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Fava de Lima F, Siqueira de Nóbrega R, Cesare Biselli PJ, Takachi Moriya H. Central venous pressure waveform analysis during sleep/rest: a novel approach to enhance intensive care unit post-extubation monitoring of extubation failure. J Clin Monit Comput 2024; 38:961-979. [PMID: 38954170 DOI: 10.1007/s10877-024-01171-0] [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: 08/25/2023] [Accepted: 04/25/2024] [Indexed: 07/04/2024]
Abstract
This pilot study aimed to investigate the relation between cardio-respiratory parameters derived from Central Venous Pressure (CVP) waveform and Extubation Failure (EF) in mechanically ventilated ICU patients during post-extubation period. This study also proposes a new methodology for analysing these parameters during rest/sleep periods to try to improve the identification of EF. We conducted a prospective observational study, computing CVP-derived parameters including breathing effort, spectral analyses, and entropy in twenty critically ill patients post-extubation. The Dynamic Warping Index (DWi) was calculated from the respiratory component extracted from the CVP signal to identify rest/sleep states. The obtained parameters from EF patients and patients without EF were compared both during arbitrary periods and during reduced DWi (rest/sleep). We have analysed data from twenty patients of which nine experienced EF. Our findings may suggest significantly increased respiratory effort in EF patients compared to those successfully extubated. Our study also suggests the occurrence of significant change in the frequency dispersion of the cardiac signal component. We also identified a possible improvement in the differentiation between the two groups of patients when assessed during rest/sleep states. Although with caveats regarding the sample size, the results of this pilot study may suggest that CVP-derived cardio-respiratory parameters are valuable for monitoring respiratory failure during post-extubation, which could aid in managing non-invasive interventions and possibly reduce the incidence of EF. Our findings also indicate the possible importance of considering sleep/rest state when assessing cardio-respiratory parameters, which could enhance respiratory failure detection/monitoring.
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Affiliation(s)
- Felipe Fava de Lima
- Biomedical Engineering Laboratory, Escola Politécnica, University of São Paulo (USP), São Paulo, Brazil.
| | | | | | - Henrique Takachi Moriya
- Biomedical Engineering Laboratory, Escola Politécnica, University of São Paulo (USP), São Paulo, Brazil
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Gavelli F, Castello LM, Monnet X, Azzolina D, Nerici I, Priora S, Via VG, Bertoli M, Foieni C, Beltrame M, Bellan M, Sainaghi PP, De Vita N, Patrucco F, Teboul JL, Avanzi GC. Decrease of haemoconcentration reliably detects hydrostatic pulmonary oedema in dyspnoeic patients in the emergency department - a machine learning approach. Int J Emerg Med 2024; 17:114. [PMID: 39237860 PMCID: PMC11375861 DOI: 10.1186/s12245-024-00698-y] [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: 07/02/2024] [Accepted: 08/26/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND Haemoglobin variation (ΔHb) induced by fluid transfer through the intestitium has been proposed as a useful tool for detecting hydrostatic pulmonary oedema (HPO). However, its use in the emergency department (ED) setting still needs to be determined. METHODS In this observational retrospective monocentric study, ED patients admitted for acute dyspnoea were enrolled. Hb values were recorded both at ED presentation (T0) and after 4 to 8 h (T1). ΔHb between T1 and T0 (ΔHbT1-T0) was calculated as absolute and relative value. Two investigators, unaware of Hb values, defined the cause of dyspnoea as HPO and non-HPO. ΔHbT1-T0 ability to detect HPO was evaluated. A machine learning approach was used to develop a predictive tool for HPO, by considering the ability of ΔHb as covariate, together with baseline patient characteristics. RESULTS Seven-hundred-and-six dyspnoeic patients (203 HPO and 503 non-HPO) were enrolled over 19 months. Hb levels were significantly different between HPO and non-HPO patients both at T0 and T1 (p < 0.001). ΔHbT1-T0 were more pronounced in HPO than non-HPO patients, both as relative (-8.2 [-11.2 to -5.6] vs. 0.6 [-2.1 to 3.3] %) and absolute (-1.0 [-1.4 to -0.8] vs. 0.1 [-0.3 to 0.4] g/dL) values (p < 0.001). A relative ΔHbT1-T0 of -5% detected HPO with an area under the receiver operating characteristic curve (AUROC) of 0.901 [0.896-0.906]. Among the considered models, Gradient Boosting Machine showed excellent predictive ability in identifying HPO patients and was used to create a web-based application. ΔHbT1-T0 was confirmed as the most important covariate for HPO prediction. CONCLUSIONS ΔHbT1-T0 in patients admitted for acute dyspnoea reliably identifies HPO in the ED setting. The machine learning predictive tool may represent a performing and clinically handy tool for confirming HPO.
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Affiliation(s)
- Francesco Gavelli
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy.
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy.
