W ea nin g a nd E xtu ba tin g P rot oc ol a pr os pe cti ve ob ser va tio na l s tud y 5 P rot oc oli ze d v en tila tor w ea nin g v ers es us ua l c are : A ra nd om ize d c on tro lle d t ria l 2 02 0 R CT 42 00 IC U Pa tie nts W ea nin g P rot oc ol: SB T f rom R esp ira tor y T he rap y 6 In ten siv e C are W ea nin g ( iC are W ea n) pro toc ol on w ea nin g f rom 2 02 0 R CT 2 47 IC U pa tie nts Int erv en tio n: IC are W ea n P rot oc ol - m ec ha nic al ve nti lat ion : a si ng le- bli nd ed m ult ice ntr e r an do mi sed B EA CO N He alt hS ys tem : A dv ice E na ble d c on tro l tr ial co mp ari ng an op en -lo op de cis ion su pp ort sy ste m a nd ro uti ne ca re, in th e g en era l in ten siv e c are un it [Healthcare in Low-resource Settings 2024;12:13010] [page 720] Non -co mmerc ial us e o nly (P<0.001). Vizcaychipi et al. describe the protocol for evaluating the BEACON Caresystem’s effectiveness in the general medical ICU population.20 This protocol is pivotal for utilizing advice and applies only to patients intubated for over 24 hours, highlighting the BEACON Care system as an effective ventilation strategy. Caderwall et al. argue that the weaning protocol is not suitable for all ventilated patients, particularly in PMV conditions.21 Therefore, weaning protocols may not be relevant for ICUs that use individu- alized treatment approaches. However, individualized treatment plans necessitate collaborative efforts to reduce ICU mortality and length of stay. Upon evaluating six separate studies, it was deter- mined that all weaning protocols were both safe and effective for patient care. The effectiveness of these protocols was established through the analysis of statistical data, specifically the duration of intubation and the success rate of extubation when compared to instances where no protocol was employed, or only clinical assess- ment was used. Secondary outcome Ventilator duration One study strongly suggested that the average duration of intu- bation in the patient group with the nurse’s weaning protocol was shorter than in the patient group with the doctor’s protocol (P = 0.0001).17 As many as 80% of patients are ready for weaning before a clinical decision or clinical judgment from a doctor. In addition, the study also suggested that there was a significant dif- ference in the duration of MV in female and male patients in the nurse’s weaning protocol group (P = 0.039). Moreover, another study was found that the duration of intubation in the weaning pro- tocol group was longer than the usual care group (P<0.001).19 Length of stay According to Japanese studies in 2019 found that there was no notable difference in the duration of stay between the two groups, with a P-value of 0.16.22 However, one study findings revealed that the weaning protocol resulted in a reduction in the length of stay, with a P-value of <0.001 because of the implementation of RT’s weaning protocol.19 Furthermore, Brazilian studies indicated that individuals in the difficult weaning category experienced an extended period on mechanical ventilation compared to those in other classifications. Mortality According to Nitta’s research , there was no significant differ- ence in mortality rates between the two groups, which were found to be 1.2% and 6.9%.22 However, these figures were lower than previously reported. Vahedian’s research showed that the mortality rate was constant at P = 0.19.22 On the other hand, Lago’s study found an increased risk of death, particularly in the difficult wean- ing classification group.18 Disscussion Mechanical ventilators assist respiratory function and maintain alveolar gas exchange. The main goal of using a ventilator is to restore spontaneous breathing and enable weaning. Weaning is essential to prevent complications like dyspnea, respiratory arrest, Ventilator Acquired Pneumonia (VAP), and death. Hence, early weaning is recommended once the patient exhibits signs of spon- taneous breathing. The global consensus currently endorses the ICU Liberation ABCDEF bundle for evidence-based ICU care. These guidelines recommend ventilator weaning procedures that include Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT) to improve patient recovery and ICU treatment effi- cacy.24 In some countries, data on the ABCDEF bundle’s use are limited, and there is no evidence of routine, awake, and scheduled breathing trials. Ventilator weaning often involves individualized processes without standardized protocols, relying on medical deci- sions for weaning and extubation.8 Over the past two decades, nurses’ involvement in the weaning process has grown due to the implementation of weaning proto- cols.12 Studies indicate that the participation of nurses and thera- pists benefits ventilator weaning. Research by Roh et al. in South Korea found that nurse-administered weaning protocols are safe and reduce weaning time from mechanical ventilation in respirato- ry failure patients.13 The weaning protocol represents a shared objective for all ICU team members caring for mechanically ven- tilated patients who are successfully weaned with ventilation sup- port.23 Typical weaning protocols comprise three main components: readiness assessment standards, ventilator support reduction guidelines, and decannulation criteria. However, these elements may vary across protocols, and not all explicitly outline extubation criteria.19 This systematic review identifies four effective weaning protocols in the ICU: i) nurse weaning protocols, ii) respiratory therapist weaning protocols, iii) collaborative weaning protocols, and iv) systematic automatic weaning