1
|
Luo L, Li Y, Wang L, Sun B, Tong Z. Ultrasound evaluation of cardiac and diaphragmatic function at different positions during a spontaneous breathing trial predicting extubation outcomes: a retrospective cohort study. BMC Med Imaging 2024; 24:217. [PMID: 39148010 PMCID: PMC11328514 DOI: 10.1186/s12880-024-01357-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 07/05/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND The ratio (E/Ea) of mitral Doppler inflow velocity to annular tissue Doppler wave velocity by transthoracic echocardiography and diaphragmatic excursion (DE) by diaphragm ultrasound have been confirmed to predict extubation outcomes. However, few studies focused on the predicting value of E/Ea and DE at different positions during a spontaneous breathing trial (SBT), as well as the effects of △E/Ea and △DE (changes in E/Ea and DE during a SBT). METHODS This study was a reanalysis of the data of 60 difficult-to-wean patients in a previous study published in 2017. All eligible participants were organized into respiratory failure (RF) group and extubation success (ES) group within 48 h after extubation, or re-intubation (RI) group and non-intubation (NI) group within 1 week after extubation. The risk factors for respiratory failure and re-intubation including E/Ea and △E/Ea, DE and △DE at different positions were analyzed by multivariate logistic regression, respectively. The receiver operating characteristic (ROC) curves of E/Ea (septal, lateral, average) and DE (right, left, average) were compared with each other, respectively. RESULTS Of the 60 patients, 29 cases developed respiratory failure within 48 h, and 14 of those cases required re-intubation within 1 week. Multivariate logistic regression showed that E/Ea were all associated with respiratory failure, while only DE (right) and DE (average) after SBT were related to re-intubation. There were no statistic differences among the ROC curves of E/Ea at different positions, nor between the ROC curves of DE. No statistical differences were shown in △E/Ea between RF and ES groups, while △DE (average) was remarkably higher in NI group than that in RI group. However, multivariate logistic regression analysis showed that △DE (average) was not associated with re-intubation. CONCLUSIONS E/Ea at different positions during a SBT could predict postextubation respiratory failure with no statistical differences among them. Likewise, only DE (right) and DE (average) after SBT might predict re-intubation with no statistical differences between each other.
Collapse
Affiliation(s)
- Ling Luo
- Department of Respiratory and Critical Care Medicine, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Yidan Li
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lifang Wang
- Epidemiology Research Center, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China.
| |
Collapse
|
2
|
Cappellini I, Cardoni A, Campagnola L, Consales G. MUltiparametric Score for Ventilation Discontinuation in Intensive Care Patients: A Protocol for an Observational Study. Methods Protoc 2024; 7:45. [PMID: 38804339 PMCID: PMC11130949 DOI: 10.3390/mps7030045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/08/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Mechanical ventilation significantly improves patient survival but is associated with complications, increasing healthcare costs and morbidity. Identifying optimal weaning times is paramount to minimize these risks, yet current methods rely heavily on clinical judgment, lacking specificity. METHODS This study introduces a novel multiparametric predictive score, the MUSVIP (MUltiparametric Score for Ventilation discontinuation in Intensive care Patients), aimed at accurately predicting successful extubation. Conducted at Santo Stefano Hospital's ICU, this single-center, observational, prospective cohort study will span over 12 months, enrolling adult patients undergoing invasive mechanical ventilation. The MUSVIP integrates variables measured before and during a spontaneous breathing trial (SBT) to formulate a predictive score. RESULTS Preliminary analyses suggest an Area Under the Curve (AUC) of 0.815 for the MUSVIP, indicating high predictive capacity. By systematically applying this score, we anticipate identifying patients likely to succeed in weaning earlier, potentially reducing ICU length of stay and associated healthcare costs. CONCLUSION This study's findings could significantly influence clinical practices, offering a robust, easy-to-use tool for optimizing weaning processes in ICUs.
Collapse
Affiliation(s)
- Iacopo Cappellini
- Department of Critical Care, Section of Anesthesiology and Critical Care, Azienda USL Toscana Centro, Ospedale Santo Stefano, 59100 Prato, Italy; (L.C.); (G.C.)
| | - Andrea Cardoni
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy;
| | - Lorenzo Campagnola
- Department of Critical Care, Section of Anesthesiology and Critical Care, Azienda USL Toscana Centro, Ospedale Santo Stefano, 59100 Prato, Italy; (L.C.); (G.C.)
| | - Guglielmo Consales
- Department of Critical Care, Section of Anesthesiology and Critical Care, Azienda USL Toscana Centro, Ospedale Santo Stefano, 59100 Prato, Italy; (L.C.); (G.C.)
| |
Collapse
|
3
|
Leyba K, Longino A, Ormesher R, Krienke M, Van Ochten N, Zimmerman K, McCormack L, Martin K, Thai T, Furgeson S, Teitelbaum I, Burke J, Douglas I, Gill E. Venous excess ultrasonography (VExUS) captures dynamic changes in volume status surrounding hemodialysis: A multicenter prospective observational study. RESEARCH SQUARE 2024:rs.3.rs-4185584. [PMID: 38659788 PMCID: PMC11042415 DOI: 10.21203/rs.3.rs-4185584/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Background The evaluation of volume status is essential to clinical decision-making, yet multiple studies have shown that physical exam does not reliably estimate a patient's intravascular volume. Venous excess ultrasound score (VExUS) is an emerging volume assessment tool that utilizes inferior vena cava (IVC) diameter and pulse-wave Doppler waveforms of the portal, hepatic and renal veins to evaluate venous congestion. A point-of-care ultrasound exam initially developed by Beaubein-Souligny et al., VExUS represents a reproducible, non-invasive and accurate means of assessing intravascular congestion. VExUS has recently been validated against RHC-the gold-standard of hemodynamic evaluation for volume assessment. While VExUS scores were shown to correlate with elevated cardiac filling pressures (i.e., right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP)) at a static point in time, the ability of VExUS to capture dynamic changes in volume status has yet to be elucidated. We hypothesized that paired VExUS examinations performed before and after hemodialysis (HD) would reflect changes in venous congestion in a diverse patient population. Methods Inpatients with end-stage renal disease undergoing intermittent HD were evaluated with transabdominal VExUS and lung ultrasonography before and following HD. Paired t-tests were conducted to assess differences between pre-HD and post-HD VExUS scores, B-line scores and dyspnea scores. Results Fifty-six patients were screened for inclusion in this study. Ten were excluded due to insufficient image quality or incomplete exams, and forty-six patients (ninety-two paired ultrasound exams) were included in the final analysis. Paired t-test analysis of pre-HD and post-HD VExUS scores revealed a mean VExUS grade change of 0.82 (p<0.001) on a VExUS scale ranging from 0 to 4. The mean difference in B-line score following HD was 0.8 (p=0.001). There was no statistically significant difference in subjective dyspnea score (p=0.41). Conclusions Large-volume fluid removal with HD was represented by changes in VExUS score, highlighting the utility of the VExUS exam to capture dynamic shifts in intravascular volume status. Future studies should evaluate change in VExUS grade with intravenous fluid or diuretic administration, with the ultimate goal of evaluating the capacity of a standardized bedside ultrasound protocol to guide inpatient volume optimization.
Collapse
|
4
|
Al-Husinat L, Jouryyeh B, Rawashdeh A, Robba C, Silva PL, Rocco PRM, Battaglini D. The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients. Diagnostics (Basel) 2024; 14:398. [PMID: 38396437 PMCID: PMC10888003 DOI: 10.3390/diagnostics14040398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/22/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.
Collapse
Affiliation(s)
- Lou’i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Basil Jouryyeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Ahlam Rawashdeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, 16132 Genova, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
| |
Collapse
|
5
|
Vignon P. Cardiopulmonary interactions during ventilator weaning. Front Physiol 2023; 14:1275100. [PMID: 37745230 PMCID: PMC10512459 DOI: 10.3389/fphys.2023.1275100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Weaning a critically-ill patient from the ventilator is a crucial step in global management. This manuscript details physiological changes induced by altered heart-lung interactions during the weaning process, illustrates the main mechanisms which could lead to weaning failure of cardiac origin, and discuss a tailored management based on the monitoring of changes in central hemodynamics during weaning. The transition from positive-pressure ventilation to spontaneous breathing results in abrupt hemodynamic and metabolic changes secondary to rapidly modified heart-lung interactions, sudden changes in cardiac loading conditions, and increased oxygen demand. These modifications may elicit an excessive burden on both the respiratory and cardiovascular systems, result in a rapid and marked increase of left ventricular filling pressure, and ultimately result in a weaning-induced pulmonary oedema (WIPO). The T-piece trial induces the greatest burden on respiratory and cardiocirculatory function when compared to spontaneous breathing trial using pressure support ventilation with positive or zero end-expiratory pressure. Since LV overload is the mainstay of WIPO, positive fluid balance and SBT-induced acute hypertension are the most frequently reported mechanisms of weaning failure of cardiac origin. Although the diagnosis of WIPO historically relied on an abrupt elevation of pulmonary artery occlusion pressure measured during right heart catheterization, it is nowadays commonly documented by echocardiography Doppler. This non-invasive approach is best suited for identifying high-risk patients, depicting the origin of WIPO, and tailoring individual management. Whether this strategy increases the success rate of weaning needs to be evaluated in a population at high risk of weaning failure of cardiac origin.
Collapse
Affiliation(s)
- Philippe Vignon
- Medical-surgical ICU and Inserm CIC 1435, Dupuytren University Hospital, Limoges, France
- Faculty of Medicine, University of Limoges, Limoges, France
| |
Collapse
|
6
|
Zhang H, Lian H, Wang X, Zhang Q, Liu D. Tricuspid annular plane systolic excursion/mitral annular plane systolic excursion ratio in critically ill patients: an index of right- and left-ventricular function mismatch and a risk factor for cardiogenic pulmonary edema. BMC Anesthesiol 2023; 23:175. [PMID: 37217863 DOI: 10.1186/s12871-023-02142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND This study aimed to explore whether the tricuspid annular systolic excursion (TAPSE)/mitral annular systolic excursion (MAPSE) ratio was associated with the occurrence of cardiogenic pulmonary edema (CPE) in critically ill patients. MATERIALS AND METHODS This was a prospective observational study conducted in a tertiary hospital. Adult patients admitted to the intensive care unit who were on mechanical ventilation or in need of oxygen therapy were prospectively screened for enrolment. The diagnosis of CPE was determined based on lung ultrasound and echocardiography findings. TAPSE ≥ 17 mm and MAPSE ≥ 11 mm were used as normal references. RESULTS Among the 290 patients enrolled in this study, 86 had CPE. In the logistic regression analysis, the TASPE/MAPSE ratio was independently associated with the occurrence of CPE (odds ratio 4.855, 95% CI: 2.215-10.641, p < 0.001). The patients' heart function could be categorized into four types: normal TAPSE in combination with normal MAPSE (TAPSE↑/MAPSE↑) (n = 157), abnormal TAPSE in combination with abnormal MAPSE (TAPSE↓/MAPSE↓) (n = 40), abnormal TAPSE in combination with normal MAPSE (TAPSE↓/MAPSE↑) (n = 50) and normal TAPSE in combination with abnormal MAPSE (TAPSE↑/MAPSE↓) (n = 43). The prevalence of CPE in patients with TAPSE↑/MAPSE↓ (86.0%) was significantly higher than that in patients with TAPSE↑/MAPSE↑ (15.3%), TAPSE↓/MAPSE↓ (37.5%), or TAPSE↓/MAPSE↑ (20.0%) (p < 0.001). The ROC analysis showed that the area under the curve for the TAPSE/MAPSE ratio was 0.761 (95% CI: 0.698-0.824, p < 0.001). A TAPSE/MAPSE ratio of 1.7 allowed the identification of patients at risk of CPE with a sensitivity of 62.8%, a specificity of 77.9%, a positive predictive value of 54.7% and a negative predictive value of 83.3%. CONCLUSIONS The TAPSE/MAPSE ratio can be used to identify critically ill patients at higher risk of CPE.