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Hôpitaux universitaires Paris- Saclay, APHP, rue du Général Leclerc, Paris, France.
| | - Luigi Mario Castello
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy
| | - Xavier Monnet
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Hôpitaux universitaires Paris- Saclay, APHP, rue du Général Leclerc, Paris, France
| | - Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy
| | - Ilaria Nerici
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy
| | - Simona Priora
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy
| | - Valentina Giai Via
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy
| | - Matteo Bertoli
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy
| | - Claudia Foieni
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy
| | - Michela Beltrame
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
| | - Pier Paolo Sainaghi
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
| | - Nello De Vita
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
| | - Filippo Patrucco
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, Hôpitaux universitaires Paris- Saclay, APHP, rue du Général Leclerc, Paris, France
| | - Gian Carlo Avanzi
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Via Solaroli 17, Novara, 28100, Italy
- Emergency Medicine Department, AOU Maggiore della Carità di Novara, C.so Mazzini 18, Novara, 28100, Italy
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Jozwiak M, Teboul JL. Heart-Lungs interactions: the basics and clinical implications. Ann Intensive Care 2024; 14:122. [PMID: 39133379 PMCID: PMC11319696 DOI: 10.1186/s13613-024-01356-5] [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: 05/02/2024] [Accepted: 07/24/2024] [Indexed: 08/13/2024] Open
Abstract
Heart-lungs interactions are related to the interplay between the cardiovascular and the respiratory system. They result from the respiratory-induced changes in intrathoracic pressure, which are transmitted to the cardiac cavities and to the changes in alveolar pressure, which may impact the lung microvessels. In spontaneously breathing patients, consequences of heart-lungs interactions are during inspiration an increase in right ventricular preload and afterload, a decrease in left ventricular preload and an increase in left ventricular afterload. In mechanically ventilated patients, consequences of heart-lungs interactions are during mechanical insufflation a decrease in right ventricular preload, an increase in right ventricular afterload, an increase in left ventricular preload and a decrease in left ventricular afterload. Physiologically and during normal breathing, heart-lungs interactions do not lead to significant hemodynamic consequences. Nevertheless, in some clinical settings such as acute exacerbation of chronic obstructive pulmonary disease, acute left heart failure or acute respiratory distress syndrome, heart-lungs interactions may lead to significant hemodynamic consequences. These are linked to complex pathophysiological mechanisms, including a marked inspiratory negativity of intrathoracic pressure, a marked inspiratory increase in transpulmonary pressure and an increase in intra-abdominal pressure. The most recent application of heart-lungs interactions is the prediction of fluid responsiveness in mechanically ventilated patients. The first test to be developed using heart-lungs interactions was the respiratory variation of pulse pressure. Subsequently, many other dynamic fluid responsiveness tests using heart-lungs interactions have been developed, such as the respiratory variations of pulse contour-based stroke volume or the respiratory variations of the inferior or superior vena cava diameters. All these tests share the same limitations, the most frequent being low tidal volume ventilation, persistent spontaneous breathing activity and cardiac arrhythmia. Nevertheless, when their main limitations are properly addressed, all these tests can help intensivists in the decision-making process regarding fluid administration and fluid removal in critically ill patients.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, CHU de Nice Hôpital Archet 1, 151 Route Saint Antoine de Ginestière, 06200, Nice, France.
- UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, 06200, Nice, France.
| | - Jean-Louis Teboul
- Faculté de Médecine Paris-Saclay, Université Paris-Saclay, 94270, Le Kremlin-Bicêtre, France
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Groenland CNL, Blijleven MA, Ramzi I, Dubois EA, Heunks L, Endeman H, Wils EJ, Baggen VJM. The Value of Ischemic Cardiac Biomarkers to Predict Spontaneous Breathing Trial or Extubation Failure: A Systematic Review. J Clin Med 2024; 13:3242. [PMID: 38892952 PMCID: PMC11173145 DOI: 10.3390/jcm13113242] [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: 04/17/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Background: It is unclear whether other cardiac biomarkers than NT-proBNP can be useful in the risk stratification of patients weaning from mechanical ventilation. The aim of this study is to summarize the role of ischemic cardiac biomarkers in predicting spontaneous breathing trial (SBT) or extubation failure. Methods: We systematically searched Embase, MEDLINE, Web of Science, and Cochrane Central for studies published before January 2024 that reported the association between ischemic cardiac biomarkers and SBT or extubation failure. Data were extracted using a standardized form and methodological assessment was performed using the QUIPS tool. Results: Seven observational studies investigating four ischemic cardiac biomarkers (Troponin-T, Troponin-I, CK-MB, Myoglobin) were included. One study reported a higher peak Troponin-I in patients with extubation failure compared to extubation success (50 ng/L [IQR, 20-215] versus 30 ng/L [IQR, 10-86], p = 0.01). A second study found that Troponin-I measured before the SBT was higher in patients with SBT failure in comparison to patients with SBT success (100 ± 80 ng/L versus 70 ± 130 ng/L, p = 0.03). A third study reported a higher CK-MB measured at the end of the SBT in patients with weaning failure (SBT or extubation failure) in comparison to weaning success (8.77 ± 20.5 ng/mL versus 1.52 ± 1.42 ng/mL, p = 0.047). Troponin-T and Myoglobin as well as Troponin-I and CK-MB measured at other time points were not found to be related to SBT or extubation failure. However, most studies were underpowered and with high risk of bias. Conclusions: The association with SBT or extubation failure is limited for Troponin-I and CK-MB and appears absent for Troponin-T and Myoglobin, but available studies are hampered by significant methodological drawbacks. To more definitively determine the role of ischemic cardiac biomarkers, future studies should prioritize larger sample sizes, including patients at risk of cardiac disease, using stringent SBTs and structured timing of laboratory measurements before and after SBT.
