Utility of Lung Ultrasonography for Early Diagnosis and Monitoring of Ventilator-associated Pneumonia in Mechanically Ventilated Patients: A Prospective Observational Study

Abstract

Background and aims

Ventilator-associated pneumonia (VAP) is a common intensive care unit (ICU) complication linked to increased morbidity and delayed diagnosis. Lung ultrasound (LUS) is a bedside, radiation-free tool with potential for early detection and monitoring. This study aimed to evaluate the diagnostic accuracy of LUS compared to expert panel adjudication and assess its role in monitoring treatment response.

Patients and methods

In this prospective observational study conducted in a tertiary ICU, 206 adult patients ventilated for >48 hours underwent serial LUS starting 48 hours post-intubation. Lung ultrasound findings were compared with Clinical Pulmonary Infection Score (CPIS) and expert panel diagnosis (gold standard). Aeration scores were assessed; patients with a Δ score >2 between day 1 and day 5 of antibiotic therapy were considered responders.

Results

Of the 206 patients, 73 developed VAP as confirmed by the expert panel. Lung ultrasound detected VAP significantly earlier than expert adjudication (median 150 vs 178.5 hours; p < 0.001), with 80.7% of cases diagnosed earlier by LUS. Lung ultrasound showed 91.78% sensitivity, 87.97% specificity, 80.7% positive predictive value (PPV), and 95.1% negative predictive value (NPV). Among 64 patients eligible for aeration score analysis, responders (n = 24) showed a non-significant trend toward higher 28-day survival (75 vs 52.5%, p = 0.074). Intensive care unit stay and ventilator duration were comparable between groups.

Conclusion

Lung ultrasound demonstrates high diagnostic accuracy and enables earlier VAP detection compared to clinical scores. It effectively tracks disease progression and treatment response through serial aeration scores. Incorporating LUS into routine ICU care may enhance diagnostic timeliness and support individualized treatment strategies.

Trial registration

The study was approved by the Institutional Ethics Committee of the IMS and SUM Hospital (Ref. no/ECR/627/Inst/OR/2014) and was registered with the Clinical Trials Registry of India (CTRI) under the registration number CTRI/2022/10/046326.

How to cite this article

Roy C, Choudhury S, Chhotray P, Patra ESK, Panda S, Mishra SB. Utility of Lung Ultrasonography for Early Diagnosis and Monitoring of Ventilator-associated Pneumonia in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med 2025;29(9):753–759.

Highlights

This study highlights lung ultrasound (LUS) as a reliable bedside tool for early ventilator-associated pneumonia (VAP) diagnosis and monitoring, enabling significantly earlier detection than Clinical Pulmonary Infection Score (CPIS). It demonstrates high diagnostic accuracy, supports dynamic aeration scoring for real-time assessment, and confirms the feasibility of integrating daily LUS into routine intensive care unit (ICU) workflows for individualized care.

Introduction

Ventilator-associated pneumonia is a significant and prevalent issue in ICUs worldwide, particularly among mechanically ventilated patients, with reported incidences as high as 49.2% in some settings.^1,2 Accurate and timely diagnosis of VAP is critical, as it directly impacts clinical decision-making and patient outcomes. However, the nonspecific nature of clinical criteria and the time required for bacteriological cultures often delay the initiation of appropriate antimicrobial therapy, potentially contributing to the emergence of antibiotic resistance.^3–8

The CPIS, while commonly used for VAP diagnosis, demonstrates limited diagnostic accuracy and fails to provide dynamic monitoring. Chest X-ray (CXR), often integral to CPIS, lacks sensitivity and specificity, especially in critically ill patients with pre-existing lung abnormalities or supine positioning.^9,10

In this context, LUS has emerged as a promising diagnostic modality. Lung ultrasound offers superior sensitivity and specificity compared to CXR, particularly in identifying subpleural consolidations and dynamic air bronchograms.¹¹ Moreover, LUS is a bedside, radiation-free technique, provides real-time visualization of pulmonary pathology. When combined with biomarkers, LUS enhances the timely diagnosis and management of VAP, supports continuous monitoring, and reduces diagnostic delays, thereby improving patient care in the ICU setting.^12,13 However, existing studies have primarily focused on diagnostic performance without incorporating expert-adjudicated reference standards or evaluating longitudinal aeration changes during treatment. Furthermore, the clinical feasibility and operational integration of daily LUS in ICU workflows have been sparsely addressed. This study aimed to address these gaps by assessing the effectiveness of LUS in the early diagnosis of VAP by comparing its diagnostic performance against that of an expert adjudication panel. It also explores the clinical implications of early VAP detection using LUS and its potential to guide individualized management strategies.