Collapse
Affiliation(s)
- Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
| | - Qing Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| |
Collapse
|
7
|
Chuang CY, Hsu HS, Chen GJ, Chuang TY, Tsai MH. Underweight predicts extubation failure after planned extubation in intensive care units. PLoS One 2023; 18:e0284564. [PMID: 37053252 PMCID: PMC10101394 DOI: 10.1371/journal.pone.0284564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Body weight is associated with different physiological changes and the association between weight and mortality in critical care setting had been discussed before. In this study, we investigated the linkage between underweight and post-extubation failure in mechanical ventilated patients in critical setting. METHODS This is a retrospective cohort study including patients who were admitted to medical or surgical intensive care units (ICU) between June 2016 and July 2018 and had received endotracheal intubation for more than 72 hours. Those who passed spontaneous breathing trial and underwent a planned extubation were enrolled. Extubation failure was defined as those who required reintubation within the first 72 hours for any reasons. The probability of extubation failure was calculated. Demographic and clinical characteristics were recorded. Multivariate logistic regression models were then used to determine the potential risk factors associated with extubation failure. RESULTS Overall, 268 patients met the inclusion criteria and were enrolled in our study for analysis. The median age of included patients was 67 years (interquartile range, 55-80 years) with 65.3% being male; 63.1% of the patients were included from medical ICU. The proportion of extubation failure in our cohort was 7.1% (19/268; 95% confidence interval [CI], 4.3-10.9%). Overall, underweight patients had the highest risk of extubation failure (8/50), as compared with normoweight (9/135) and overweight patients (2/83). In the multivariate analysis, being underweight (adjust OR [aOR], 3.80, compared to normoweight; 95% CI, 1.23-11.7) and lower maximal inspiratory airway pressure (aOR per one cmH2O decrease, 1.05; 95% CI 1.00-1.09) remained significantly associated with extubation failure. CONCLUSION In our study, being underweight and lower maximal inspiratory airway pressure was associated with post-extubation respiratory failure after a planned extubation.
Collapse
Affiliation(s)
- Chung-Yeh Chuang
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Han-Shui Hsu
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Thoracic Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Guan-Jhou Chen
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Infection Control Room, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Tzu-Yi Chuang
- Department of Chest Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Ming-Han Tsai
- Department of Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| |
Collapse
|
8
|
Formenti P, Coppola S, Massironi L, Annibali G, Mazza F, Gilardi L, Pozzi T, Chiumello D. Left Ventricular Diastolic Dysfunction in ARDS Patients. J Clin Med 2022; 11:jcm11205998. [PMID: 36294319 PMCID: PMC9604741 DOI: 10.3390/jcm11205998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/26/2022] [Accepted: 10/07/2022] [Indexed: 12/16/2022] Open
Abstract
Background: The aim of this study was to evaluate the possible presence of diastolic dysfunction and its possible effects in terms of respiratory mechanics, gas exchange and lung recruitability in mechanically ventilated ARDS. Methods: Consecutive patients admitted in intensive care unit (ICU) with ARDS were enrolled. Echocardiographic evaluation was acquired at clinical PEEP level. Lung CT-scan was performed at 5 and 45 cmH2O. In the study, 2 levels of PEEP (5 and 15 cmH2O) were randomly applied. Results: A total of 30 patients were enrolled with a mean PaO2/FiO2 and a median PEEP of 137 ± 52 and 10 [9–10] cmH2O, respectively. Of those, 9 patients (30%) had a diastolic dysfunction of grade 1, 2 and 3 in 33%, 45% and 22%, respectively, without any difference in gas exchange and respiratory mechanics. The total lung weight was significantly higher in patients with diastolic dysfunction (1669 [1354–1909] versus 1554 [1146–1942] g) but the lung recruitability was similar between groups (33.3 [27.3–41.4] versus 30.6 [20.0–38.8] %). Left ventricular ejection fraction (57 [39–62] versus 60 [57–60]%) and TAPSE (20.0 [17.0–24.0] versus 24.0 [20.0–27.0] mL) were similar between the two groups. The response to changes of PEEP from 5 to 15 cmH2O in terms of oxygenation and respiratory mechanics was not affected by the presence of diastolic dysfunction. Conclusions: ARDS patients with left ventricular diastolic dysfunction presented a higher amount of lung edema and worse outcome.
Collapse
Affiliation(s)
- Paolo Formenti
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, 20142 Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, 20142 Milan, Italy
| | - Laura Massironi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, 20142 Milan, Italy
| | - Giacomo Annibali
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Francesco Mazza
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Lisa Gilardi
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Tommaso Pozzi
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, 20142 Milan, Italy
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
- Coordinated Research Center on Respiratory Failure, University of Milan, 2014 Milan, Italy
- Correspondence:
| |
Collapse
|
9
|
Abstract
PURPOSE OF REVIEW Due to heart, lung and diaphragm interactions during weaning from mechanical ventilation, an ultrasound integrated approach may be useful in the detection of dysfunctions potentially leading to weaning failure. In this review, we will summarize the most recent advances concerning the ultrasound applications relevant to the weaning from mechanical ventilation. RECENT FINDINGS The role of ultrasonographic examination of heart, lung and diaphragm has been deeply investigated over the years. Most recent findings concern the ability of lung ultrasound in detecting weaning induced pulmonary edema during spontaneous breathing trial. Furthermore, in patients at high risk of cardiac impairments, global and anterolateral lung ultrasound scores have been correlated with weaning and extubation failure, whereas echocardiographic indexes were not. For diaphragmatic ultrasound evaluation, new indexes have been proposed for the evaluation of diaphragm performance during weaning, but further studies are needed to validate these results. SUMMARY The present review summarizes the potential role of ultrasonography in the weaning process. A multimodal integrated approach allows the clinician to comprehend the pathophysiological processes of weaning failure.
Collapse
|
10
|
Berger D, Wigger O, de Marchi S, Grübler MR, Bloch A, Kurmann R, Stalder O, Bachmann KF, Bloechlinger S. The effects of positive end-expiratory pressure on cardiac function: a comparative echocardiography-conductance catheter study. Clin Res Cardiol 2022; 111:705-719. [PMID: 35381904 PMCID: PMC9151717 DOI: 10.1007/s00392-022-02014-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/21/2022] [Indexed: 01/09/2023]
Abstract
Background Echocardiographic parameters of diastolic function depend on cardiac loading conditions, which are altered by positive pressure ventilation. The direct effects of positive end-expiratory pressure (PEEP) on cardiac diastolic function are unknown. Methods Twenty-five patients without apparent diastolic dysfunction undergoing coronary angiography were ventilated noninvasively at PEEPs of 0, 5, and 10 cmH2O (in randomized order). Echocardiographic diastolic assessment and pressure–volume-loop analysis from conductance catheters were compared. The time constant for pressure decay (τ) was modeled with exponential decay. End-diastolic and end-systolic pressure volume relationships (EDPVRs and ESPVRs, respectively) from temporary caval occlusion were analyzed with generalized linear mixed-effects and linear mixed models. Transmural pressures were calculated using esophageal balloons. Results τ values for intracavitary cardiac pressure increased with the PEEP (n = 25; no PEEP, 44 ± 5 ms; 5 cmH2O PEEP, 46 ± 6 ms; 10 cmH2O PEEP, 45 ± 6 ms; p < 0.001). This increase disappeared when corrected for transmural pressure and diastole length. The transmural EDPVR was unaffected by PEEP. The ESPVR increased slightly with PEEP. Echocardiographic mitral inflow parameters and tissue Doppler values decreased with PEEP [peak E wave (n = 25): no PEEP, 0.76 ± 0.13 m/s; 5 cmH2O PEEP, 0.74 ± 0.14 m/s; 10 cmH2O PEEP, 0.68 ± 0.13 m/s; p = 0.016; peak A wave (n = 24): no PEEP, 0.74 ± 0.12 m/s; 5 cmH2O PEEP, 0.7 ± 0.11 m/s; 10 cmH2O PEEP, 0.67 ± 0.15 m/s; p = 0.014; E’ septal (n = 24): no PEEP, 0.085 ± 0.016 m/s; 5 cmH2O PEEP, 0.08 ± 0.013 m/s; 10 cmH2O PEEP, 0.075 ± 0.012 m/s; p = 0.002]. Conclusions PEEP does not affect active diastolic relaxation or passive ventricular filling properties. Dynamic echocardiographic filling parameters may reflect changing loading conditions rather than intrinsic diastolic function. PEEP may have slight positive inotropic effects. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02267291, registered 17. October 2014. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-022-02014-1.
Collapse
Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Olivier Wigger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Klinik Für Kardiologie, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Stefano de Marchi
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin R Grübler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Zentrum Für Intensivmedizin, Kantonsspital Luzern, Luzern, Switzerland
| | - Reto Kurmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Klinik Für Kardiologie, Kantonsspital Luzern, Luzern, Switzerland
| | | | - Kaspar Felix Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Zentrum Für Intensivmedizin, Kantonsspital Luzern, Luzern, Switzerland
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital,, University of Bern, Bern, Switzerland
| | - Stefan Bloechlinger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Klinik Für Kardiologie, Kantonsspital Winterthur, Winterthur, Switzerland
| |
Collapse
|
11
|
Gao X, Zou X, Li R, Shu H, Yu Y, Yang X, Shang Y. Application of POCUS in patients with COVID-19 for acute respiratory distress syndrome management: a narrative review. BMC Pulm Med 2022; 22:52. [PMID: 35123448 PMCID: PMC8817642 DOI: 10.1186/s12890-022-01841-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/24/2022] [Indexed: 01/08/2023] Open
Abstract
COVID-19 has inflicted the world for over two years. The recent mutant virus strains pose greater challenges to disease prevention and treatment. COVID-19 can cause acute respiratory distress syndrome (ARDS) and extrapulmonary injury. Dynamic monitoring of each patient's condition is necessary to timely tailor treatments, improve prognosis and reduce mortality. Point-of-care ultrasound (POCUS) is broadly used in patients with ARDS. POCUS is recommended to be performed regularly in COVID-19 patients for respiratory failure management. In this review, we summarized the ultrasound characteristics of COVID-19 patients, mainly focusing on lung ultrasound and echocardiography. Furthermore, we also provided the experience of using POCUS to manage COVID-19-related ARDS.
Collapse
|
12
|
Kundu R, Baidya DK, Anand RK, Maitra S, Soni KD, Subramanium R. Integrated ultrasound protocol in predicting weaning success and extubation failure: a prospective observational study. Anaesthesiol Intensive Ther 2022; 54:156-163. [PMID: 35413786 PMCID: PMC10156490 DOI: 10.5114/ait.2022.115351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 01/30/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Difficulty in weaning from mechanical ventilation is encountered in appro-ximately 20% of patients in the intensive care unit. We assessed the utility of a combined lung, diaphragmatic, and cardiac ultrasound protocol to predict extubation failure. MATERIAL All patients extubated following a successful spontaneous breathing trial (SBT) were included in the study. Lung ultrasonography score (LUS), diaphragmatic thickness fraction (DTF), changes in velocity time integral (VTI) to passive leg raise at the beginning of SBT, and change in LUS following SBT were recorded. RESULTS A total of 60 patients who underwent successful SBT were included in the study. Twenty-seven patients required either non-invasive or invasive mechanical ventilation during the next 48 hours and were classified as weaning failure (Group F). The remaining 33 patients were designated as weaning success (Group S). Compared to group S, patients in Group F had significantly longer ICU length of stay (6.96 ± 4.30 days vs. 11.66 ± 3.85 days, P < 0.001), higher LUS change during SBT (1 [0-2] vs. 2 [1-4], P < 0.001), lower DTF (30.87 ± 5.32 vs. 27.88 ± 6.24, P = 0.04), and showed lower VTI increment to PLR (13.63 ± 3.44 vs. 9.11 ± 4.59, P < 0.001). Using a binary logistic regression model, DTF < 26% (odds ratio 6.20, 95% CI: 1.06-36.04) and VTI change to PLR < 10.2% (odds ratio 6.16, 95% CI: 1.14-33.13) were found to be significant predictors of weaning failure (P < 0.05). The AUROC for VTI and DTF for predicting weaning failure were 0.79 and 0.64, respectively. CONCLUSIONS An integrated ultrasound protocol using a combination of lung, diaphragm, and cardiac sonography was a reliable predictor of weaning failure.