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Affiliation(s)
- Carline N. L. Groenland
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
| | - Maud A. Blijleven
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
| | - Imane Ramzi
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
| | - Eric A. Dubois
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
- Department of Intensive Care, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland Ziekenhuis, 3045 PM Rotterdam, The Netherlands;
| | - Vivan J. M. Baggen
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, 3015 GD Rotterdam, The Netherlands
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Song J, Luo Q, Lai X, Hu W, Yu Y, Wang M, Yang K, Chen G, Chen W, Li Q, Hu C, Gong S. Combined cardiac, lung, and diaphragm ultrasound for predicting weaning failure during spontaneous breathing trial. Ann Intensive Care 2024; 14:60. [PMID: 38641687 PMCID: PMC11031537 DOI: 10.1186/s13613-024-01294-2] [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: 12/08/2023] [Accepted: 04/10/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Weaning from invasive mechanical ventilation (MV) is a complex and challenging process that involves multiple pathophysiological mechanisms. A combined ultrasound evaluation of the heart, lungs, and diaphragm during the weaning phase can help to identify risk factors and underlying mechanisms for weaning failure. This study aimed to investigate the accuracy of lung ultrasound (LUS), transthoracic echocardiography (TTE), and diaphragm ultrasound for predicting weaning failure in critically ill patients. METHODS Patients undergoing invasive MV for > 48 h and who were readied for their first spontaneous breathing trial (SBT) were studied. Patients were scheduled for a 2-h SBT using low-level pressure support ventilation. LUS and TTE were performed prospectively before and 30 min after starting the SBT, and diaphragm ultrasound was only performed 30 min after starting the SBT. Weaning failure was defined as failure of SBT, re-intubation, or non-invasive ventilation within 48 h. RESULTS Fifty-one patients were included, of whom 15 experienced weaning failure. During the SBT, the global, anterior, and antero-lateral LUS scores were higher in the failed group than in the successful group. Receiver operating characteristic curve analysis showed that the areas under the curves for diaphragm thickening fraction (DTF) and global and antero-lateral LUS scores during the SBT to predict weaning failure were 0.678, 0.719, and 0.721, respectively. There was no correlation between the LUS scores and the average E/e' ratio during the SBT. Multivariate analysis identified antero-lateral LUS score > 7 and DTF < 31% during the SBT as independent predictors of weaning failure. CONCLUSION LUS and diaphragm ultrasound can help to predict weaning failure in patients undergoing an SBT with low-level pressure support. An antero-lateral LUS score > 7 and DTF < 31% during the SBT were associated with weaning failure.
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Affiliation(s)
- Jia Song
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Qiancheng Luo
- Department of Critical Care Medicine, Shanghai Pudong New Area Gongli Hospital, No. 219, Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Xinle Lai
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Weihang Hu
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Yihua Yu
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Minjia Wang
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Kai Yang
- The 2nd Clinical Medical College, Zhejiang Chinese Medical University, No. 548, Binwen Road, Binjiang District, Hangzhou, 310053, China
| | - Gongze Chen
- The 2nd Clinical Medical College, Zhejiang Chinese Medical University, No. 548, Binwen Road, Binjiang District, Hangzhou, 310053, China
| | - Wenwei Chen
- The 2nd Clinical Medical College, Zhejiang Chinese Medical University, No. 548, Binwen Road, Binjiang District, Hangzhou, 310053, China
| | - Qian Li
- The 2nd Clinical Medical College, Zhejiang Chinese Medical University, No. 548, Binwen Road, Binjiang District, Hangzhou, 310053, China
| | - Caibao Hu
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China.
| | - Shijin Gong
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China.
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Castro R, Born P, Muñoz F, Guzmán C, Kattan E, Hernandez G, Bakker J. Fluid Responsiveness Is Associated with Successful Weaning after Liver Transplant Surgery. J Pers Med 2024; 14:429. [PMID: 38673056 PMCID: PMC11051314 DOI: 10.3390/jpm14040429] [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: 03/18/2024] [Revised: 04/10/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
A positive fluid balance may evolve to fluid overload and associate with organ dysfunctions, weaning difficulties, and increased mortality in ICU patients. We explored whether individualized fluid management, assessing fluid responsiveness via a passive leg-raising maneuver (PLR) before a spontaneous breathing trial (SBT), is associated with less extubation failure in ventilated patients with a high fluid balance admitted to the ICU after liver transplantation (LT). We recruited 15 LT patients in 2023. Their postoperative fluid balance was +4476 {3697, 5722} mL. PLR maneuvers were conducted upon ICU admission (T1) and pre SBT (T2). Cardiac index (CI) changes were recorded before and after each SBT (T3). Seven patients were fluid-responsive at T1, and twelve were responsive at T2. No significant differences occurred in hemodynamic, respiratory, and perfusion parameters between the fluid-responsive and fluid-unresponsive patients at any time. Fluid-responsive patients at T1 and T2 increased their CI during SBT from 3.1 {2.8, 3.7} to 3.7 {3.4, 4.1} mL/min/m2 (p = 0.045). All fluid-responsive patients at T2 were extubated after the SBTs and consolidated extubation. Two out of three of the fluid-unresponsive patients experienced weaning difficulties. We concluded that fluid-responsive patients post LT may start weaning earlier and achieve successful extubation despite a high postoperative fluid balance. This highlights the profound impact of personalized assessments of cardiovascular state on critical surgical patients.
