*Corresponding author:Sherif A Mohamed, Associate Professor of Pulmonary Medicine, Department of Chest Diseases and Tuberculosis, Faculty of Medicine, Assiut University, 71516 Assiut, Egypt
How to cite this article: Sherif M, Sayed A E, Nermeen A, Azza A. Weaning of Mechanically Ventilated Patients with COVID-19: Value of Modified Burns
Wean Assessment Program Scores. Glob J Oto, 2020; 23 (5): 556122 DOI: 10.19080/GJO.2020.23.556122
Background: Most patients with acute respiratory distress syndrome (ARDS) due to COVID-19 warrant intubation and mechanical ventilation (MV).
Methods: As COVID-19 is a relatively new disease to us, with distinct clinical and pathophysiologic features and with massive burden on the health care facilities, particularly the intensive care units (ICUs), it is wise to think in using tools that are feasible, easy and save time and money. Previous studies showed that modified Burns wean assessment program (mBWAP) is a good predictor of weaning success.
Results: mBWAP proved useful as a good predictor of successful weaning and extubation in patients requiring long-term MV longer than 21 days, as well as in patients with respiratory disorders admitted to the respiratory ICU.
Conclusion: Previous data for mBWAP are encouraging and deserve utilizing it as a predictor tool for weaning from MV in patients with COVID-19. Further prospective studies are warranted.
Weaning predictors are those physiological tests used to predict whether a patient is likely to tolerate weaning [1,2]. Weaning predictors can be categorized as measurements of oxygenation and gas exchange, measurements of respiratory system load, measurements of respiratory muscle capacity, and integrative indices. Within these categories, some measurements may be further characterized as simple to measure at the bedside versus complex measurements that may require special equipment. Weaning predictor measurements should identify all patients ready to breathe independently and they should be safe and easy to perform, highly reproducible, and not subject to confounding influences. They should also use equipment and techniques that are routinely available in intensive care units (ICUs).
Even though many weaning parameters and predictors have been reported in the literature, there is no consensus on the most useful predictive indicators , particularly in patients with respiratory disorders . Moreover, despite that rapid shallow breathing index (RSBI) was the most frequently used parameter, there is no evidence that RSBI-dependent weaning improves clinical outcomes, such as duration of weaning, duration of mechanical ventilation (MV), length of stay, or reintubation rate .
The original checklist of Burns wean assessment program (BWAP) was developed as tool to measure patient’s readiness for weaning from the ventilator. This tool evaluates parameters of patients’ weaning from the ventilator systematically and examines all parameters related to pulmonary function, gas changes,
physiological and psychological conditions of patients . It is
an easy-to-use checklist, and its parameters could be measured
within 10 minutes. The modified version of BWAP was developed
by Jiang, et al.  who proved that this tool was a good predictor of
successful weaning and extubation in patients requiring LTMV for
longer than 21 days. Their results also suggested that a m-BWAP
score ≥60 is associated with successful extubation outcomes.
Jeong & coworkers  prospectively enrolled 103 patients in
a medical ICU and concluded that m-BWAP score was a good
predictor of weaning success in patients with an endotracheal
tube in place at first spontaneous breathing trial (SBT).
Recently, the utility of m-BWAP in predicting the weaning
success in patients with respiratory disorders admitted to the
respiratory ICU was studied in Egypt . Patients with respiratory
failure requiring MV for longer than 48hours were included.
They were divided into successful and unsuccessful weaning
groups according to their outcomes. A total of 91 patients were
enrolled. The majority had chronic obstructive pulmonary
diseases (COPD); 40%, overlap syndrome (24%), and obesity
hypoventilation syndrome (OHS); 15%. The successful group had
significantly higher m-BWAP scores than that in the unsuccessful
group (median 65; range 35 to 80 vs. median 45; range 30 to 65;
p=0.000), with area under the curve (AUC) of 0.854; 95% CI 0.766
to 0.919), p value <0.001. At cut-off value of ≥55, the sensitivity
and specificity of m-BWAP to predict successful weaning were
73.77% and 84.85%, respectively. The AUC for m-BWAP was
significantly higher than that for RSBI .
Modified burns wean assessment program scores
and weaning of mechanically ventilated patients with
Although SARS-CoV and SARS-CoV-2 (COVID-19) have certain
similarities in biological, epidemiological, and pathological
characteristics, there is a unique important difference. During the
SARS epidemic, a total of 8422 patients worldwide were infected
with SARS-CoV, of whom 919 died, with a mortality rate of 9.5%.
However currently, more than 2.3 million people worldwide are
infected with COVID-19, and a global case fatality rate of 4.9% .
The major morbidity and mortality from COVID-19 is largely
due to acute viral pneumonitis that evolves to acute respiratory
distress syndrome (ARDS). Most patients with acute respiratory
distress syndrome (ARDS) due to COVID-19 will warrant
intubation and mechanical ventilation. Previous studies showed
that mBWAP is a good predictor of weaning success [4,7]. As
COVID-19 is a relatively new disease to us, with distinct clinical
and pathophysiologic features and with massive burden on the
health care facilities, particularly the intensive care units, it is wise
to think in using tools that are feasible, easy and save time and
money. We think that mBWAP will be an ideal one. However, before
we expect this ideality, we should think in 2 important points. The
first is Will implementing mBWAP in patients with COVID-19 be
different from that in patients with chronic respiratory disorders
? In another way, patients with COVID-19 include those with
previous chronic respiratory disorders as well as “de novo”
patients, ie COVID-19 in previously health subjects.
Those 2 “phenotypes” of patients will be different in their
lung compliance and mechanics, interaction with the ventilator,
as well their duration of mechanical ventilation, and lastly their
weaning. COVID-19 leads to an atypical form of acute respiratory
distress syndrome with relatively well-preserved lung compliance
despite severe hypoxemia. Extubation is a high-risk procedure in
patients with COVID-19 because of direct contact with patients
and exposure to airway droplets and aerosols. Therefore, it is
of crucial importance to ensure that the decision to extubate is
appropriate so that the patients are not harmed by extubation,
and the hazards related to the cycle of reintubation and extubation
are avoided . An important goal of extubation is to ensure
that patients tolerate extubation and to minimize the chance that
they will require reintubation. High-risk factors for reintubation
include age, Acute Physiology and Chronic Health Evaluation
(APACHE) II score, RSBI, and positive fluid balance. A low PaO2/
FiO2 ratio at extubation may be a risk factor for reintubation
due to respiratory insufficiency [10,11]. The second is, do we
have enough comparative data for mBWAP to other weaning
parameters? Are these data enough to expect utility of mBWAP in
patients with COVID-19?
Data regarding the weaning process had shown an evolution
from using single parameters in the respiratory system to a
more global perspective which combines systemic parameters
and overall patient status to predict the success of weaning
and extubation. In a recent systemic review, 56 parameters or
scores that can predict weaning or extubation outcomes were
assessed. RSBI was the most studied and relied upon parameter
for weaning and extubation success. Moreover, parameters
beyond respiratory ones can predict weaning and extubation
outcome . Nevertheless, further clinical studies utilizing these
comprehensive and global parameters need further evaluation
prior to being relied up in clinical settings. To the best of our
knowledge, mBWAP has not been tried in patients with COVID-19
yet. We wonder if prospective studies can be carried out on using
mBWAP in patients with COVID-19.
Epstein SK (2003) Weaning from ventilatory support. In: Textbook of Pulmonary Diseases, (7th), Crapo JD, Glassroth J, Karlinsky J, King TE (Eds), Lippincott, Williams & Wilkins, Philadelphia, USA,pp 1089.