Collapse
Affiliation(s)
- Riddhi Kundu
- Department of Critical Care Medicine, Manipal Hospitals, New Delhi, India
| | - Dalim K. Baidya
- Department of Anaesthesiology, Pain Medicine, and Critical Care, All India Institute of Medical Sciences(AIIMS), New Delhi, India
| | - Rahul K. Anand
- Department of Anaesthesiology, Pain Medicine, and Critical Care, All India Institute of Medical Sciences(AIIMS), New Delhi, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine, and Critical Care, All India Institute of Medical Sciences(AIIMS), New Delhi, India
| | - Kapil D. Soni
- Department of Trauma and Critical Care, All India Institute of Medical Sciences(AIIMS), New Delhi, India
| | - Rajeshwari Subramanium
- Department of Anaesthesiology, Pain Medicine, and Critical Care, All India Institute of Medical Sciences(AIIMS), New Delhi, India
| |
Collapse
|
13
|
Zeid D, Ahmed W, Soliman R, Alazab A, Elsawy AS. Ultrasound-Guided Preload Indices during Different Weaning Protocols of Mechanically Ventilated Patients and its Impact on Weaning Induced Cardiac Dysfunction. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Elevation of the left ventricular (LV) filling pressure can occur during weaning of mechanical ventilation due to increase in LV preload and/or changes in LV compliance and LV afterload.
AIM: The aim of the study was to evaluate respiratory changes in internal jugular vein and inferior vena cava during weaning from mechanical ventilation.
METHODS: Prospective observational study conducted on 80 consecutive patients. Patients were divided randomly into two groups who met the readiness criteria to start spontaneous breathing trial (SBT) either on pressure support ventilation (PS/CPAP) for 30 min or T-piece for 120 min. Weaning failure was defined as a failed SBT or reintubation within 48 h. Echocardiographic evaluation was done on assisted controlled ventilation and at the end of SBT for preload assessment.
RESULTS: Mitral Septal E/E’ Cutoff value ≥6.1 with sensitivity 81% and specificity 84.2%, and AUC 0.73 for predicting weaning failure. IVC distensibility index on CPAP cutoff value ≥66.5% with sensitivity 100% and specificity 68.4%, and AUC 0.85. In Group II, Mitral Septal E/E’ Cut off value ≥5.8 with sensitivity 83% and specificity 90.9%, AUC 0.83, IVC collapsibility index Cut off value ≥45.5% with sensitivity 72% and specificity 86%, AUC 0.73.
CONCLUSION: Mitral Septal E/E’ could predict weaning-induced diastolic dysfunction. IVC plays an important role in predicting weaning failure.
Collapse
|
14
|
Wu ZH, Tang Y, Zhao M, Yu H, Li HD. Association between elevated brain natriuretic peptide levels and weaning failure: A systematic review and meta-analysis. Int J Clin Pract 2021; 75:e14850. [PMID: 34516015 DOI: 10.1111/ijcp.14850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/10/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Cardiovascular dysfunction has been reported as an important mechanism of weaning failure, and recent data suggest that elevated brain natriuretic peptide (BNP) levels is associated with an increased risk of weaning failure. Therefore, we performed this meta-analysis to evaluate the correlation between elevated BNP levels and weaning failure in critically ill patients subject to mechanical ventilation. METHODS A systematic search in Cochrane Library, Embase, PubMed and Web of Science was performed up to September 25, 2019. Standard mean differences (SMD) and corresponding 95% confidence intervals (CIs) of the BNP levels were calculated for each study. RESULTS Nine studies with a total number of 589 were included in the final meta-analysis. The results showed that elevated BNP levels were significantly associated with the risk of weaning failure (SMD: 0.76, 95% CI: 0.47 to 1.05, P < .00001). The finding was consistent with the BNP measured before (SMD: 0.68, 95% CI: 0.26 to 1.11, P = .002) or at the end of spontaneous breathing trial (SBT) (SMD: 0.85, 95% CI: 0.52 to 1.18, P < .00001). CONCLUSIONS This meta-analysis showed that increased plasma BNP concentration was associated with weaning failure in ICU patients.
Collapse
Affiliation(s)
- Zeng-Hong Wu
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Tang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meng Zhao
- School of Life Sciences, Westlake University, Hangzhou, China
- Institute of Biology, Westlake Institute for Advanced Study, Hangzhou, China
| | - Hong Yu
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hua-Dong Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
15
|
Ultrasound Assessment in Cardiogenic Shock Weaning: A Review of the State of the Art. J Clin Med 2021; 10:jcm10215108. [PMID: 34768629 PMCID: PMC8585073 DOI: 10.3390/jcm10215108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 12/23/2022] Open
Abstract
Cardiogenic shock (CS) is associated with a high in-hospital mortality despite the achieved advances in diagnosis and management. Invasive mechanical ventilation and circulatory support constitute the highest step in cardiogenic shock therapy. Once established, taking the decision of weaning from such support is challenging. Intensive care unit (ICU) bedside echocardiography provides noninvasive, immediate, and low-cost monitoring of hemodynamic parameters such as cardiac output, filling pressure, structural disease, congestion status, and device functioning. Supplemented by an ultrasound of the lung and diaphragm, it is able to provide valuable information about signs suggesting a weaning failure. The aim of this article was to review the state of the art taking into account current evidence and knowledge on ICU bedside ultrasound for the evaluation of weaning from mechanical ventilation and circulatory support in cardiogenic shock.
Collapse
|
16
|
Santos PAD, Ribas A, Quadros TCC, Blattner CN, Boniatti MM. Postextubation fluid balance is associated with extubation failure: a cohort study. Rev Bras Ter Intensiva 2021; 33:422-427. [PMID: 35107553 PMCID: PMC8555406 DOI: 10.5935/0103-507x.20210057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/02/2021] [Indexed: 11/25/2022] Open
Abstract
Objetivo Avaliar se há associação entre o balanço
hídrico nas 48 horas após a extubação e a falha
da extubação. Métodos Este é um estudo de coorte prospectiva que incluiu os pacientes
admitidos à unidade de terapia intensiva de um hospital
terciário no sul do Brasil entre março e dezembro de 2019.
Incluíram-se os pacientes que necessitaram de
ventilação mecânica por pelo menos 24 horas e foram
extubados durante o período do estudo. O desfecho primário foi
falha da extubação, considerada como necessidade de reintubar
dentro das primeiras 72 horas após a extubação. O
desfecho secundário foi um desfecho combinado de falha da
extubação ou necessidade de ventilação
não invasiva terapêutica. Resultados Foram incluídos 101 pacientes. Observou-se falha da
extubação em 29 (28,7%) deles. Na análise univariada,
pacientes com balanço hídrico negativo acima de 1L no
período de 48 horas após a extubação tiveram
menor taxa de falha da extubação (12,0%), em
comparação a pacientes com balanço hídrico
negativo nas 48 horas após a extubação menor que 1L
(34,2%; p = 0,033). A duração da ventilação
mecânica e o balanço hídrico negativo nas 48 horas
após a extubação inferior a 1L se associaram com falha
da extubação na análise multivariada quando corrigido
pelo Simplified Acute Physiology Score 3. Quando avaliou-se
o desfecho combinado, apenas o balanço hídrico nas 48 horas
pós-extubação inferior a 1L manteve
associação, quando corrigido pelo Simplified Acute
Physiology Score 3 e duração da
ventilação mecânica. Conclusão O balanço hídrico nas 48 horas após a
extubação se associa com falha da extubação.
São necessários mais estudos para avaliar se evitar um
balanço hídrico positivo nesse período poderia melhorar
os desfechos do desmame.
Collapse
Affiliation(s)
- Priscila Albrecht Dos Santos
- Departamento de Terapia Intensiva, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Alexandre Ribas
- Departamento de Terapia Intensiva, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Thiele Cabral Coelho Quadros
- Departamento de Terapia Intensiva, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Clarissa Netto Blattner
- Departamento de Terapia Intensiva, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Márcio Manozzo Boniatti
- Departamento de Terapia Intensiva, Hospital de Clínicas de Poto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| |
Collapse
|
17
|
Gokkus H, Cosgun Z, Cosgun M, Ekici MA, Kalaycioglu O. Sonographic Evaluation of Pulmonary Interstitial Edema in Patient With Preeclampsia. Ultrasound Q 2021; 37:267-271. [PMID: 34478426 DOI: 10.1097/ruq.0000000000000554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The aim of this study was to sonographically detect pulmonary edema, which is a major problem in pregnant women with preeclampsia, in the interstitial phase. We evaluated 41 preeclampsia patients and 21 control subjects prospectively. In the preeclampsia group, 26 patients had severe features, whereas the other 15 patients had none. To detect early fluid loading in lungs, sonographic B lines were counted from the intercostal space by using ultrasonography, and left ventricular loading findings were examined for corporation by using transthoracic echocardiography both before and after birth. In severe preeclampsia, the number of B lines before and after birth is statistically significant compared with the other groups. In addition, the total number of B lines calculated at 24 hours after delivery was significantly lower than that calculated before delivery (P < 0.018). In terms of prenatal E values, a statistically significant difference was found between all groups (P < 0.001). A strong positive and statistically significant relationship was found between B lines and prenatal E/e' (r = 0.768; P < 0.001). The overall accuracy rate of the prenatal E/e' and E value for estimation of the B line number classification is 0.791 (95% confidence interval, 0.674-0.908; P < 0.001) and 0.829 (95% confidence interval, 0.722-0.936; P < 0.001), respectively. Pulmonary edema is a serious complication in patients with severe preeclampsia and may be detected interstitially in some patients, even if it does not occur clinically.
Collapse
Affiliation(s)
- Halil Gokkus
- Department of Radiology, Izzet Baysal State Hospital
| | | | | | | | - Oya Kalaycioglu
- Biostatistics and Medical Informatics, Izzet Baysal Faculty of Medicine, Izzet Baysal University, Bolu, Turkey
| |
Collapse
|
18
|
Dres M, Estellat C, Baudel JL, Beloncle F, Cousty J, Galbois A, Guérin L, Labbe V, Labro G, Lebut J, Mira JP, Prat G, Quenot JP, Dessap A. Comparison of a preventive or curative strategy of fluid removal on the weaning of mechanical ventilation: a study protocol for a multicentre randomised open-label parallel-group trial. BMJ Open 2021; 11:e048286. [PMID: 34400454 PMCID: PMC8370501 DOI: 10.1136/bmjopen-2020-048286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/29/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Fluid overload is associated with a poor prognosis in the critically ill patients, especially at the time of weaning from mechanical ventilation as it may promote weaning failure from cardiac origin. Some data suggest that early administration of diuretics would shorten the duration of mechanical ventilation. However, this strategy may expose patients to a higher risk of haemodynamic and metabolic complications. Currently, there is no recommendation for the use of diuretics during weaning and there is an equipoise on the timing of their initiation in this context. METHODS AND ANALYSIS This study is a multicentre randomised controlled trial comparing two strategies of fluid removal during weaning in 13 French intensive care units (ICU). The preventive strategy is initiated systematically when the fluid balance or weight change is positive and the patients have criteria for clinical stability; the curative strategy is initiated only in case of weaning failure documented as of cardiac origin. Four hundred and ten patients will be randomised with a 1:1 ratio. The primary outcome is the duration of weaning from mechanical ventilation, defined as the number of days between randomisation and successful extubation (alive without reintubation nor tracheostomy within the 7 days after extubation) at day 28. Secondary outcomes include daily and cumulated fluid balance, metabolic and haemodynamic complications, ventilator-associated pneumonia, weaning complications, number of ventilator-free days, total duration of mechanical ventilation, the length of stay in ICU and mortality in ICU, in hospital and, at day 28. A subgroup analysis for the primary outcome is planned in patients with kidney injury (Kidney Disease: Improving Global Outcomes class 2 or more) at the time of randomisation. ETHICS AND DISSEMINATION The study has been approved by the ethics committee (Comité de Protection des Personnes Paris 1) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04050007. PROTOCOL VERSION V.1; 12 March 2019.