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Affiliation(s)
- Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Pablo Born
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Felipe Muñoz
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Camila Guzmán
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Department of Intensive Care, Erasmus MC University Medical Center, P.O. Box 2040, 3000 Rotterdam, The Netherlands
- Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, NY 10019, USA
- NYU School of Medicine, Langone, New York, NY 10016, USA
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Mezidi M, Yonis H, Chauvelot L, Deniel G, Dhelft F, Gaillet M, Noirot I, Folliet L, Chabert P, David G, Danjou W, Baboi L, Bettinger C, Bernon P, Girard M, Provoost J, Bazzani A, Bitker L, Richard JC. Spontaneous breathing trial with pressure support on positive end-expiratory pressure and extensive use of non-invasive ventilation versus T-piece in difficult-to-wean patients from mechanical ventilation: a randomized controlled trial. Ann Intensive Care 2024; 14:59. [PMID: 38630372 PMCID: PMC11024068 DOI: 10.1186/s13613-024-01290-6] [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: 11/30/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The aim of this study is to assess whether a strategy combining spontaneous breathing trial (SBT) with both pressure support (PS) and positive end-expiratory pressure (PEEP) and extended use of post-extubation non-invasive ventilation (NIV) (extensively-assisted weaning) would shorten the time until successful extubation as compared with SBT with T-piece (TP) and post-extubation NIV performed in selected patients as advocated by guidelines (standard weaning), in difficult-to-wean patients from mechanical ventilation. METHODS The study is a single-center prospective open label, randomized controlled superiority trial with two parallel groups and balanced randomization with a 1:1 ratio. Eligible patients were intubated patients mechanically ventilated for more than 24 h who failed their first SBT using TP. In the extensively-assisted weaning group, SBT was performed with PS (7 cmH2O) and PEEP (5 cmH2O). In case of SBT success, an additional SBT with TP was performed. Failure of this SBT-TP was an additional criterion for post-extubation NIV in this group in addition to other recommended criteria. In the standard weaning group, SBT was performed with TP, and NIV was performed according to international guidelines. The primary outcome criterion was the time between inclusion and successful extubation evaluated with a Cox model with adjustment on randomization strata. RESULTS From May 2019 to March 2023, 98 patients were included and randomized in the study (49 in each group). Four patients were excluded from the intention-to-treat population (2 in both groups); therefore, 47 patients were analyzed in each group. The extensively-assisted weaning group had a higher median age (68 [58-73] vs. 62 [55-71] yrs.) and similar sex ratio (62% male vs. 57%). Time until successful extubation was not significantly different between extensively-assisted and standard weaning groups (median, 172 [50-436] vs. 95 [47-232] hours, Cox hazard ratio for successful extubation, 0.88 [95% confidence interval: 0.55-1.42] using the standard weaning group as a reference; p = 0.60). All secondary outcomes were not significantly different between groups. CONCLUSION An extensively-assisted weaning strategy did not lead to a shorter time to successful extubation than a standard weaning strategy. Trial registration The trial was registered on ClinicalTrials.gov (NCT03861117), on March 1, 2019, before the inclusion of the first patient. https://clinicaltrials.gov/study/NCT03861117 .
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Affiliation(s)
- Mehdi Mezidi
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France.
- Université Lyon 1, Université de Lyon, Lyon, France.
| | - Hodane Yonis
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Louis Chauvelot
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Deniel
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
| | - François Dhelft
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Maxime Gaillet
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Ines Noirot
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laure Folliet
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Paul Chabert
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Guillaume David
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - William Danjou
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Loredana Baboi
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Clotilde Bettinger
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pauline Bernon
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Mehdi Girard
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Judith Provoost
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alwin Bazzani
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laurent Bitker
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
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8
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Ramasco F, Nieves-Alonso J, García-Villabona E, Vallejo C, Kattan E, Méndez R. Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies. J Pers Med 2024; 14:176. [PMID: 38392609 PMCID: PMC10890552 DOI: 10.3390/jpm14020176] [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: 12/23/2023] [Revised: 01/15/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.
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Affiliation(s)
- Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Jesús Nieves-Alonso
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Esther García-Villabona
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Carmen Vallejo
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Eduardo Kattan
- Departamento de Medicina Intensiva del Adulto, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
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9
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Rubulotta F, Blanch Torra L, Naidoo KD, Aboumarie HS, Mathivha LR, Asiri AY, Sarlabous Uranga L, Soussi S. Mechanical Ventilation, Past, Present, and Future. Anesth Analg 2024; 138:308-325. [PMID: 38215710 DOI: 10.1213/ane.0000000000006701] [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: 01/14/2024]
Abstract
Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.
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Affiliation(s)
- Francesca Rubulotta
- From the Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Lluis Blanch Torra
- Department of Critical Care, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Kuban D Naidoo
- Division of Critical Care, University of Witwatersrand, Johannesburg, South Africa
| | - Hatem Soliman Aboumarie
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield Hospitals, London, United Kingdom
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom
| | - Lufuno R Mathivha
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, The Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand
| | - Abdulrahman Y Asiri
- Department of Internal Medicine and Critical Care, King Khalid University Medical City, Abha, Saudi Arabia
- Department of Critical Care Medicine, McGill University
| | - Leonardo Sarlabous Uranga
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network - Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto
- UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Institut national de la santé et de la recherche médicale (INSERM), Université de Paris Cité, France
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10
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Sanfilippo F, Messina A, Scolletta S, Bignami E, Morelli A, Cecconi M, Landoni G, Romagnoli S. The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion. Anaesth Crit Care Pain Med 2023; 42:101283. [PMID: 37516408 DOI: 10.1016/j.accpm.2023.101283] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Roma, Italy.