Patients and Methods

This prospective observational study was conducted in the Department of Critical Care Medicine (Medical Intensive Care Unit) at the Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India. The study was approved by the Institutional Ethics Committee of the IMS and SUM Hospital (Ref. no/ECR/627/Inst/OR/2014) and was registered with the Clinical Trials Registry of India (CTRI) under the registration number CTRI/2022/10/046326.

The study included adult patients aged 18 years or older who were expected to require invasive mechanical ventilation for more than 48 hours. Exclusion criteria were as follows: Patients younger than 18 years, those not requiring mechanical ventilation, anticipated ventilation duration of less than 48 hours, death within 48 hours of intubation, and contraindications to mini-bronchoalveolar lavage (mini-BAL) procedures, which were clinicians’ decision based on clinical condition, especially FiO₂ and PEEP settings.

Severe hypoxemia unresponsive to oxygen therapy (risk of worsening desaturation during the procedure).

• Hemodynamic instability (e.g., shock not responsive to fluids or vasopressors).

• Severe bronchospasm (risk of further airway compromise).

• Significant coagulopathy (e.g., platelet count < 20,000/µL, INR >2.0, or active bleeding).

These criteria ensure a targeted study population comprising adult patients requiring prolonged mechanical ventilation while excluding those who may not benefit from or are unsuitable for the study procedures.

Patient screening and eligibility assessment were conducted daily by designated study investigators not involved in direct patient management, applying standardized inclusion and exclusion criteria. Patients who developed new-onset hemodynamic instability, refractory shock, or other exclusion criteria after enrollment had planned study procedures (such as LUS or mini-BAL) postponed until clinical stabilization. If clinical instability persisted such that protocol assessments could not be safely performed within the prespecified time frame, the patient was withdrawn from further study-related procedures but continued to receive routine clinical care. After obtaining ethical clearance and securing informed consent from the patients or their legally authorized representatives (where the patient could not consent), LUS was performed using a bedside ultrasound machine (SAMSUNG HS40, SAMSUNG MEDISON CO., LTD) equipped with a 2–5 MHz (C2-5) convex transducer. All LUS examinations were performed and interpreted by a single investigator who had independently performed over 50 LUS examinations under supervision, prior to the study initiation. The investigator was blinded to other outcome parameters and not involved in patient care.

Ultrasonographic examinations were conducted 48 hours post-intubation until VAP was diagnosed according to predefined LUS criteria, with the patients positioned in a semi-recumbent posture to optimize imaging conditions and patient comfort. Simultaneously, CPIS was calculated daily, and clinical diagnosis of VAP was made when the CPIS score exceeded six. For every suspected case, a dossier of all clinical, microbiological, and radiological data (excluding LUS results) was provided to a blinded expert panel, which retrospectively adjudicated the presence or absence of VAP and served as the gold standard for final diagnosis. The comparison of time to VAP diagnosis was based on the timing of LUS vs CPIS criteria crossing their diagnostic thresholds.

Each hemithorax was systematically assessed by dividing it into six regions using the parasternal, anterior axillary, and posterior axillary lines, resulting in anterior, lateral, and posterior zones on both lungs, subdivided into superior and inferior areas. This ensured comprehensive pulmonary coverage and standardized documentation. Ultrasonographic findings focused on VAP indicators, such as subpleural consolidations, dynamic air bronchograms, B-lines, and pleural effusions, were meticulously recorded for each region. Concurrently, clinical data, including demographics, severity scores, ventilator settings, and lab results, were collected.