Collapse
Affiliation(s)
- Martin Dres
- Service de Médecine intensive Réanimation, APHP.Sorbonne Université, Hôpital Pitie Salpêtriere, Paris, France
| | - Candice Estellat
- Département de Santé Publique, APHP.Sorbonne Université, Hôpital Pitie Salpetriere, Paris, Île-de-France, France
| | - Jean-Luc Baudel
- Service de Médecine intensive Réanimation, APHP.Sorbonne Université, Hôpital Saint Antoine, Paris, Île-de-France, France
| | - François Beloncle
- Service de Médecine intensive Réanimation et médedine hyperbare, CHU Angers, Angers, Pays de la Loire, France
| | - Julien Cousty
- Service de Réanimation Polyvalente, CHU de La Réunion Sites Sud Saint-Pierre, Saint-Pierre, Réunion
| | - Arnaud Galbois
- Service de Réanimation polyvalente, Hôpital Claude Galien, Quincy-sous-Senart, France
| | - Laurent Guérin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Bicêtre, Le Kremlin-Bicetre, France
| | - Vincent Labbe
- Service de Réanimation et USC Médico-Chirurgicale, APHP.Sorbonne University, Tenon Hospital, Paris, France
| | - Guylaine Labro
- Service de Réanimation médicale, Centre Hospitalier de Mulhouse, Mulhouse, France
| | - Jordane Lebut
- Service de Réanimation et Surveillance Continue, Groupement Hospitalier Nord Essonne, Longjumeau, Île-de-France, France
| | - Jean-Paul Mira
- Service de Médecine intensive Réanimation, Groupe Hospitalier Paris Centre-Hôpital Cochin, Paris, Île-de-France, France
| | - Gwenael Prat
- Service de Médecine intensive et Réanimation, CHU de Brest, Brest, France
| | | | - Armand Dessap
- Service de Médecine Intensive Réanimation, APHP. Hôpitaux Universitaires Henri Mondor, Creteil, France
| |
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW Among noninvasive lung imaging techniques that can be employed at the bedside electrical impedance tomography (EIT) and lung ultrasound (LUS) can provide dynamic, repeatable data on the distribution regional lung ventilation and response to therapeutic manoeuvres.In this review, we will provide an overview on the rationale, basic functioning and most common applications of EIT and Point of Care Ultrasound (PoCUS, mainly but not limited to LUS) in the management of mechanically ventilated patients. RECENT FINDINGS The use of EIT in clinical practice is supported by several studies demonstrating good correlation between impedance tomography data and other validated methods of assessing lung aeration during mechanical ventilation. Similarly, LUS also correlates with chest computed tomography in assessing lung aeration, its changes and several pathological conditions, with superiority over other techniques. Other PoCUS applications have shown to effectively complement the LUS ultrasound assessment of the mechanically ventilated patient. SUMMARY Bedside techniques - such as EIT and PoCUS - are becoming standards of the care for mechanically ventilated patients to monitor the changes in lung aeration, ventilation and perfusion in response to treatment and to assess weaning from mechanical ventilation.
Collapse
|
20
|
Sanfilippo F, Di Falco D, Noto A, Santonocito C, Morelli A, Bignami E, Scolletta S, Vieillard-Baron A, Astuto M. Association of weaning failure from mechanical ventilation with transthoracic echocardiography parameters: a systematic review and meta-analysis. Br J Anaesth 2020; 126:319-330. [PMID: 32988600 DOI: 10.1016/j.bja.2020.07.059] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/26/2020] [Accepted: 07/26/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Weaning from mechanical ventilation is a challenging step during recovery from critical illness. Weaning failure or early reintubation are associated with increased morbidity and mortality, exposing patients to life-threatening complications. Cardiac dysfunction represents the most common cause of weaning failure. We conducted a systematic review and meta-analysis to evaluate the association between transthoracic echocardiographic parameters and weaning failure. METHODS We performed a systematic search of MEDLINE and EMBASE screening for prospective studies providing echocardiographic data collected just before the beginning of spontaneous breathing trial and outcome of the weaning attempt. We primarily focused on parameters currently recommended for evaluation of left ventricular (LV) systolic or diastolic dysfunction. RESULTS We included 11 studies in our primary analysis, which included data on LV ejection fraction (LVEF, n=10 studies) and parameters recommended for the assessment of LV diastolic function (E/e' ratio n=10; E/A ratio n=9; E wave n=8; and e' wave n=7). Weaning failure was significantly associated to a higher E/e' ratio (standardised mean difference [SMD]=1.70, 95% confidence interval [CI; 0.78-2.62]; P<0.001), lower e' wave (SMD=-1.22, 95% CI [-2.33 to -0.11]; P=0.03), and higher E wave (SMD=0.97, 95% CI [0.29-1.65]; P=0.005). We found no association between weaning failure and LVEF (SMD=-0.86, 95% CI [-1.92-0.20]; P=0.11) and E/A ratio (SMD=0.00, 95% CI [-0.30-0.31]; P=0.98). CONCLUSIONS Weaning failure is associated with parameters indicating worse LV diastolic function (E/e', e' wave, E wave) and increased LV filling pressure (E/e' ratio). The association between weaning failure and LV systolic dysfunction as evaluated by LVEF is more unclear. More studies are needed to clarify this aspect and regarding the role of right ventricular function.
Collapse
Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, A.O.U. 'Policlinico-Vittorio Emanuele', Catania, Italy.
| | - Davide Di Falco
- School of Anaesthesia and Intensive Care, University Hospital 'G. Rodolico', University of Catania, Catania, Italy
| | - Alberto Noto
- Department of Anesthesia and Critical Care, A.O.U. Policlinico 'G. Martino', University of Messina, Messina, Italy
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, A.O.U. 'Policlinico-Vittorio Emanuele', Catania, Italy
| | - Andrea Morelli
- Department of Internal Clinical, Anesthesiological and Cardiovascular Sciences, University of Rome, 'La Sapienza', Rome, Italy
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Sabino Scolletta
- Department of Urgency and Emergency, of Organ Transplantation, Anesthesia and Intensive Care, Siena University Hospital, Siena, Italy
| | - Antoine Vieillard-Baron
- Intensive Care Medicine Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Boulogne-Billancourt, France; INSERM, UMR-1018, CESP, Team Kidney and Heart, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Marinella Astuto
- Department of Anesthesia and Intensive Care, A.O.U. 'Policlinico-Vittorio Emanuele', Catania, Italy; School of Anaesthesia and Intensive Care, University Hospital 'G. Rodolico', University of Catania, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| |
Collapse
|
21
|
Goudelin M, Champy P, Amiel JB, Evrard B, Fedou AL, Daix T, François B, Vignon P. Left ventricular overloading identified by critical care echocardiography is key in weaning-induced pulmonary edema. Intensive Care Med 2020; 46:1371-1381. [PMID: 32377766 PMCID: PMC7223421 DOI: 10.1007/s00134-020-06061-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/17/2020] [Indexed: 01/15/2023]
Abstract
Purpose To assess the role of left ventricular overload and cumulated fluid balance in the development weaning-induced pulmonary edema (WIPO). Methods Ventilated patients in sinus rhythm with COPD and/or heart failure (ejection fraction ≤ 40%) were studied. Echocardiography was performed immediately before and during a 30-min spontaneous breathing trial (SBT) using a T-tube. Patients who failed were treated according to echocardiography results before undergoing a second SBT. Results Twelve of 59 patients failed SBT, all of them developing WIPO. Patients who succeeded SBT had lower body weight (− 2.5 kg [− 4.8; − 1] vs. + 0.75 kg [− 2.95; + 5.57]: p = 0.02) and cumulative fluid balance (− 2326 ml [− 3715; + 863] vs. + 143 ml [− 2654; + 4434]: p = 0.007) than those who developed WIPO. SBT-induced central hemodynamic changes were more pronounced in patients who developed WIPO, with higher E wave velocity (122 cm/s [92; 159] vs. 93 cm/s [74; 109]: p = 0.017) and E/A ratio (2.1 [1.2; 3.6] vs. 0.9 [0.8; 1.4]: p = 0.001), and shorter E wave deceleration time (85 ms [72; 125] vs. 147 ms [103; 175]: p = 0.004). After echocardiography-guided treatment, all patients who failed the first SBT were successfully extubated. Fluid balance was then negative (− 2224 ml [− 7056; + 100] vs. + 146 ml [− 2654; + 4434]: p = 0.005). Left ventricular filling pressures were lower (E/E′: 7.3 [5; 10.4] vs. 8.9 [5.9; 13.1]: p = 0.028); SBT-induced increase in E wave velocity (+ 10.6% [− 2.7/ + 18] vs. + 25.6% [+ 12.7/ + 49]: p = 0.037) and of mitral regurgitation area were significantly smaller. Conclusion In high-risk patients, WIPO appears related to overloaded left ventricle associated with excessive fluid balance. SBT-induced central hemodynamic changes monitored by CCE help in guiding therapy for successful weaning. Electronic supplementary material The online version of this article (10.1007/s00134-020-06061-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Marine Goudelin
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Pauline Champy
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Jean-Bernard Amiel
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Bruno Evrard
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Anne-Laure Fedou
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Thomas Daix
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Bruno François
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France. .,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France. .,Faculty of Medicine, University of Limoges, 87000-Limoges, France. .,Réanimation Polyvalente, CHU Dupuytren, 2 Avenue Martin Luther king, 87000, Limoges, France.
| |
Collapse
|
22
|
Fathy S, Hasanin AM, Raafat M, Mostafa MMA, Fetouh AM, Elsayed M, Badr EM, Kamal HM, Fouad AZ. Thoracic fluid content: a novel parameter for predicting failed weaning from mechanical ventilation. J Intensive Care 2020; 8:20. [PMID: 32161651 PMCID: PMC7059362 DOI: 10.1186/s40560-020-00439-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/27/2020] [Indexed: 01/15/2023] Open
Abstract
Background Weaning of patients from the mechanical ventilation remains one of the critical decisions in intensive care unit. This study aimed to evaluate the accuracy of thoracic fluid content (TFC) as a predictor of weaning outcome. Methods An observational cohort study included 64 critically ill surgical patients who were eligible for extubation. Before initiating the spontaneous breathing trial, the TFC was measured using the electrical cardiometry technology. Patients were followed up after extubation and divided into successful weaning group and failed weaning group. Both groups were compared according to respiratory and cardiovascular parameters. Receiver operating characteristic (ROC) curves were constructed to evaluate the ability of TFC to predict weaning outcome. Results The number of successfully weaned patients was 41/64 (64%). Twenty (31%) patients had impaired cardiac contractility, and of them, 13/20 (64%) patients were successfully extubated. Both groups, successful weaning group and failed weaning group, were comparable in most of baseline characteristics; however, the TFC was significantly higher in the failed weaning group compared to the successful weaning group. The area under the ROC curves (AUCs) showed moderate predictive ability for the TFC in predicting weaning failure (AUC [95% confidence interval] 0.69 [0.57-0.8], cutoff value > 50 kΩ-1), while the predictive ability of TFC was excellent in the subgroup of patients with ejection fraction < 40% (AUC [95% confidence interval 0.93 [0.72-1], cutoff value > 50 kΩ-1). Conclusions Thoracic fluid content showed moderate ability for predicting weaning outcome in surgical critically ill patients. However, in the subgroup of patients with ejection fraction less than 40%, TFC above 50 kΩ-1 has an excellent ability to predict weaning failure.
Collapse
Affiliation(s)
- Shymaa Fathy
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| | - Ahmed M Hasanin
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| | - Mohamed Raafat
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| | - Maha M A Mostafa
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| | - Ahmed M Fetouh
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| | - Mohamed Elsayed
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| | - Esraa M Badr
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| | - Hanan M Kamal
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| | - Ahmed Z Fouad
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, Cairo, 11559 Egypt
| |
Collapse
|
23
|
Ultrasonographic evaluation of lung and heart in predicting successful weaning in mechanically ventilated neurosurgical patients. J Clin Monit Comput 2020; 35:189-197. [PMID: 31927703 PMCID: PMC7222928 DOI: 10.1007/s10877-020-00460-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 01/08/2020] [Indexed: 11/25/2022]
Abstract
In critically ill neurosurgical patients, delayed and premature extubation increases the risk of morbidity and mortality. Assessment of critically ill patients before and during spontaneous breathing trial (SBT) is crucial in predicting weaning failure. We explored the trend of changes with integrated lung and cardiac ultrasonography in predicting success of weaning in neurosurgical patients. Lung ultrasound and cardiac ultrasound was performed before and after 30 min and 120 min of SBT. Lung ultrasound score (LUS, range 0–36) was calculated using a predefined method of assessment of six chest regions on either side. The left ventricular function was evaluated by measuring fractional area change. The maximum velocities of mitral inflow E and A waves (E/A), deceleration time of E wave (DTE) and tissue doppler based E′ wave at lateral annulus to calculate E/E′, were measured to assess left ventricular filling pressure. Twenty seven patients underwent SBT, among these 22 had success and five had failure of SBT. The SBT failure group had higher baseline LUS and progressively higher LUS during SBT compared to the success group, suggesting significant lung de-recruitment. There was significant increase in the LV filling pressure (increase E/A and E/E′, decrease in DTE) after 30 and 120 min of SBT in failure group compared to the success group. Point of care lung and cardiac ultrasonography may be useful in detecting cardiopulmonary changes induced by SBT. Higher lung aeration loss and LV filling pressure were observed with SBT failure group.