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Stefano Romagnoli
- Department of Health Science, Section of Anaesthesia and Intensive Care, University of Florence, Department of Anetshesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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11
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Khalpey Z, Wilson P, Suri Y, Culbert H, Deckwa J, Khalpey A, Rozell B. Leveling Up: A Review of Machine Learning Models in the Cardiac ICU. Am J Med 2023; 136:979-984. [PMID: 37343909 DOI: 10.1016/j.amjmed.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/23/2023]
Abstract
Machine learning has emerged as a significant tool to augment the medical decision-making process. Studies have steadily accrued detailing algorithms and models designed using machine learning to predict and anticipate pathologic states. The cardiac intensive care unit is an area where anticipation is crucial in the division between life and death. In this paper, we aim to review important studies describing the utility of machine learning algorithms to describe the future of artificial intelligence in the cardiac intensive care unit, especially in regards to the prediction of successful ventilatory weaning, acute respiratory distress syndrome, arrhythmia, and acute kidney injury.
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Affiliation(s)
- Zain Khalpey
- Division of Cardiothoracic Surgery, Heart and Vascular Institute, HonorHealth, Scottsdale, Ariz.
| | | | - Yash Suri
- University of Arizona College of Medicine, Tucson
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12
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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.
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Affiliation(s)
- Philippe Vignon
- Medical-surgical ICU and Inserm CIC 1435, Dupuytren University Hospital, Limoges, France
- Faculty of Medicine, University of Limoges, Limoges, France
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13
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Spinelli E, Scaramuzzo G, Slobod D, Mauri T. Understanding cardiopulmonary interactions through esophageal pressure monitoring. Front Physiol 2023; 14:1221829. [PMID: 37538376 PMCID: PMC10394627 DOI: 10.3389/fphys.2023.1221829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/07/2023] [Indexed: 08/05/2023] Open
Abstract
Esophageal pressure is the closest estimate of pleural pressure. Changes in esophageal pressure reflect changes in intrathoracic pressure and affect transpulmonary pressure, both of which have multiple effects on right and left ventricular performance. During passive breathing, increasing esophageal pressure is associated with lower venous return and higher right ventricular afterload and lower left ventricular afterload and oxygen consumption. In spontaneously breathing patients, negative pleural pressure swings increase venous return, while right heart afterload increases as in passive conditions; for the left ventricle, end-diastolic pressure is increased potentially favoring lung edema. Esophageal pressure monitoring represents a simple bedside method to estimate changes in pleural pressure and can advance our understanding of the cardiovascular performance of critically ill patients undergoing passive or assisted ventilation and guide physiologically personalized treatments.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research) Ca’ Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Gaetano Scaramuzzo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, QC, Canada
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research) Ca’ Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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14
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Gong X, Zhu L, Zhang M, Liu Y, Li C, Xu Z, Zheng J. Utilizing Spontaneous Ventilation Modes in Patients Underwent Corrective Surgery for Right Ventricular Outflow Tract Obstructive Congenital Heart Disease: A Crossover Study. Rev Cardiovasc Med 2023; 24:143. [PMID: 39076742 PMCID: PMC11273051 DOI: 10.31083/j.rcm2405143] [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: 11/22/2022] [Revised: 01/02/2023] [Accepted: 01/10/2023] [Indexed: 07/31/2024] Open
Abstract
Background This study aimed to determine whether the hemodynamics of patients with right ventricle outflow tract obstructive congenital heart disease (RVOTO-CHD) improve after corrective surgery by changing the ventilation mode. Methods Patients with RVOTO-CHD who underwent corrective surgery were enrolled in this study. Echocardiography and advanced hemodynamic monitoring were performed using the pulse indicator continuous cardiac output (PiCCO) technology in the pressure-regulated volume control (PRVC) mode, followed with switching to the pressure support ventilation (PSV) mode and neurally adjusted ventilatory assist (NAVA) mode in random order. Results Overall, 31 patients were enrolled in this study from April 2021 to October 2021. Notably, changing the ventilation mode from PRVC to a spontaneous mode (PSV or NAVA) led to better cardiac function outcomes, including right ventricular cardiac index (PRVC: 3.19 ± 1.07 L/min/ m 2 vs. PSV: 3.45 ± 1.32 L/min/ m 2 vs. NAVA: 3.82 ± 1.03 L/min/ m 2 , p < 0.05) and right ventricle contractility (tricuspid annular peak systolic velocity) (PRVC: 6.58 ± 1.40 cm/s vs. PSV: 7.03 ± 1.33 cm/s vs. NAVA: 7.94 ± 1.50 cm/s, p < 0.05), as detected via echocardiography. Moreover, in the NAVA mode, PiCCO-derived cardiac index (PRVC: 2.92 ± 0.54 L/min/ m 2 vs. PSV: 3.04 ± 0.56 L/min/ m 2 vs. NAVA: 3.20 ± 0.62 L/min/ m 2 , p < 0.05), stroke volume index (PRVC: 20.38 ± 3.97 mL/ m 2 vs. PSV: 21.23 ± 4.33 mL/ m 2 vs. NAVA: 22.00 ± 4.33 mL/ m 2 , p < 0.05), and global end diastolic index (PRVC: 295.74 ± 78.39 mL/ m 2 vs. PSV: 307.26 ± 91.18 mL/ m 2 vs. NAVA: 323.74 ± 102.87 mL/ m 2 , p < 0.05) improved, whereas extravascular lung water index significantly reduced (PRVC: 16.42 ± 7.90 mL/kg vs. PSV: 15.42 ± 5.50 mL/kg vs. NAVA: 14.4 ± 4.19 mL/kg, p < 0.05). Furthermore, peak inspiratory pressure, mean airway pressure, driving pressure, and compliance of the respiratory system improved in the NAVA mode. No deaths were reported in this study. Conclusions We found that utilizing spontaneous ventilator modes, especially the NAVA mode, after corrective surgery in patients with RVOTO-CHD may improve their right heart hemodynamics and respiratory mechanics. However, further randomized controlled trials are required to verify the advantages of spontaneous ventilation modes in such patients. Clinical Trial Registration NCT04825054.