The LUS scoring system assigns points based on specific ultrasonographic findings: Two points are given for the presence of a dynamic air bronchogram in any lung region; one point each is assigned for lobar or subpleural consolidation present in two or more areas; and two points are awarded if both at least one lobar and one subpleural consolidation are identified. A total LUS score of ≥2 was used as the threshold for diagnosing VAP. These criteria and cut-off were selected based on prior studies demonstrating that dynamic air bronchograms and multifocal consolidations are highly specific sonographic markers for pneumonia in critically ill, mechanically ventilated patients.¹⁴ Lung ultrasound aeration score (LUSS) was assessed on a scale from 0 to 3: 0 for normal aeration, one for moderate loss (three or more well-spaced B-lines), two for severe loss (coalescent B-lines or subpleural consolidations), and three for complete loss (dynamic air bronchograms). The global aeration score was derived from the most severe findings in 12 regions.¹² Patients with a decrease in LUSS of two between days 1 and 5 of antibiotic treatment were classified as responders (delta aeration score >2), while those without a decrease or with an increase in LUSS were classified as non-responders.¹⁵

Clinical VAP was diagnosed by the treating physician based on the CPIS, which integrates multiple clinical, radiological, and laboratory parameters. The CPIS includes the following components: body temperature, leukocyte count, volume and character of tracheal secretions, oxygenation (PaO₂/FiO₂ ratio), chest radiograph findings, and results of microbiological cultures. A CPIS score of ≥6 was considered indicative of VAP and was used as the diagnostic threshold in this study. This approach recognizes the limitations of scoring systems and emphasizes the importance of clinical expertise in ICU patient management.

Given the absence of a universally accepted gold standard for diagnosing VAP, this study employed an expert adjudication panel as the reference standard. It comprises three senior intensivists, each with more than 10 years of ICU experience and no involvement in direct patient care or ultrasound interpretation. The panel followed a standardized, blinded adjudication process, independently reviewing comprehensive clinical data for each suspected case. This included the following:

• Clinical parameters: Fever or hypothermia, purulent tracheal secretions, worsening oxygenation (PaO₂/FiO₂), leukocytosis or leukopenia.

• Radiological findings: Presence of a new or progressive infiltrate on CXR.

• Microbiological results: Positive cultures from endotracheal aspirates or mini-BAL samples.

All three domains were considered in making the diagnosis. The panel was blinded to LUS findings and CPIS scores to minimize bias. After independent review, the panelists reached a consensus diagnosis for each case, classifying patients as either “VAP present” or “VAP absent.” Cases without consensus underwent detailed discussions until unanimous agreement was achieved. This adjudication approach aligns with current best practices and reflects a pragmatic gold standard for VAP diagnosis in the absence of a single definitive diagnostic test, as recommended in recent literature.

Data collection was performed prospectively by study investigators who were not involved in patient care, using standardized forms to ensure consistency and minimize bias. All data were subsequently entered into a secure database. Statistical analysis was conducted independently by a designated investigator who was not involved in LUS image acquisition or clinical management, to ensure objectivity in data interpretation. Baseline data on patient demographics, comorbidities, ICU admission reasons, and illness severity scores, including the Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation II (APACHE II), were collected to provide a comprehensive overview of health status and VAP risk factors. Lung ultrasound, CPIS, and lung aeration scores were recorded at predefined time points (i.e., at the time of diagnosis of VAP, both by LUS and clinically, and at day 5) to monitor changes. Microbiological samples were obtained using mini-BAL procedures to identify pathogens and guide antimicrobial therapy.

The primary objective of this study was to assess the effectiveness of LUS in the early diagnosis of VAP by comparing its diagnostic performance against that of an expert adjudication panel. This evaluation involved assessing the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of LUS findings in the diagnosis of VAP. Secondary outcomes included examining correlations between changes in lung aeration scores and clinical outcomes, such as 28-day survival rates, as well as measuring the duration of mechanical ventilation and the length of ICU stay. These outcomes were chosen to provide a comprehensive assessment of LUS as a diagnostic tool for VAP and its potential impact on patient care in an intensive care setting.

Sample size calculation was conducted to ensure sufficient precision in estimating the diagnostic sensitivity of LUS for VAP. Based on previous literature, we assumed an expected LUS sensitivity of 90%, with a desired confidence interval width of ± 7%, and the minimum required number of VAP cases was 71.

We meticulously collected the data and entered it into a secure database for thorough analysis. We described continuous variables using the median and interquartile range (IQR). This approach provides a robust measure of the central tendency and variability that is less affected by outliers than the mean and standard deviation. Categorical variables are expressed as frequencies and percentages to illustrate the distribution of the different categories within our sample.