Collapse
|
24
|
Bouhemad B, Mojoli F, Nowobilski N, Hussain A, Rouquette I, Guinot PG, Mongodi S. Use of combined cardiac and lung ultrasound to predict weaning failure in elderly, high-risk cardiac patients: a pilot study. Intensive Care Med 2020; 46:475-484. [DOI: 10.1007/s00134-019-05902-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022]
|
25
|
Abstract
Congestion is one of the most prominent characteristics of patients presented with decompensated heart failure and it implies unfavorable prognosis for the heart failure patient. Neurohumoral and immuno-inflammatory activation secondary to cardiac dysfunction constitute the pivotal mechanisms driving the heart failure syndrome that results in progressive fluid accumulation. In addition, fluid redistribution between different vascular compartments in human body guided from sympathetic activity constitutes another mechanism for heart failure decompensation. Ultrasound applied in the form of echocardiography provides invaluable data for the assessment of intracardiac filling pressures. The type of renal venous flow can provide the degree of renal congestion and probably insight into the pathophysiology of the decompensation of heart failure. Assessment of lung congestion in the patient with heart failure can be accomplished by lung ultrasonography. Additionally, clinical studies on the role of ultrasound in the management and prognosis of the congested patient are reviewed. Special heart failure population supported with left ventricular assist devices and extracorporeal membrane oxygenation support constitute an area where ultrasound guidance of fluid management has gained important role.
Collapse
|
26
|
Bedet A, Tomberli F, Prat G, Bailly P, Kouatchet A, Mortaza S, Vivier E, Rosselli S, Lipskaia L, Carteaux G, Razazi K, Mekontso Dessap A. Myocardial ischemia during ventilator weaning: a prospective multicenter cohort study. Crit Care 2019; 23:321. [PMID: 31533788 PMCID: PMC6751853 DOI: 10.1186/s13054-019-2601-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/06/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Weaning-induced cardiac pulmonary edema (WiPO) is one of the main mechanisms of weaning failure during mechanical ventilation. We hypothesized that weaning-induced cardiac ischemia (WiCI) may contribute to weaning failure from cardiac origin. METHODS A prospective cohort study of patients mechanically ventilated for at least 24 h who failed a first spontaneous breathing trial (SBT) was conducted in four intensive care units. Patients were explored during a second SBT using multiple tools (echocardiography, continuous 12-lead ST monitoring, biomarkers) to scrutinize the mechanisms of weaning failure. WiPO definition was based on three criteria (echocardiographic signs of increased left atrial pressure, increase in B-type natriuretic peptides, or increase in protein concentration during SBT) according to a conservative definition (at least two criteria) and a liberal definition (at least one criterion). WiCI was diagnosed according to the third universal definition of myocardial infarction proposed by the European Society of Cardiology (ESC) and the American Heart Association (AHA) statement for exercise testing. RESULTS Among patients who failed a first SBT, WiPO occurred in 124/208 (59.6%) and 44/208 (21.2%) patients, according to the liberal and conservative definition, respectively. Among patients with ST monitoring, WiCI was diagnosed in 36/177 (20.3%) and 12/177 (6.8%) of them, according to the ESC and AHA definitions, respectively. WiCI was not associated with WiPO and was not associated with weaning outcomes. Only two patients of the cohort were treated for an acute coronary syndrome after the second SBT, and seven other patients required coronary angiography during the weaning period. CONCLUSIONS This observational study showed the common occurrence of pulmonary edema in mechanically ventilated patients who failed a first SBT, but the association with cardiac ischemia and weaning outcomes was weak.
Collapse
Affiliation(s)
- Alexandre Bedet
- Medical Intensive Care Unit, DHU A-TVB, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, F-94010, France.
- Mondor Institute of Biomedical Research, CARMAS Research Group, Paris Est Créteil University, Créteil, F-94010, France.
| | - Françoise Tomberli
- Surgical Intensive Care Unit, DHU A-TVB, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, F-94010, France
| | - Gwenael Prat
- Intensive Care Unit, Cavale Blanche, Brest Regional University Hospital, 29200, Brest, France
| | - Pierre Bailly
- Intensive Care Unit, Cavale Blanche, Brest Regional University Hospital, 29200, Brest, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Angers University Hospital, 49933, Angers, France
| | - Sater Mortaza
- Medical Intensive Care Unit, Angers University Hospital, 49933, Angers, France
| | - Emmanuel Vivier
- Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 69007, Lyon, France
| | - Sylvene Rosselli
- Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 69007, Lyon, France
| | - Larissa Lipskaia
- Medical Intensive Care Unit, DHU A-TVB, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, F-94010, France
- Mondor Institute of Biomedical Research, CARMAS Research Group, Paris Est Créteil University, Créteil, F-94010, France
| | - Guillaume Carteaux
- Medical Intensive Care Unit, DHU A-TVB, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, F-94010, France
- Mondor Institute of Biomedical Research, CARMAS Research Group, Paris Est Créteil University, Créteil, F-94010, France
| | - Keyvan Razazi
- Medical Intensive Care Unit, DHU A-TVB, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, F-94010, France
- Mondor Institute of Biomedical Research, CARMAS Research Group, Paris Est Créteil University, Créteil, F-94010, France
| | - Armand Mekontso Dessap
- Medical Intensive Care Unit, DHU A-TVB, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, F-94010, France
- Mondor Institute of Biomedical Research, CARMAS Research Group, Paris Est Créteil University, Créteil, F-94010, France
| |
Collapse
|
27
|
Contribution of Levosimendan in Weaning from Mechanical Ventilation in Patients with Left Ventricular Dysfunction: A Pilot Study. Crit Care Res Pract 2019; 2019:7169492. [PMID: 31428473 PMCID: PMC6681623 DOI: 10.1155/2019/7169492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/04/2019] [Indexed: 12/17/2022] Open
Abstract
Purpose Mechanically ventilated patients with left ventricular (LV) dysfunction are at risk of weaning failure. We hypothesized that optimization of cardiovascular function might facilitate the weaning process. Therefore, we investigated the efficacy of levosimendan in difficult-to-wean patients with impaired LV performance. Materials and Methods Nineteen mechanically ventilated patients, with LV ejection fraction (LVEF) 34 ± 8%, difficult-to-wean from the ventilator, were assessed by transthoracic echocardiography before the start and at the end of a spontaneous breathing trial (SBT) (first SBT). Eight patients successfully weaned. The remaining 11 failed-to-wean patients received a 24-hour infusion of levosimendan, and they were reassessed during a second SBT. Results After levosimendan administration, LVEF increased from 30 ± 10 to 36 ± 3% (p=0.01). End-SBT peak e′ velocity increased from 7 to 9 cm/s (p=0.02). E/e′ increased from 10.5 to 12.9 during the first SBT, whereas it remained constant at 10 throughout the second SBT (p=0.01). During the second SBT, partial pressure of arterial oxygen and central venous oxygen saturation improved, compared to the first one (93 ± 34 vs. 67 ± 28 mmHg, p=0.03, and 66 ± 11% vs. 57 ± 9%, p=0.02, respectively). Nine of the 11 patients were successfully weaned from the ventilator. Conclusions In difficult-to-wean from mechanical ventilation patients with LV dysfunction, levosimendan might contribute to successful weaning by improving both systolic and diastolic LV function.
Collapse
|
28
|
Ferré A, Guillot M, Lichtenstein D, Mezière G, Richard C, Teboul JL, Monnet X. Lung ultrasound allows the diagnosis of weaning-induced pulmonary oedema. Intensive Care Med 2019; 45:601-608. [PMID: 30863935 DOI: 10.1007/s00134-019-05573-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/19/2019] [Indexed: 12/19/2022]
Abstract
RATIONALE Detecting weaning-induced pulmonary oedema (WIPO) is important because its treatment might prompt extubation. For this purpose, lung ultrasound might be an attractive tool, since it demonstrates pulmonary oedema through the appearance of B-lines. OBJECTIVES To test the ideal profile (increase in the number of B-lines) for diagnosing WIPO. METHODS Before and at the end of 62 spontaneous breathing trials (SBT) performed in 42 patients, we prospectively assessed lung ultrasound on four anterior chest wall points. B-lines were counted before and at the end of SBT. We looked for the threshold of B-line increase (Delta-B-lines) that provided the best diagnostic accuracy, compared to the reference diagnosis of WIPO established by experts blinded to lung ultrasound. RESULTS SBT failed in 33 cases. WIPO occurred in 17 cases and all failed. The best diagnostic accuracy was reached with a Delta-B-lines ≥ 6. Among WIPO, the number of B-lines increased by ≥ 6 in 15 cases (including 13 cases with an increase of ≥ 8 B-lines). Among the 16 cases with SBT failure but without WIPO, the Delta-B-lines was ≥ 6 in two cases. Among the 33 cases with SBT failure, this profile diagnosed WIPO with a sensitivity of 88% (64-98) and a specificity of 88% (62-98) [area under the receiver operating characteristic curve 0.91 (0.75-0.98)]. Among the 29 cases with SBT success, a Delta-B-lines ≥ 6 occurred in two cases. CONCLUSIONS This study suggests that a Delta-B-lines ≥ 6 on four anterior points allows the diagnosis of WIPO with the best accuracy. This should be confirmed in larger populations.
Collapse
Affiliation(s)
- Alexis Ferré
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Max Guillot
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Daniel Lichtenstein
- AP-HP, Service de réanimation médicale, Hôpital Ambroise-Paré, Boulogne, Paris, France
| | - Gilbert Mezière
- Service de réanimation polyvalente, Centre Hospitalier Gaston Ramon, Sens, France
| | - Christian Richard
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France. .,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.
| |
Collapse
|
29
|
Tongyoo S, Thomrongpairoj P, Permpikul C. Efficacy of echocardiography during spontaneous breathing trial with low‐level pressure support for predicting weaning failure among medical critically ill patients. Echocardiography 2019; 36:659-665. [DOI: 10.1111/echo.14306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/17/2019] [Accepted: 02/07/2019] [Indexed: 12/16/2022] Open
Affiliation(s)
- Surat Tongyoo
- Division of Critical CareDepartment of MedicineFaculty of Medicine Siriraj HospitalMahidol University Bangkok Thailand
| | - Preecha Thomrongpairoj
- Division of Critical CareDepartment of MedicineFaculty of Medicine Siriraj HospitalMahidol University Bangkok Thailand
| | - Chairat Permpikul
- Division of Critical CareDepartment of MedicineFaculty of Medicine Siriraj HospitalMahidol University Bangkok Thailand
| |
Collapse
|
30
|
Routsi C, Stanopoulos I, Kokkoris S, Sideris A, Zakynthinos S. Weaning failure of cardiovascular origin: how to suspect, detect and treat-a review of the literature. Ann Intensive Care 2019; 9:6. [PMID: 30627804 PMCID: PMC6326918 DOI: 10.1186/s13613-019-0481-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/02/2019] [Indexed: 01/09/2023] Open
Abstract
Among the multiple causes of weaning failure from mechanical ventilation, cardiovascular dysfunction is increasingly recognized as a quite frequent cause that can be treated successfully. In this review, we summarize the contemporary evidence of the most important clinical and diagnostic aspects of weaning failure of cardiovascular origin with special focus on treatment. Pathophysiological mechanisms are complex and mainly include increase in right and left ventricular preload and afterload and potentially induce myocardial ischemia. Patients at risk include those with preexisting cardiopulmonary disease either known or suspected. Clinically, cardiovascular etiology as a predominant cause or a contributor to weaning failure, though critical for early diagnosis and intervention, may be difficult to be recognized and distinguished from noncardiac causes suggesting the need of high suspicion. A cardiovascular diagnostic workup including bedside echocardiography, lung ultrasound, electrocardiogram and biomarkers of cardiovascular dysfunction or other adjunct techniques and, in selected cases, right heart catheterization and/or coronary angiography, should be obtained to confirm the diagnosis. Official clinical practice guidelines that address treatment of a confirmed weaning-induced cardiovascular dysfunction do not exist. As the etiologies of weaning-induced cardiovascular dysfunction are diverse, principles of management depend on the individual pathophysiological mechanisms, including preload optimization by fluid removal, guided by B-type natriuretic peptide measurement, nitrates administration in excessive afterload and/or myocardial ischemia, contractility improvement in severe systolic dysfunction as well as other rational treatment in specific indications in order to lead to successful weaning from mechanical ventilation.