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Affiliation(s)
- Xiaolei Gong
- Cardiac Intensive Care Unit, Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 200127 Shanghai, China
| | - Limin Zhu
- Cardiac Intensive Care Unit, Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 200127 Shanghai, China
| | - Mingjie Zhang
- Cardiac Intensive Care Unit, Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 200127 Shanghai, China
| | - Yujie Liu
- Cardiac Intensive Care Unit, Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 200127 Shanghai, China
| | - Chunxiang Li
- Cardiac Intensive Care Unit, Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 200127 Shanghai, China
| | - Zhuoming Xu
- Cardiac Intensive Care Unit, Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 200127 Shanghai, China
| | - Jinghao Zheng
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 200127 Shanghai, China
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15
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Ghamari AA, Amini K, Daei Sorkhabi A, Sarkesh A, Saghaleini SH, Asghari R, Rezayi M, Mahmoodpoor A. Diagnostic value of an increase in central venous pressure during SBT for prediction of weaning failure in mechanically ventilated patients: A cross-sectional study. Health Sci Rep 2023; 6:e1204. [PMID: 37064307 PMCID: PMC10102306 DOI: 10.1002/hsr2.1204] [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: 11/25/2022] [Revised: 03/12/2023] [Accepted: 03/24/2023] [Indexed: 04/18/2023] Open
Abstract
Background Timely and successful extubation is an essential step forward in clinical practice to minimize complications of mechanical ventilation and unsuccessful weaning processes. Thus, research into predictive factors of weaning outcome to optimize spontaneous breathing trial (SBT) precision before extubation is critical in intensive care practices. In this study, we aimed to investigate the predictive factors of the weaning outcome before and during SBT in mechanically ventilated patients. Methods In this cross-sectional study, 159 mechanically ventilated patients who were eligible for SBT were enrolled. Of these patients, 140 had successful extubation, whereas the remainder failed. Each patient's PaCO2 and PaO2 levels, respiratory rate (RR), SpO2, mean arterial pressure (MAP), heart rate (HR), and central venous pressure (CVP) values at the start of SBT, 3 min later, and at the end of SBT were measured. These values, along with the patients' clinical characteristics, were then investigated to determine if there was any correlation between these variables and the weaning outcome. Results Our analysis revealed that increase in CVP, independent of hemoglobin (Hb) concentration, PaO2, SpO2, duration of mechanical ventilation (MV), length of intensive care unit (ICU) stay, and SBT process, as well as underlying disease, was positively correlated with extubation/weaning failure. While age, gender, vital signs (MAP, RR, and HR), sequential organ failure assessment (SOFA), and acute physiology and chronic health evaluation (APACHE) scores had no significant correlation with patients' extubation outcomes. Conclusion According to our findings, integrating CVP assessment into SBT besides routine indices measurement and monitoring can be considered for the prediction of weaning outcome in critically ill mechanically ventilated patients.
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Affiliation(s)
- Ali Akbar Ghamari
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Keivan Amini
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Amin Daei Sorkhabi
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Aila Sarkesh
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Seyed Hadi Saghaleini
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Roghayeh Asghari
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Mansour Rezayi
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Ata Mahmoodpoor
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
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16
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Viegas P, Ageno E, Corsi G, Tagariello F, Razakamanantsoa L, Vilde R, Ribeiro C, Heunks L, Patout M, Fisser C. Highlights from the Respiratory Failure and Mechanical Ventilation 2022 Conference. ERJ Open Res 2023; 9:00467-2022. [PMID: 36949961 PMCID: PMC10026011 DOI: 10.1183/23120541.00467-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022] Open
Abstract
The Respiratory Intensive Care Assembly of the European Respiratory Society gathered in Berlin to organise the second Respiratory Failure and Mechanical Ventilation Conference in June 2022. The conference covered several key points of acute and chronic respiratory failure in adults. During the 3-day conference, ventilatory strategies, patient selection, diagnostic approaches, treatment and health-related quality of life topics were addressed by a panel of international experts. Lectures delivered during the event have been summarised by Early Career Members of the Assembly and take-home messages highlighted.