protocols. According to Ghanbari et al., the nurse’s weaning protocol uses the Burn’s Weaning Scale (BWS).17 This is consistent with previous research suggesting that a high Burn Score predicts successful weaning, extubation, reduced intubation duration, and shorter hospital stays.25. In the past five years, the BWS has been used in five ICUs, with an 88% success rate and a 12% failure rate. The Burn’s Protocol, particularly effective in younger patients during wean- ing, includes 26 questions on general and respiratory assessments and is supported by various tools and guidelines such as assess- ment checklists, weaning trial protocols, and sedation guidelines. ICU healthcare professionals are authorized to conduct ventilator weaning. A study by Vahedian, an RCT on weaning protocols managed by thera- pists, indicated that respiratory therapists, along with doctors and nurses, participated in the process. The study demonstrated that respiratory therapists adhered to predefined criteria and guidelines from Spontaneous Breathing Trials, assessing physiological vari- ables, Blood Gas Analysis (GBA) results, RSBI, and NIF.26 The weaning process begins with recognizing the signs of readiness for spontaneous breathing from each patient. Health workers and inter-collaborative processes are needed in making the right decisions about the patient care process. Research by C-J Cederwall states that the weaning protocol is very effective in patients with PMV, but the rest of the weaning decisions are made based on the collaboration of ICU nurses and doctors.19,27 In con- trast to the study conducted by Ghanbari et al. which focused on comparing the use of weaning protocols by nurses with the clinical judgment of doctors, which proved that nurse protocols were more effective with shorter duration ventilator use results.22 All reviewed studies employed a uniform weaning method, specifically the use of SBT per ICU Liberation guidelines. Nitta’s study utilized SBT for 30 minutes,18 while Vahedian et al. applied the SBT procedure for 120 minutes, following weaning screening Article [page 721] [Healthcare in Low-resource Settings 2024;12:13010] Non -co mmerc ial us e o nly and various physical examinations to assess patient readiness.19 Another study, using a systematic protocol with instruments, con- ducted SBT after confirming satisfactory signs and respiratory val- ues.20 Additionally, A.F. Lago’s study indicated that weaning is effective when patients are classified by their ventilator weaning level. The weaning protocol primarily enhances patient outcomes by reducing intubation duration, length of stay, and mortality rate.28-29 A systematic review identified three major outcomes. A study by A. Ghanberi found that intubation duration was shorter, reducing the risk of VAP and PMV. Although length of stay can vary, suc- cessful weaning generally shortens it, except in high-risk patients where a prolonged stay is expected. Notably, a reduction in mor- tality rate has not been observed in patients undergoing protocol weaning compared to standard care, likely due to disease severity, comorbidities, and other factors. Weaning patients from mechanical ventilators is crucial for improving outcomes and reducing complications like VAP, PMV, and mortality. Evidence-based guidelines, including the ICU Liberation ABCDEF bundle with SAT and SBT, are globally endorsed. However, implementation data is limited and often excludes many countries lacking standardized protocols. Research indicates that weaning protocols developed by nurses, respiratory therapists, and automated systems are effective and safe, with nurse-designed protocols notably decreasing ventilation duration compared to standard care. Using the Burn’s Weaning Scale, nurs- es can formulate guidelines that significantly improve weaning success rates. Despite the benefits of standardized weaning proto- cols, the lack of uniformity across different settings is problematic. Variability in patient populations, protocol details, and implemen- tation practices can result in inconsistent weaning outcomes. Additionally, while shorter ventilator durations and reduced lengths of stay are commonly noted, the effect on mortality rates remains inconclusive, influenced by disease severity and comor- bidities. References 1. Marshall JC, Bosco L, Adhikari NK, et al. What is an intensive care unit? a report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2017;37:270-6. 2. Jonkman AH, Rauseo M, Carteaux G, et al. Proportional modes of ventilation: technology to assist physiology. Intensive Care Med 2020;46:2301-13. 3. Gunther I, Pradhan D, Lubinsky A, et al. Use of a multidisci- plinary mechanical ventilation weaning protocol to improve patient outcomes and empower staff in a medical intensive care unit. Dimens Crit Care Nurs 2021;40:67-74. 4. Holm A, Karlsson V, Nikolajsen L, Dreyer P. Strengthening and supporting nurses’ communication with mechanically ven- tilated patients in the intensive care unit: development of a communication intervention. Int J Nurs Stud Adv 2021;3:100025. 5. Cuzco C, Torres-Castro R, Torralba Y, et al. Nursing interven- tions for patient empowerment during intensive care unit dis- charge: a systematic review. Int J Environ Res Public Health 2021;18:11049. 6. McNett M, O’Mathúna D, Tucker S, et al. A scoping review of implementation science in adult critical care settings. Crit Care Explor 2020;2:e0301. 7. Curley MAQ, Wypij D, Watson RS, et al. Protocolized seda- tion vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial. JAMA 2015;313:379-89. 8. 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