Collapse
Affiliation(s)
- Christina Routsi
- First Department of Critical Care, Medical School, National and Kapodistrian University of Athens, “Evangelismos” Hospital, Ipsilantou 45-47, 10676 Athens, Greece
| | - Ioannis Stanopoulos
- Respiratory Failure Unit, Medical School, “G. Papanikolaou” Hospital, Aristotle University, Thessaloníki, Greece
| | - Stelios Kokkoris
- First Department of Critical Care, Medical School, National and Kapodistrian University of Athens, “Evangelismos” Hospital, Ipsilantou 45-47, 10676 Athens, Greece
| | - Antonios Sideris
- Department of Cardiology, “Evangelismos” Hospital, Athens, Greece
| | - Spyros Zakynthinos
- First Department of Critical Care, Medical School, National and Kapodistrian University of Athens, “Evangelismos” Hospital, Ipsilantou 45-47, 10676 Athens, Greece
| |
Collapse
|
31
|
Amarja H, Bhuvana K, Sriram S. Prospective Observational Study on Evaluation of Cardiac Dysfunction Induced during the Weaning Process. Indian J Crit Care Med 2019; 23:15-19. [PMID: 31065203 PMCID: PMC6481267 DOI: 10.5005/jp-journals-10071-23106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Context Weaning induced cardiac dysfunction can occur without underlying heart disease. Changes in intrathoracic pressure, systemic vascular resistance, preload and afterload leading to heart-lung interactions are the possible explanatory mechanisms Aims The aim of the current study was whether the assessment and identification of cardiac dysfunction induced during the weaning process could predict the outcome of extubation. Settings and design A prospective observational study with convenience sampling method was conducted from May 2015 to April 2016 after institutional ethical committee approval (ref 161/2015). Materials and methods Patients over eighteen and planned for extubation were included. Weaning method used was a spontaneous breathing trial (SBT) by pressure support-positive end-expiratory pressure (PS-PEEP). Baseline characteristics, weaning, and echocardiography parameters were collected pre extubation. Post-extubation echocardiographic parameters were collected within six hours as per the protocol. The primary outcome was extubation failure (reintubation within 48 hours). Secondary outcomes were ICU length of stay and ICU mortality. Statistical analysis Statistical method used is STATA™ (Version14, College Station TX). Results Out of one hundred and sixty-one patients, twenty-one failed extubation (13.04 %). Pre-extubation echocardiographic parameters were similar in two groups except for preexisting LV systolic dysfunction. Post-extubation E/e` (9.30 vs. 7.71 p = 0.018) was higher in the extubation failure group. Extubation failure group had higher intensive care unit (ICU) length of stay and ICU mortality. Conclusion In our study E/e` during a weaning trial did not predict extubation success. Cardiac dysfunction induced during weaning may get masked during weaning and manifests postextubation. This needs to be verified in subsequent studies. Key messages Cardiac dysfunction induced during the weaning process may get masked and manifests post-extubation. Echocardiographic assessment during the weaning process and post-extubation helps to evaluate and identify the patients at risk of reintubation. How to cite this article Amarja H, Bhuvana K, Sriram S. Prospective Observational Study on Evaluation of Cardiac Dysfunction Induced during the Weaning Process. Indian Journal of Critical Care Medicine, January 2019;23(1):15-19.
Collapse
Affiliation(s)
- Havaldar Amarja
- Department of Critical Care Medicine, St. John's Hospital, Bengaluru, Karnataka, India
| | - Krishna Bhuvana
- Department of Critical Care Medicine, St. John's Hospital, Bengaluru, Karnataka, India
| | - Sampath Sriram
- Department of Critical Care Medicine, St. John's Hospital, Bengaluru, Karnataka, India
| |
Collapse
|
32
|
Sanfilippo F, Scolletta S, Morelli A, Vieillard-Baron A. Practical approach to diastolic dysfunction in light of the new guidelines and clinical applications in the operating room and in the intensive care. Ann Intensive Care 2018; 8:100. [PMID: 30374644 PMCID: PMC6206316 DOI: 10.1186/s13613-018-0447-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/20/2018] [Indexed: 12/26/2022] Open
Abstract
There is growing evidence both in the perioperative period and in the field of intensive care (ICU) on the association between left ventricular diastolic dysfunction (LVDD) and worse outcomes in patients. The recent American Society of Echocardiography and European Association of Cardiovascular Imaging joint recommendations have tried to simplify the diagnosis and the grading of LVDD. However, both an often unknown pre-morbid LV diastolic function and the presence of several confounders-i.e., use of vasopressors, positive pressure ventilation, volume loading-make the proposed parameters difficult to interpret, especially in the ICU. Among the proposed parameters for diagnosis and grading of LVDD, the two tissue Doppler imaging-derived variables e' and E/e' seem most reliable. However, these are not devoid of limitations. In the present review, we aim at rationalizing the applicability of the recent recommendations to the perioperative and ICU areas, discussing the clinical meaning and echocardiographic findings of different grades of LVDD, describing the impact of LVDD on patients' outcomes and providing some hints on the management of patients with LVDD.
Collapse
Affiliation(s)
- F. Sanfilippo
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - S. Scolletta
- Unit of Intensive Care Medicine, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - A. Morelli
- Department of Anaesthesiology and Intensive Care, University of Rome, “La Sapienza”, Rome, Italy
| | - A. Vieillard-Baron
- Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France
| |
Collapse
|
33
|
Abstract
Cardiac patients are at high risk of weaning failure due to the abrupt burden to the cardiovascular system resulting from the transition from positive-pressure ventilation to spontaneous breathing. Similarly, numerous patients with borderline cardiac function, left ventricular diastolic dysfunction, chronic obstructive pulmonary disease, especially with associated fluid overload or cumulative positive fluid balance, are at high risk of weaning failure of cardiac origin. The diagnosis of weaning-induced pulmonary oedema (WiPO) relies on the measurement of elevated left ventricular filling pressure, or on the presence of a surrogate reflecting pulmonary or cardiac congestion. Plasma concentration of B-type natriuretic peptide and N-terminal proBNP, biological signs of hemoconcentration (increased circulating protein or hemoglobin levels), or measurement of extravascular pulmonary lung water using transpulmonary thermodilution have been proved valuable surrogates for the identification of weaning failure. Nevertheless, studies have not yet compared these indirect methods to precisely determine their respective diagnostic values for the identification of WiPO, especially in heart failure patients. In addition, none of these approaches directly assess left ventricular filling pressure and the mechanism of WiPO. In contrast, critical care echocardiography is ideally suited to establish the diagnosis of weaning failure of cardiac origin. It allows identifying the high-risk population, monitoring hemodynamically the patient at risk, depicting an abrupt increase of left ventricular filling pressure consistent with WiPO when the patient fails weaning, identifying the underlying mechanism of WiPO, and finally it allows tailoring the therapeutic management of the patient who failed weaning. The impact on patient-centered outcomes of such integrated management strategy based on critical care echocardiography deserves to be prospectively tested in a large population of patients at high risk of weaning failure of cardiac origin.
Collapse
Affiliation(s)
- Philippe Vignon
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France.,Clinical Investigation Center INSERM 1435, Dupuytren Teaching Hospital, Limoges, France.,Faculty of Medicine, University of Limoges, Limoges, France
| |
Collapse
|
34
|
Morttada Abd El Moteleb A. Using echocardiography and chest ultrasound for guidance of management of difficult-to-wean COPD patients. JOURNAL OF CARDIOLOGY & CURRENT RESEARCH 2018; 11. [DOI: 10.15406/jccr.2018.11.00394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
35
|
Haji K, Haji D, Canty DJ, Royse AG, Green C, Royse CF. The impact of heart, lung and diaphragmatic ultrasound on prediction of failed extubation from mechanical ventilation in critically ill patients: a prospective observational pilot study. Crit Ultrasound J 2018; 10:13. [PMID: 29971618 PMCID: PMC6029991 DOI: 10.1186/s13089-018-0096-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 05/03/2018] [Indexed: 12/19/2022] Open
Abstract
Background Failed extubation from mechanical ventilation in critically ill patients is multifactorial, complex and not well understood. We aimed to identify whether combined transthoracic echocardiography, lung and diaphragmatic ultrasound can predict extubation failure in critically ill patients. Results Fifty-three participants who were intubated > 48 h and deemed by the treating intensivist ready for extubation underwent a 60-min pre-extubation weaning trial (pressure support ≤ 10 cmH2O and positive end expiratory pressure 5 cmH2O). Prior to extubation, data collected included ultrasound assessment of left ventricular ejection fraction, left atrial area, early diastolic trans-mitral flow velocity wave (E), early diastolic trans-mitral flow velocity wave/late diastolic trans-mitral flow velocity wave (E/A), early diastolic trans-mitral flow velocity wave/early diastolic mitral annulus velocity (E/E′), interatrial septal motion, lung loss of aeration score and diaphragm movement. At the end of the weaning trial, the rapid shallow breathing index and serum B-type natriuretic peptide concentration were measured. Success and failure of weaning was assessed by defined criteria. Decision to extubate was at the discretion of the treating intensivist. Failure of extubation was defined as re-intubation, non-invasive ventilation or death within 48 h after extubation. Of 53 extubated participants, 11 failed extubation. Failed extubation was associated with diabetes, ischaemic heart disease, higher E/E′ (OR 1.27, 95% CI 1.05–1.54), left atrial area (OR 1.14, CI 1.02–1.28), fixed rightward curvature of the interatrial septum (OR 12.95, CI 2.73–61.41), and higher loss of aeration score of anterior and lateral regions of the lungs (OR 1.41, CI 1.01–1.82). Conclusions Failed extubation in mechanically ventilated patients is more prevalent if markers of left ventricular diastolic dysfunction and loss of lung aeration are present.
Collapse
Affiliation(s)
- Kavi Haji
- Department of the Intensive Care Unit, Frankton Hospital, PO Box 52, Frankston, VIC, 3199, Australia. .,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
| | - Darsim Haji
- Frankston Hospital, Frankston, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
| | - David J Canty
- Department of Surgery, University of Melbourne, Melbourne, Australia.,Department of Medicine, Health Sciences and Nursing, Monash University, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia
| | - Alistair G Royse
- Ultrasound Education Group, Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, Australia
| | - Cameron Green
- Department of the Intensive Care Unit, Frankton Hospital, PO Box 52, Frankston, VIC, 3199, Australia
| | - Colin F Royse
- Ultrasound Education Group, Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| |
Collapse
|
36
|
Harjola VP, Parissis J, Brunner-La Rocca HP, Čelutkienė J, Chioncel O, Collins SP, De Backer D, Filippatos GS, Gayat E, Hill L, Lainscak M, Lassus J, Masip J, Mebazaa A, Miró Ò, Mortara A, Mueller C, Mullens W, Nieminen MS, Rudiger A, Ruschitzka F, Seferovic PM, Sionis A, Vieillard-Baron A, Weinstein JM, de Boer RA, Crespo-Leiro MG, Piepoli M, Riley JP. Comprehensive in-hospital monitoring in acute heart failure: applications for clinical practice and future directions for research. A statement from the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2018; 20:1081-1099. [PMID: 29710416 DOI: 10.1002/ejhf.1204] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 12/17/2022] Open
Abstract
This paper provides a practical clinical application of guideline recommendations relating to the inpatient monitoring of patients with acute heart failure, through the evaluation of various clinical, biomarker, imaging, invasive and non-invasive approaches. Comprehensive inpatient monitoring is crucial to the optimal management of acute heart failure patients. The European Society of Cardiology heart failure guidelines provide recommendations for the inpatient monitoring of acute heart failure, but the level of evidence underpinning most recommendations is limited. Many tools are available for the in-hospital monitoring of patients with acute heart failure, and each plays a role at various points throughout the patient's treatment course, including the emergency department, intensive care or coronary care unit, and the general ward. Clinical judgment is the preeminent factor guiding application of inpatient monitoring tools, as the various techniques have different patient population targets. When applied appropriately, these techniques enable decision making. However, there is limited evidence demonstrating that implementation of these tools improves patient outcome. Research priorities are identified to address these gaps in evidence. Future research initiatives should aim to identify the optimal in-hospital monitoring strategies that decrease morbidity and prolong survival in patients with acute heart failure.