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Affiliation(s)
- Pedro Viegas
- Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Elisa Ageno
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gabriele Corsi
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Federico Tagariello
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Léa Razakamanantsoa
- Unité Ambulatoire d'Appareillage Respiratoire de Domicile (UAARD), Service de Pneumologie (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Paris, France
| | - Rudolfs Vilde
- Centre of Pulmonology and Thoracic Surgery, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
- Riga Stradiņš University, Riga, Latvia
| | - Carla Ribeiro
- Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maxime Patout
- Service des Pathologies du Sommeil (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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17
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Nicolotti D, Grossi S, Nicolini F, Gallingani A, Rossi S. Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review. J Clin Med 2023; 12:jcm12020497. [PMID: 36675426 PMCID: PMC9867514 DOI: 10.3390/jcm12020497] [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: 11/16/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Davide Nicolotti
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-703286
| | - Silvia Grossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Francesco Nicolini
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Alan Gallingani
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
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18
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Mezidi M, Yonis H, Chauvelot L, Danjou W, Dhelft F, Bazzani A, Girard M, Bitker L, Richard JC. Pressure support and positive end-expiratory pressure versus T-piece during spontaneous breathing trial in difficult weaning from mechanical ventilation: study protocol for the SBT-ICU study. Trials 2022; 23:993. [PMID: 36503500 PMCID: PMC9742015 DOI: 10.1186/s13063-022-06896-4] [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: 08/01/2022] [Accepted: 11/08/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Spontaneous breathing trials are performed in critically ill intubated patients in order to assess readiness to be weaned from mechanical ventilation. In patients with difficult weaning (i.e. not extubated after their first SBT), performing SBT using pressure support with or without positive end-expiratory pressure or using T-piece is debated. As ventilatory support during SBT is greater on pressure support than on T-piece and as positive end-expiratory pressure can prevent weaning-induced pulmonary oedema, we hypothesized that their combination and large use of post-extubation non-invasive ventilation may shorten the time until successful extubation as compared with T-piece, without increasing the rate of reintubation. METHODS SBT-ICU is a monocentric prospective open labelled, randomized controlled superiority trial comparing two mechanical ventilation weaning strategies; i.e. daily spontaneous breathing trials using pressure support with positive end-expiratory pressure or T-piece. The primary outcome will be time until successful extubation (defined by as extubation, without reintubation or death within the seven following days). DISCUSSION This paper describes the protocol of the SBT-ICU trial. Enrolment of patients in the study is ongoing. TRIAL REGISTRATION ClinicalTrials.gov NCT03861117. Registered on March 1, 2019, before the beginning of inclusion.
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Affiliation(s)
- Mehdi Mezidi
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Hodane Yonis
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Louis Chauvelot
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - William Danjou
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - François Dhelft
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France ,grid.25697.3f0000 0001 2172 4233Université de Lyon, Université Lyon 1, Lyon, France
| | - Alwin Bazzani
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Mehdi Girard
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Laurent Bitker
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France ,grid.25697.3f0000 0001 2172 4233Université de Lyon, Université Lyon 1, Lyon, France ,grid.7429.80000000121866389CREATIS INSERM U1294 CNRS UMR 5220, Villeurbanne, France
| | - Jean-Christophe Richard
- grid.413852.90000 0001 2163 3825Medical Intensive Care Unit, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France ,grid.25697.3f0000 0001 2172 4233Université de Lyon, Université Lyon 1, Lyon, France ,grid.7429.80000000121866389CREATIS INSERM U1294 CNRS UMR 5220, Villeurbanne, France
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19
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Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study. MEDICINA INTENSIVA (ENGLISH EDITION) 2022; 47:221-231. [PMID: 36272910 DOI: 10.1016/j.medine.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/03/2022] [Indexed: 11/06/2022]
Abstract
AIMS To assess the clinical profile and factors associated with 30-day mortality in patients with acute heart failure (AHF) admitted to the intensive care unit (ICU). DESIGN Prospective, multicentre cohort study. SCOPE Thirty-two Spanish ICUs. PATIENTS Adult patients admitted to the ICU between April and June 2017. INTERVENTION Patients were classified into three groups according to AHF status: without AHF (no AHF); AHF as the primary reason for ICU admission (primary AHF); and AHF developed during the ICU stay (secondary AHF). MAIN VARIABLES OF INTEREST Incidence of AHF and 30-day mortality. RESULTS A total of 4330 patients were included. Of these, 627 patients (14.5%) had primary (n=319; 7.4%) or secondary (n=308; 7.1%) AHF. Among the main precipitating factors, fluid overload was more common in the secondary AHF group than in the primary group (12.9% vs 23.4%, p<0.001). Patients with AHF had a higher risk of 30-day mortality than those without AHF (OR 2.45; 95% CI: 1.93-3.11). APACHE II, cardiogenic shock, left ventricular ejection fraction, early inotropic therapy, and diagnostic delay were independently associated with 30-day mortality in AHF patients. Diagnostic delay was associated with a significant increase in 30-day mortality in the secondary group (OR 6.82; 95% CI 3.31-14.04). CONCLUSIONS The incidence of primary and secondary AHF was similar in this cohort of ICU patients. The risk of developing AHF in ICU patients can be reduced by avoiding modifiable precipitating factors, particularly fluid overload. Diagnostic delay was associated with significantly higher mortality rates in patients with secondary AHF.
