Guided Protocol for Readiness to WEAN (GPR-WEAN): A consensus-based clinical framework for prescribing ventilator liberation in tracheostomised intensive care unit patients.

BACKGROUND: Liberation from mechanical ventilation in tracheostomised intensive care unit (ICU) patients is characterised by substantial interprofessional variability and an absence of standardised, multidimensional frameworks to prescribe the progression, duration, and intensity of ventilator liberation. Existing weaning indices are largely limited to intubated populations and do not operationalise functional and physiological assessments into actionable ventilator liberation strategies for patients with tracheostomy. OBJECTIVE: The aim of this study was to develop a consensus-based, clinically actionable framework for prescribing ventilator liberation in tracheostomised ICU patients. METHODS: We conducted a four-stage study comprising (i) a review of systematic reviews and meta-analyses to identify candidate predictors of ventilator liberation; (ii) a modified Delphi process involving an interprofessional ICU expert panel, conducted separately for general critical care and neurocritical populations; (iii) expert panel refinement to construct the final framework using an International Classification of Functioning, Disability and Health-aligned structure; and (iv) a structured pilot implementation to assess feasibility and protocol adherence in routine ICU practice. RESULTS: From 77 candidate predictors, the Delphi process achieved consensus on 14 core variables for each population. These variables were integrated into the GPR-WEAN (Guided Protocol for Readiness to WEAN) framework, generating a cumulative score (0-140) that stratifies patients into five functional impairment levels and links each level to explicit prescriptions for ventilator-free time. Pilot implementation involving five patients demonstrated high feasibility and 100% protocol adherence, with potentially reduced perceived interprofessional variability in ventilator liberation decisions. CONCLUSIONS: GPR-WEAN provides a structured, consensus-based clinical framework that translates multidimensional patient assessment into explicit prescriptions for ventilator liberation in tracheostomised ICU patients. By integrating respiratory, neuromuscular, metabolic, and airway protection domains, the framework offers a reproducible pathway to standardise ventilator liberation practices and supports future prospective validation across diverse critical care settings.