Collapse
Affiliation(s)
- Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | | | | | - Jelena Čelutkienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Clinic of Cardiac and Vascular Diseases, Vilnius, Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila/Institute of Emergency for Cardiovascular Disease, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel De Backer
- Department of Intensive Care Medicine, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Etienne Gayat
- Département d'Anesthésie- Réanimation-SMUR, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM-UMR 942, AP-, HP, Université Paris Diderot, Paris, France
| | | | - Mitja Lainscak
- Department of Internal Medicine and Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Johan Lassus
- Cardiology, Heart and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Josep Masip
- Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain.,Hospital Sanitas CIMA, Barcelona, Spain
| | - Alexandre Mebazaa
- U942 INSERM, AP-HP, Paris, France.,Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), Nancy, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France.,AP-HP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Òscar Miró
- Emergency Department, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk - Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | | | - Alain Rudiger
- Cardio-surgical Intensive Care Unit, University and University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Petar M Seferovic
- Department of Internal Medicine, Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center, Belgrade, Serbia
| | - Alessandro Sionis
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antoine Vieillard-Baron
- INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807 Villejuif, France, University Hospital Ambroise Paré, AP-, HP, Boulogne-Billancourt, France
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, G. da Saliceto Hospital, Piacenza, Italy
| | | |
Collapse
|
37
|
Thille AW, Reynaud F, Marie D, Barrau S, Rousseau L, Rault C, Diaz V, Meurice JC, Coudroy R, Frat JP, Robert R, Drouot X. Impact of sleep alterations on weaning duration in mechanically ventilated patients: a prospective study. Eur Respir J 2018. [DOI: 10.1183/13993003.02465-2017] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sleep is markedly altered in intensive care unit (ICU) patients and may alter respiratory performance. Our objective was to assess the impact of sleep alterations on weaning duration.We conducted a prospective physiological study at a French teaching hospital. ICU patients intubated for at least 24 h and difficult to wean were included. Complete polysomnography (PSG) was performed after the first spontaneous breathing trial failure. Presence of atypical sleep, duration of sleep stages, particularly rapid eye movement (REM) sleep, and electroencephalogram (EEG) reactivity at eyes opening were assessed by a neurologist.20 out of 45 patients studied (44%) had atypical sleep that could not be classified according to the standard criteria. Duration of weaning between PSG and extubation was significantly longer in patients with atypical sleep (median (interquartile range) 5 (2–8) versus 2 (1–2) days; p=0.001) and in those with no REM sleep compared with the others. Using multivariate logistic regression analysis, atypical sleep remained independently associated with prolonged weaning (>48 h after PSG). Altered EEG reactivity at eyes opening was a good predictor of atypical sleep.Our results suggest for the first time that brain dysfunction may have an influence on the ability to breathe spontaneously.
Collapse
|
38
|
Preliminary Exploration of Epidemiologic and Hemodynamic Characteristics of Restrictive Filling Diastolic Dysfunction Based on Echocardiography in Critically Ill Patients: A Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5429868. [PMID: 29682549 PMCID: PMC5841041 DOI: 10.1155/2018/5429868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/07/2018] [Accepted: 01/15/2018] [Indexed: 02/05/2023]
Abstract
Objective To preliminarily describe the epidemiologic and hemodynamic characteristics of critically ill patients with restrictive filling diastolic dysfunction based on echocardiography. Setting A retrospective study. Methods Epidemiologic characteristics of patients with restrictive filling diastolic dysfunction in ICU were described; clinical and hemodynamic data were preliminarily summarized and compared between patients with and without restrictive filling diastolic dysfunction; most of the data were based on echocardiography. Results More than half of the patients in ICU had diastolic dysfunction and about 16% of them had restrictive filling pattern. The patients who had restrictive filling diastolic dysfunction were more likely to have wider diameter of IVC (2.18 ± 0.50 versus 1.92 ± 0.43, P = 0.037), higher extravascular lung water score (15.9 ± 9.2 versus 13.2 ± 9.1, P = 0.014), lower left ventricular ejection fraction (EF-S: 53.0 ± 16.3 versus 59.3 ± 12.5, P = 0.014), and lower percentage of normal LAP that was estimated by E/e′ (8.9% versus 90.0%, P = 0.001) when compared with those of patients without restrictive filling diastolic dysfunction. Conclusion Our results suggest that critically ill patients with restrictive filling diastolic dysfunction may experience rising volume status, increasing extravascular lung water ultrasonic score, reducing long-axis systolic dysfunction, and less possibility of normal left atrial pressure. Intensivists are advised to pay more attention to patients with diastolic dysfunction, especially the exquisite fluid management of patients with restrictive filling pattern due to the close relationship of restrictive filling diastolic dysfunction with volume status and extravascular lung water in our study.
Collapse
|
39
|
Luo L, Li Y, Chen X, Sun B, Li W, Gu W, Wang S, Zhao S, Lv Y, Chen M, Xia J, Sui F, Mei X, Shi H, Tong Z. Different effects of cardiac and diaphragm function assessed by ultrasound on extubation outcomes in difficult-to-wean patients: a cohort study. BMC Pulm Med 2017; 17:161. [PMID: 29191205 PMCID: PMC5709823 DOI: 10.1186/s12890-017-0501-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 11/15/2017] [Indexed: 01/19/2023] Open
Abstract
Background Ultrasound is a convenient tool to evaluate cardiac and diaphragm function. The ratio (E/Ea) of mitral Doppler inflow velocity to annular tissue Doppler wave velocity by transthoracic echocardiography (TTE) and diaphragmatic excursion (DE) by diaphragm ultrasound have been confirmed in predicting extubation outcomes independently, however their different roles in the weaning process have not been determined until now. Methods We designed a cohort study to preform diaphragm ultrasound and TTE before and after the spontaneous breathing trial (SBT) in difficult-to-wean patients. Patients considered for enrollment should succeed on a SBT and have been extubated. They were followed up with the events of respiratory failure within 48 h, and divided into the respiratory failure and extubation success subgroups. Relevant risk factors predicting respiratory failure were analysed by a multivariate logistic regression model. Then, each subgroup was assessed with respect to re-intubation within 1 week, and divided into the re-intubation and non-intubation subgroups. Furthermore, relevant risk factors predicting re-intubation were also analysed in each subgroup. The area under the curve (AUC) and optimum cut-off value were identified by the receiver operating characteristic curve. Results Among 60 patients, 29 cases developed respiratory failure within 48 h, and 14 cases were re-intubated or died within 1 week, respectively. Multivariate logistic regression analysis showed that E/Ea (average) after SBT [odds ratio (OR) 1.450, 95% confidence intervals (CI) 1.092-1.926, P = 0.01] and left ventricular ejection fraction were associated with respiratory failure. The AUC of E/Ea (average) after SBT was 0.789, and a cut-off value ≥ 12.5 showed the highest diagnostic accuracy with a sensitivity and specificity of 72.4% and 77.4%, respectively. Furthermore, in the respiratory failure subgroup only DE (average) after SBT was associated with re-intubation (OR 0.690, CI 0.499-0.953, P = 0.024). The AUC of DE (average) after SBT was 0.805, and a cut-off value ≤ 12.6 mm showed the highest diagnostic accuracy with a sensitivity and specificity of 80% and 68.4%, respectively. Conclusions E/Ea (average) after SBT could help predict respiratory failure within 48 h. However, DE (average) after SBT could help predict re-intubation within 1 week in the respiratory failure subgroup. Electronic supplementary material The online version of this article (10.1186/s12890-017-0501-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ling Luo
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.,Department of Respiratory and Critical Care Medicine, Beijing Jishuitan Hospital, NO. 31 Xinjiekou East District, Beijing, 100035, China
| | - Yidan Li
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xiukai Chen
- Department of Surgery Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Wenxiong Li
- Department of Surgery Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Wei Gu
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Shuo Wang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Song Zhao
- Department of Surgery Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yanwei Lv
- Department of Clinical Epidemiology Research Center, Beijing Jishuitan Hospital, NO. 31 Xinjiekou East District, Beijing, 100035, China
| | - Mulei Chen
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Jingen Xia
- Department of Intensive care medicine, China-Japan Friendship Hospital, No.2 Yinghua East Street, Beijing, 100029, China
| | - Feng Sui
- Department of Surgery Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xue Mei
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Huanzhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, NO. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
| |
Collapse
|
40
|
|
41
|
Sanfilippo F, Corredor C, Arcadipane A, Landesberg G, Vieillard-Baron A, Cecconi M, Fletcher N. Tissue Doppler assessment of diastolic function and relationship with mortality in critically ill septic patients: a systematic review and meta-analysis. Br J Anaesth 2017; 119:583-594. [DOI: 10.1093/bja/aex254] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
|
42
|
Sanfilippo F, Santonocito C, Burgio G, Arcadipane A. The importance of diastolic dysfunction in the development of weaning-induced pulmonary oedema. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:29. [PMID: 28187775 PMCID: PMC5303246 DOI: 10.1186/s13054-017-1613-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Via Tricomi 5, 90127, Palermo, Italy.
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Via Tricomi 5, 90127, Palermo, Italy
| | - Gaetano Burgio
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Via Tricomi 5, 90127, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Via Tricomi 5, 90127, Palermo, Italy
| |
Collapse
|
43
|
Ruiz-Bailén M, Cobo-Molinos J, Castillo-Rivera A, Pola-Gallego-de-Guzmán MD, Cárdenas-Cruz A, Martínez-Amat A, Sevilla-Martínez M, Hernández-Caballero C. Stress echocardiography in patients who experienced mechanical ventilation weaning failure. J Crit Care 2017; 39:66-71. [PMID: 28219811 DOI: 10.1016/j.jcrc.2017.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 12/16/2016] [Accepted: 01/06/2017] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Critically ill patients may suffer varying degrees of temporary myocardial dysfunction during respiratory weaning that could play an important role in weaning failure. OBJECTIVES In this study, we tried to assess the existence of temporary diastolic dysfunction during respiratory weaning. METHODS Inclusion period is from 2006 to 2015. In this study, we included 181 ventilated patients with cardiogenic shock that were being weaned from mechanical ventilation. Twenty of those patients were successfully weaned from mechanical ventilation, and the rest (161) experienced complications in their weaning process. All patients had a left ventricular ejection fraction >0.45 and E/E' ratio≤8, did not require vasoactive drugs at that time, and did not have remaining significant ischemic disease. We divided our patients into 3 groups, as follows: A, patients who could not tolerate a T-tube and required pressure-support ventilation (82); B, patients who successfully tolerated a T-tube period (20); and C, patients who could not tolerate spontaneous breathing modes of mechanical ventilation and remained on assisted mechanical ventilation. We performed stress echocardiography for the last two groups; using dobutamine to assess diastolic function and using ephedrine to evaluate functional mitral regurgitation (MR). We estimated pulmonary capillary wedge pressure through the E/E' ratio and the flow in the pulmonary veins. RESULTS In group A (ie, those patients who could not tolerate a T-tube trial), we observed an increase in the E/E' ratio (6.32±0.77 vs 15.2±6.65; P=.0001) and a worsening of strain (S) and strain rate (SR) (-13.6±1.80 vs -11.88±5.6, P=.0001; and -1.3±1.28 vs -0.95±0.38, P=.0001; respectively). We did not observe a change in the E/E' ratio during stress echocardiogram on those patients with successful weaning from mechanical ventilation (7.41±0.43 vs 8.38±4.57, P=.001). However, we did see in this group an increased peak velocity of the S wave and of SR (-16.11±08.72 vs -19.89±5.62 and -1.48±0.23 vs -1.59±0.21, P=.001; respectively). In 42 weaning failure patients, the dobutamine echocardiography showed an increased E/E' ratio (7.41±0.43 vs 15.98±7.98; P=.0001) and deterioration of S (-15.41±09.56 vs -12.72±6.55; P=.0001) and SR (-1.41±0.78 vs -1.22±0.65; P=.0001). In 37 patients without systolic or diastolic impairment and functional MR grade >2, ephedrine echocardiography showed an increase of effective regurgitant volume (29.56±11.32 mL vs 46.56±0.13 mL, P=.0001) and effective regurgitant orifice area (0.19±0.09 cm2 vs 0.31±0.09 cm2, P=.0001). CONCLUSIONS Stress echocardiography may be helpful in detecting silent diastolic and systolic dysfunction or severe MR that could have a major impact on respiratory weaning.