To compare continuous variables between two independent groups, we used the Mann–Whitney U test. This non-parametric test is appropriate for non-normally distributed data, allowing for median comparisons without the assumptions of parametric tests like the t-test. For assessing changes in related samples over time, such as lung aeration scores at different time points, the Wilcoxon signed-rank test was employed. This test is ideal for paired data from the same subject at multiple time points, analyzing differences within individuals without assuming normal distribution.

The Chi-squared test assessed the association between categorical variables and outcomes, such as ultrasonographic findings and VAP diagnosis. Statistical significance was set at p-values below 0.05. Patients who died or were discharged before day 5 of antibiotic therapy were excluded from the aeration score-based response analysis due to incomplete serial ultrasound data. Analyses were conducted using IBM SPSS Statistics version 25.0, selected for its user-friendly interface and robust data management and analysis capabilities, to ensure reliable and reproducible findings.

Results

A total of 435 patients were assessed for eligibility during this study period from March 2022 to September 2023, of which 229 patients were excluded due to various reasons as mentioned above. A total of 206 patients were enrolled in the study, out of which 73 patients developed VAP confirmed by expert panel adjudication (Fig. 1). Out of 73 patients, 24 were responders, and 40 were non-responders. For nine patients, the delta aeration score could not be calculated as they died before day 5, so excluded from further subgroup analysis.

Fig. 1.

STROBE diagram of patients recruited for the study

The median age of the participants was 57 years, with 61.6% male and 38.4% female. The severity of illness was assessed using the APACHE II and SOFA scoring systems, which yielded median scores of 24 and 9, respectively. The median CPIS was 7. The median duration of mechanical ventilation was 17 days, and the median ICU stay was 19 days. The most common comorbidities were hypertension (54.8%), type 2 diabetes mellitus (38.4%), and chronic kidney disease (21.9%). The baseline characteristics are shown in Table 1.

Table 1.

Demographics and baseline characteristics

Basic details median (IQR)/frequency (%)	All (N = 73)	Responder (N = 24)	Non-responder (N = 40)	p-value
Age (yrs)	57 (42–67)	60 (50–68)	55 (36–63)	0.08
Gender
Male	45 (61.6%)	14 (58.3%)	23 (57.5%)	0.47
Female	28 (38.4%)	10 (41.7%)	17 (42.5%)
APACHE II	24 (20–29)	26 (21–29)	23 (19–28)	0.28
SOFA	9 (6–10)	8 (6–9)	9 (7–10)	0.32
CPIS	7 (4–10)	7 (4–9)	7 (5–12)	0.63
Comorbidities	N (%)
T2DM	28 (38.4%)	12 (50%)	10 (25%)	0.02
HTN	40 (54.8%)	18 (75%)	14 (35%)	0.01
CAD	3 (4.1%)	0 (0%)	1 (2.5%)	0.62
COPD	10 (13.7%)	4 (16.6%)	4 (10%)	0.34
CKD	16 (21.9%)	4 (16.6%)	6 (15%)	0.56
CLD	5 (6.8%)	1 (4.16%)	1 (2.5%)	0.61
Diagnosis	N (%)
CNS	26	9 (37.5%)	14 (35%)	0.246
Respiratory	15	6 (25%)	9 (22.5%)	0.82
Renal	8	2 (8.3%)	5 (12.5%)	0.70
GIT	12	3 (12.5%)	7 (17.5%)	0.73
CVS	4	2 (8.3%)	00	0.13
Others	8	2 (8.3%)	5 (12.5%)	0.70

APACHE, Acute Physiology and Chronic Health Evaluation; CAD, coronary artery disease; COPD, chronic obstructive airway disease; CKD, chronic kidney disease; CLD, chronic liver disease; CNS, central nervous system; CVS, cardiovascular system; DM, diabetic mellitus; GIT, gastro intestinal system; HTN, hypertension; IQR, interquartile range; SOFA, Sequential Organ Function Assessment

The median time to diagnosis was significantly shorter with LUS compared to CPIS, reflecting earlier identification. Additionally, the interquartile range was narrower for LUS, indicating more consistent diagnostic timing. In contrast, clinical diagnosis showed a broader distribution and longer median time, suggesting greater variability and delay in recognition (Fig. 2).

Fig. 2.