Collapse
Affiliation(s)
- Manuel Ruiz-Bailén
- Departamento de Ciencias de la Salud, Universidad de Jaén, Complejo Hospitalario de Jaén; Intensive Care Medicine, Complejo Hospitalario de Jaén.
| | - Jesús Cobo-Molinos
- Departamento de Ciencias de la Salud, Universidad de Jaén, Complejo Hospitalario de Jaén
| | | | | | | | - Antonio Martínez-Amat
- Departamento de Ciencias de la Salud, Universidad de Jaén, Complejo Hospitalario de Jaén
| | | | | |
Collapse
|
44
|
Liu J, Shen F, Teboul JL, Anguel N, Beurton A, Bezaz N, Richard C, Monnet X. Cardiac dysfunction induced by weaning from mechanical ventilation: incidence, risk factors, and effects of fluid removal. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:369. [PMID: 27836002 PMCID: PMC5106814 DOI: 10.1186/s13054-016-1533-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 10/14/2016] [Indexed: 01/22/2023]
Abstract
Background Weaning-induced pulmonary oedema (WiPO) is a well-recognised cause of failure of weaning from mechanical ventilation, but its incidence and risk factors have not been reliably described. We wanted to determine the incidence and risk factors in a population of critically ill patients. In addition, we wanted to describe the effects of diuretics when they are administered in this context. Methods We monitored 283 consecutive spontaneous breathing trials (SBT; T-piece trial) performed in 81 patients. In cases with cardiac output monitoring (n = 85, 29 patients), a passive leg raising (PLR) test was performed before SBT. Three experts established the diagnosis of WiPO based on various patient characteristics. Results SBT failed in 128 cases (45 % of all SBT). WiPO occurred in 59 % of these failing cases. Compared to patients without WiPO (n = 52), patients with at least one WiPO (n = 29) had a higher prevalence of chronic obstructive pulmonary disease (COPD) (38 % vs. 12 %, respectively; p < 0.01), previous “structural” cardiopathy (dilated and/or hypertrophic and/or hypokinetic cardiopathy and/or significant valvular disease, 9 % vs. 25 %, respectively; p < 0.01), obesity (45 % vs. 17 %, respectively; p < 0.01), and low left ventricular ejection fraction (55 % vs. 21 %, respectively; p = 0.01). At logistic regression, COPD (odds ratio (OR) 8.7, 95 % confidence interval (CI) 2.0–37.3), previous structural cardiopathy (OR 4.5, 95 % CI 1.4–14.1), and obesity (OR 3.6, 95 % CI 1.2–12.6) were independent risk factors for experiencing at least one episode of WiPO. In 16 cases with WiPO and a negative PLR at baseline, treatment including diuretics was started. In 9 of these cases, the PLR remained negative before the following SBT. A new episode of WiPO occurred in 7 of these instances, while the two other were extubated. In 7 other cases, the PLR became positive before the following SBT. WiPO did not occur anymore in 6 of these 7 patients who were extubated, while the remaining one was not. Conclusions In our population of critically ill patients, WiPO was responsible for 59 % of weaning failures. COPD, previous “structural” cardiopathy, and, to a lesser extent, obesity were the main risk factors. When a treatment including fluid removal had changed preload-independence to preload-dependence, the following SBT was very likely to succeed.
Collapse
Affiliation(s)
- Jinglun Liu
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Shen
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Department of Critical Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jean-Louis Teboul
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Nadia Anguel
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Alexandra Beurton
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Nadia Bezaz
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Christian Richard
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Xavier Monnet
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| |
Collapse
|
45
|
|
46
|
Suárez JC, López P, Mancebo J, Zapata L. Diastolic dysfunction in the critically ill patient. Med Intensiva 2016; 40:499-510. [PMID: 27569679 DOI: 10.1016/j.medin.2016.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/14/2016] [Accepted: 06/20/2016] [Indexed: 12/16/2022]
Abstract
Left ventricular diastolic dysfunction is a common finding in critically ill patients. It is characterized by a progressive deterioration of the relaxation and the compliance of the left ventricle. Two-dimensional and Doppler echocardiography is a cornerstone in its diagnosis. Acute pulmonary edema associated with hypertensive crisis is the most frequent presentation of diastolic dysfunction critically ill patients. Myocardial ischemia, sepsis and weaning failure from mechanical ventilation also may be associated with diastolic dysfunction. The treatment is based on the reduction of pulmonary congestion and left ventricular filling pressures. Some studies have found a prognostic role of diastolic dysfunction in some diseases such as sepsis. The present review aims to analyze thoroughly the echocardiographic diagnosis and the most frequent scenarios in critically ill patients in whom diastolic dysfunction plays a key role.
Collapse
Affiliation(s)
- J C Suárez
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - P López
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - J Mancebo
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - L Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain.
| |
Collapse
|
47
|
Critical care ultrasonography in acute respiratory failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:228. [PMID: 27524204 PMCID: PMC4983787 DOI: 10.1186/s13054-016-1400-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/01/2016] [Indexed: 12/12/2022]
Abstract
Acute respiratory failure (ARF) is a leading indication for performing critical care ultrasonography (CCUS) which, in these patients, combines critical care echocardiography (CCE) and chest ultrasonography. CCE is ideally suited to guide the diagnostic work-up in patients presenting with ARF since it allows the assessment of left ventricular filling pressure and pulmonary artery pressure, and the identification of a potential underlying cardiopathy. In addition, CCE precisely depicts the consequences of pulmonary vascular lesions on right ventricular function and helps in adjusting the ventilator settings in patients sustaining moderate-to-severe acute respiratory distress syndrome. Similarly, CCE helps in identifying patients at high risk of ventilator weaning failure, depicts the mechanisms of weaning pulmonary edema in those patients who fail a spontaneous breathing trial, and guides tailored therapeutic strategy. In all these clinical settings, CCE provides unparalleled information on both the efficacy and tolerance of therapeutic changes. Chest ultrasonography provides further insights into pleural and lung abnormalities associated with ARF, irrespective of its origin. It also allows the assessment of the effects of treatment on lung aeration or pleural effusions. The major limitation of lung ultrasonography is that it is currently based on a qualitative approach in the absence of standardized quantification parameters. CCE combined with chest ultrasonography rapidly provides highly relevant information in patients sustaining ARF. A pragmatic strategy based on the serial use of CCUS for the management of patients presenting with ARF of various origins is detailed in the present manuscript.
Collapse
|
48
|
de Meirelles Almeida CA, Nedel WL, Morais VD, Boniatti MM, de Almeida-Filho OC. Diastolic dysfunction as a predictor of weaning failure: A systematic review and meta-analysis. J Crit Care 2016; 34:135-41. [PMID: 27067288 DOI: 10.1016/j.jcrc.2016.03.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 02/13/2016] [Accepted: 03/09/2016] [Indexed: 12/16/2022]
Affiliation(s)
| | - W L Nedel
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | - V D Morais
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | - M M Boniatti
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - O C de Almeida-Filho
- Doppler Echocardiography Laboratory, Hospital das Clínicas de Ribeirão Preto, Ribeirão Preto, Brazil
| |
Collapse
|
49
|
Konomi I, Tasoulis A, Kaltsi I, Karatzanos E, Vasileiadis I, Temperikidis P, Nanas S, Routsi CI. Left Ventricular Diastolic Dysfunction—An Independent Risk Factor for Weaning Failure from Mechanical Ventilation. Anaesth Intensive Care 2016; 44:466-73. [DOI: 10.1177/0310057x1604400408] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The objective of this study was to investigate the contribution of left ventricular (LV) diastolic dysfunction to weaning failure, along with the levels of the currently used cardiac biomarkers. Forty-two mechanically ventilated patients, who fulfilled criteria for weaning from mechanical ventilation (MV), underwent a two-hour spontaneous breathing trial (SBT). Transthoracic echocardiography (TTE) was performed before the start of the SBT. The grade of LV diastolic dysfunction was assessed by pulsed-wave Doppler and tissue Doppler imaging at the level of the mitral valve. Haemodynamic and respiratory parameters were recorded. Blood levels of B-type natriuretic peptide (BNP), troponin I, creatine kinase–MB, and myoglobin were measured on MV and at the end of the SBT. Weaning success was defined as the patient's ability to tolerate spontaneous breathing for more than 48 hours. Fifteen patients failed to wean. LV diastolic dysfunction was significantly associated with weaning failure ( P <0.001). The grade of diastolic dysfunction was significantly correlated with BNP levels both on MV and at the end of the SBT ( P <0.001, r = 0.703 and P <0.001, r = 0.709, respectively). BNP levels on MV were lower in patients who successfully weaned compared to those who did not (361 ± 523 ng/l versus 643 ± 382 ng/l respectively, P=0.008). The presence of diastolic dysfunction was independently associated with weaning failure (odds ratio [OR] 11.23, confidence interval [CI] 1.16–109.1, P=0.037) followed by respiratory frequency/tidal volume (OR 1.05, CI 1.00–1.10, P=0.048). Therefore, assessment of LV diastolic function before the start of weaning could be useful to identify patients at risk of weaning failure.
Collapse
Affiliation(s)
- I. Konomi
- Department of Intensive Care, Evangelismos Hospital, Athens, Greece
| | - A. Tasoulis
- Department of Intensive Care, Evangelismos Hospital, Athens, Greece
| | - I. Kaltsi
- Department of Intensive Care, Evangelismos Hospital, Athens, Greece
| | - E. Karatzanos
- Department of Intensive Care, Evangelismos Hospital, Athens, Greece
| | - I. Vasileiadis
- Department of Intensive Care, Evangelismos Hospital, Athens, Greece
| | - P. Temperikidis
- Department of Intensive Care, Evangelismos Hospital, Athens, Greece
| | - S. Nanas
- Department of Intensive Care and Cardiopulmonary Exercise Testing and Rehabilitation Laboratory, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - C. I. Routsi
- Intensivist, National and Kapodistrian University of Athens, Department of Intensive Care, Evangelismos Hospital, Athens, Greece
| |
Collapse
|
50
|
Tseng YH, Ko HK, Tseng YC, Lin YH, Kou YR. Atrial Fibrillation on Intensive Care Unit Admission Independently Increases the Risk of Weaning Failure in Nonheart Failure Mechanically Ventilated Patients in a Medical Intensive Care Unit: A Retrospective Case-Control Study. Medicine (Baltimore) 2016; 95:e3744. [PMID: 27196499 PMCID: PMC4902442 DOI: 10.1097/md.0000000000003744] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/13/2016] [Accepted: 04/21/2016] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is one of the most frequent arrhythmias in clinical practice. Previous studies have reported the influence of AF on patients with heart failure (HF). The effect of AF on the non-HF critically ill patients in a medical intensive care unit (ICU) remains largely unclear. The study aimed to investigate the impact of AF presenting on ICU admission on the weaning outcome of non-HF mechanically ventilated patients in a medical ICU.A retrospective observational case-control study was conducted over a 1-year period in a medical ICU at Taipei Veterans General Hospital, a tertiary medical center in north Taiwan. Non-HF mechanically ventilated patients who were successful in their spontaneous breathing trial and underwent ventilator discontinuation were enrolled. The primary outcome measure was the ventilator status after the first episode of ventilator discontinuation.A total of 285 non-HF patients enrolled were divided into AF (n = 62) and non-AF (n = 223) groups. Compared with the non-AF patients, the AF patients were significantly associated with old age (P = 0.002), a higher rate of acute respiratory distress syndrome causing respiratory failure (P = 0.015), a higher percentage of sepsis before liberation from mechanical ventilation (MV) (P = 0.004), and a higher serum level of blood urea nitrogen on the day of liberation from MV (P = 0.003). Multivariate logistic regression analysis demonstrated that AF independently increased the risk of weaning failure [adjusted odds ratio (AOR), 3.268; 95% confidence interval (CI), 1.254-8.517; P = 0.015]. Furthermore, the AF patients were found to be independently associated with a high rate of ventilator dependence (log rank test, P = 0.026), prolonged total ventilator use (AOR, 1.979; 95% CI, 1.032-3.794; P = 0.040), increased length of ICU stay (AOR, 2.256; 95% CI, 1.049-4.849; P = 0.037), increased length of hospital stay (AOR, 2.921; 95% CI, 1.363-6.260; P = 0.006), and increased ICU mortality (AOR, 4.143; 95% CI, 1.381-12.424; P = 0.011).AF on ICU admission is an independent risk factor for weaning failure and significantly associated with poor hospital outcome in non-HF mechanically ventilated patients in a medical ICU.
Collapse
Affiliation(s)
- Yen-Han Tseng
- From the Department of Chest Medicine, Taipei Veterans General Hospital (Y-HT, H-KK), School of Medicine (Y-HT, H-KK, Y-CT), Department of Family Medicine, School of Medicine (Y-HL), Institute of Physiology, School of Medicine (YRK), Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei (YRK), Department of Surgery, Kaohsiung Veterans General Hospital, Pingtung Branch, Pingtung (Y-CT), and Department of Family Medicine, Taipei Hospital, Ministry of Health and Welfare, Taiwan, Republic of China (Y-HL)
| | | | | | | | | |
Collapse
|