Graphical representation of time difference (in hours) between diagnosing VAP by lung ultrasonography and clinical diagnosis by CPIS

Diagnostic Accuracy of LUS

A total of 206 patients were evaluated using LUS and adjudicated by an expert clinical panel. Lung ultrasound identified consolidation consistent with pneumonia in 83 patients (40.3%). Of these, pneumonia was confirmed by the expert panel in 67 cases, yielding a PPV of 80.7% and a false-positive rate of 12.03% (16/133). Among the 123 patients with a negative LUS finding, pneumonia was subsequently diagnosed in six cases by the expert panel, corresponding to a false-negative rate of 8.22% and a NPV of 95.1%. Using expert diagnosis as the gold standard, LUS demonstrated a sensitivity of 91.78% and a specificity of 87.97% (Fig. 3).

Fig. 3.

Impact of expert panel adjudication on VAP diagnosis

Among the 73 patients diagnosed with VAP, 64 were eligible for follow-up aeration score analysis, as nine patients died before day 5 of antibiotic treatment. Of these, 24 patients (37.5%) were classified as responders, defined by a delta aeration score >2 between day 1 and day 5 of therapy. The survival rate among responders was 75.0%, compared to 52.5% in non-responders—a difference that approached but did not reach statistical significance (p = 0.074). Although responders had slightly longer median ICU stays (21 vs 19 days) and ventilator durations (19 vs 18 days), these differences were not statistically significant (p = 0.574 and p = 0.453, respectively) (Table 2). Serial LUS assessments demonstrated dynamic changes in lung aeration: The median aeration score was 17 (IQR: 14–20) at the time of LUS diagnosis (AS-1) and 20 (IQR: 16–24) on the day of clinical diagnosis and antibiotic escalation (AS-2) and declined to 18 (IQR: 14–24) by day 5 of treatment (AS-3) (Table 3).

Table 2.

Secondary outcome variables

Outcome variable	All	Responder	Non-responder	p-value
Ventilator days median (IQR)	17 (12–22)	19 (14–24)	18 (12–21)	0.45
LOS (ICU) median (IQR)	19 (15–25)	21 (16–25)	19 (15–27)	0.57
28-day survival
Survivor N (%)	39 (61%)	18 (75.0%)	21 (52.5%)	0.07
Non-survivor N (%)	25 (39%)	6 (25.0%)	19 (47.5%)	–

ICU, intensive care unit; LOS, length of stay

Table 3.

Lung ultrasonographic parameters

Parameters	Media (IQR)
LUS score at diagnosis of VAP	3 (2–3)
Aeration score on day of VAP diagnosis by LUS: (AS-1)	17 (14–20)
Aeration score on day of clinical diagnosis and antibiotic escalation: (AS-2)	20 (16–24)
Aeration score on d5 of antibiotic escalation: (AS-3)	18 (14–24)

LUS, lung ultrasound; VAP, ventilator-associated pneumonia

Discussion

This prospective study demonstrates that LUS enables earlier detection of VAP in critically ill adults compared to conventional clinical assessment. Lung ultrasound identified VAP at a median of 150 hours post-intubation vs 178.5 hours for CPIS (p < 0.001), supporting its value as a prompt, bedside diagnostic tool. Early diagnosis is critical, as delayed initiation of antibiotics is associated with adverse outcomes in ICU patients.

Lung ultrasound offers additional practical advantages, particularly for resource-limited settings. As a portable, radiation-free, and low-cost modality, LUS can be performed at the bedside, eliminating the need for patient transport and expensive imaging infrastructure. This accessibility makes LUS especially valuable where access to computed tomography (CT) or serial chest X-rays is limited and supports its broader integration into standard ICU care.^11,12

Given the lack of a universally accepted gold standard for VAP diagnosis, our study adopted a blinded expert panel as the reference standard, integrating clinical, microbiological, and radiological data. This consensus-based approach addresses the limitations of single-method criteria: BAL cultures may yield false negatives due to prior antibiotics, while clinical scores such as CPIS lack specificity due to overlap with non-infectious processes like ARDS or pulmonary edema.^16–18 Although this approach introduces some subjectivity, recent studies support its clinical validity and relevance, making expert panel adjudication one of the most pragmatic and accepted reference standards for VAP research.^19,20

Our results align with previous studies and meta-analyses demonstrating that LUS outperforms chest radiography and clinical scores in pneumonia detection, with pooled sensitivities for LUS reaching up to 96%.^21–23 This diagnostic advantage in our cohort likely stems from LUS's ability to identify subpleural consolidations and dynamic air bronchograms, which often precede changes seen on radiography.²⁴

While our findings reinforce the diagnostic value of LUS in VAP, this study introduces important clinical distinctions. Lung ultrasound-enabled earlier identification of VAP, with a median time to diagnosis of 150 hours post-intubation compared to 178.5 hours with CPIS (p < 0.001), providing greater temporal precision than previously reported in the literature. This early detection has important implications for timely intervention in critically ill patients. Notably, our use of a detailed LUS scoring system, combined with systematic daily assessments starting at 48 hours post-intubation and a focus on an adult ICU population, may explain the higher specificity (87.9%) and PPV (80.7%) observed at a diagnostic score threshold of ≥2. These methodological refinements likely contributed to the robust diagnostic performance demonstrated in this cohort.

However, LUS did not achieve perfect agreement with the expert panel reference standard. This is likely attributable to its inherent limitations in distinguishing infectious from non-infectious consolidations—such as atelectasis, pulmonary edema, or infarction—which may appear similar on ultrasound. Additionally, LUS is most sensitive for detecting peripheral lesions and may miss centrally located VAP, highlighting the importance of integrating LUS findings with comprehensive clinical and laboratory assessment for optimal diagnostic accuracy.

Beyond diagnosis, this study underscores the value of serial LUS for monitoring treatment response. Patients with early improvement in lung aeration over five days showed a trend toward higher 28-day survival (75 vs 52.5%, p = 0.074), although the study was not powered to detect mortality differences, and this finding should be interpreted cautiously. Serial LUS provided timely insights into disease progression, supporting individualized care. Non-responders had poorer outcomes, highlighting the need for alternative therapies in this subgroup.

There are several limitations. As a single-center study with 73 VAP cases in adult patients, generalizability is limited. Exclusion of patients with contraindications to mini-BAL may introduce selection bias. All LUS assessments were performed by a single, certified investigator using a standardized protocol, but operator dependence remains a concern; structured training and future integration of AI-based tools may help address this. CT, often considered a diagnostic gold standard, was not used due to safety concerns, and so we relied on expert panel adjudication. Long-term outcomes such as antibiotic stewardship and cost-effectiveness were not evaluated.

Despite these limitations, the study's rigorous design—including blinded expert adjudication and validated LUS scoring—strengthens the findings. Multicenter studies with larger samples and extended follow-up are needed to further validate the role of LUS for early diagnosis and monitoring of VAP in the ICU.

Conclusion

This prospective observational study demonstrates that LUS enables earlier detection and monitoring of VAP in critically ill patients compared to CPIS. Although patients with early improvement in lung aeration exhibited higher survival rates, this difference did not reach statistical significance. Larger studies are needed to validate the prognostic utility of LUS and to determine its impact on clinical outcomes in this population.

Availability of Data and Materials

All data generated or analyzed during this study are included in this published article.

Author Contributions

Cherian Roy: Conceptualization; Writing original draft.

Satyajit Choudhury: Methodology; Writing original draft; Supervision.

Pritam Chhotray: Design of the work; Manuscript editing.

E Shantanu Kumar Patra: Data analysis; manuscript editing

Sagarika Panda: Methodology; supervision; writing original draft.

Shakti Bedanta Mishra: Conceptualization; supervision; manuscript editing.

Acknowledgments

The authors would like to thank the paramedical and nursing staff for their unwavering commitment to patient care.

Ethics Approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Ethics Committee of the IMS and SUM Hospital (Ref. no/ECR/627/Inst/OR/2014).

Clinical Trial Registry Number

CTRI/2022/10/046326.

Orcid

Cherian Roy https://orcid.org/0000-0002-9241-4299

Satyajit Choudhury https://orcid.org/0000-0003-4931-6447

Pritam Chhotray https://orcid.org/0000-0002-1996-1181

E Shantanu K Patra https://orcid.org/0000-0003-2707-6825

Sagarika Panda https://orcid.org/0000-0002-8547-5720

Shakti B Mishra https://orcid.org/0000-0001-6634-1877