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20
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Kattan E, Castro R, Miralles-Aguiar F, Hernández G, Rola P. The emerging concept of fluid tolerance: A position paper. J Crit Care 2022; 71:154070. [PMID: 35660844 DOI: 10.1016/j.jcrc.2022.154070] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 12/14/2022]
Abstract
Fluid resuscitation is a core component of emergency and critical care medicine. While the focus of clinicians has largely been on detecting patients who would respond to fluid therapy, relatively little work has been done on assessing patients' tolerance to this therapy. In this article we seek to review the concept of fluid tolerance, propose a working definition, and introduce relevant clinical signals by which physicians can assess fluid tolerance, hopefully becoming a starting point for further research.
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Affiliation(s)
- Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | | | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Philippe Rola
- Chief of Service, Intensive Care Unit, Hopital Santa Cabrini, CIUSSS EMTL, Montreal, Canada.
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21
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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.
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22
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Pierrakos C, Geke Algera A, Simonis F, Cherpanath TGV, Lagrand WK, Paulus F, Bos LDJ, Schultz MJ. Abnormal Right Ventricular Myocardial Performance Index Is Not Associated With Outcomes in Invasively Ventilated Intensive Care Unit Patients Without Acute Respiratory Distress Syndrome—Post hoc Analysis of Two RCTs. Front Cardiovasc Med 2022; 9:830165. [PMID: 35711375 PMCID: PMC9197438 DOI: 10.3389/fcvm.2022.830165] [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: 12/06/2021] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe objective of the study was to determine the association between right ventricular (RV) myocardial performance index (MPI) and successful liberation from the ventilator and death within 28 days.MethodsPost hoc analysis of 2 ventilation studies in invasively ventilated patients not having ARDS. RV-MPI was collected through transthoracic echocardiography within 24–48 h from the start of invasive ventilation according to the study protocols. RV-MPI ≤ 0.54 was considered normal. The primary endpoint was successful liberation from the ventilator < 28 days; the secondary endpoint was 28-day mortality.ResultsA total of 81 patients underwent transthoracic echocardiography at median 30 (24–42) h after the start of ventilation—in 73 (90%) patients, the RV-MPI could be collected. A total of 56 (77%) patients were successfully liberated from the ventilator < 28 days; A total of 22 (30%) patients had died before or at day 28. A total of 18 (25%) patients had an abnormal RV-MPI. RV-MPI was neither associated with successful liberation from the ventilator within 28 days [HR, 2.2 (95% CI 0.47–10.6); p = 0.31] nor with 28-day mortality [HR, 1.56 (95% CI 0.07–34.27); p = 0.7].ConclusionIn invasively ventilated critically ill patients without ARDS, an abnormal RV-MPI indicative of RV dysfunction was not associated with time to liberation from invasive ventilation.
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Affiliation(s)
- Charalampos Pierrakos
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
- *Correspondence: Charalampos Pierrakos,
| | - Anna Geke Algera
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Fabienne Simonis
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Thomas G. V. Cherpanath
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Wim K. Lagrand
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Frederique Paulus
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Lieuwe D. J. Bos
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Marcus J. Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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23
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Zapata L, Guía C, Gómez R, García-Paredes T, Colinas L, Portugal-Rodriguez E, Rodado I, Leache I, Fernández-Ferreira A, Hermosilla-Semikina I, Roche-Campo F. Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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24
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Monnet X. Should We Wean Patients off Vasopressors before Weaning Them off Ventilation? Am J Respir Crit Care Med 2022; 205:980-981. [PMID: 35259082 PMCID: PMC9851479 DOI: 10.1164/rccm.202201-0175ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Xavier Monnet
- Medical Intensive Care UnitParis-Saclay University HospitalsLe Kremlin-Bicêtre, France
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25
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Zarrabian B, Wunsch H, Stelfox HT, Iwashyna TJ, Gershengorn HB. Liberation from Invasive Mechanical Ventilation with Continued Receipt of Vasopressor Infusions. Am J Respir Crit Care Med 2022; 205:1053-1063. [PMID: 35107416 DOI: 10.1164/rccm.202108-2004oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Weaning protocols for discontinuation of invasive mechanical ventilation often mandate resolution of shock. Whether extubation while receiving vasopressors is associated with harm is uncertain. OBJECTIVES To examine whether extubation while still receiving vasopressors is associated with worse outcomes. METHODS We performed a retrospective cohort study of adults in Calgary ICUs who received vasopressors with invasive mechanical ventilation and an extubation attempt. The primary exposure was continued vasopressor use at extubation. The primary outcome was reintubation within 96-hours. Secondary outcomes included in-hospital mortality and ICU/hospital length of stay (LOS). We assessed associations of vasopressor use at extubation with outcomes using multivariable competing-risk (reintubation/LOS) and Cox proportional-hazards (mortality) models. MEASUREMENTS AND MAIN RESULTS Of 6140 patients who received invasive mechanical ventilation while on vasopressors, 721 (11.7%) were extubated while receiving vasopressors and 5419 (88.3%) after discontinuation. Extubation on vasopressors was not, in aggregate, significantly associated with an increased hazard of reintubation (sub-hazard ratio, 1.81 [95% CI: 0.91 - 3.61], P=0.09). Both mortality (HR 1.22 [1.02-1.47], P=0.03) and time to hospital discharge (SHR for remaining hospitalized 0.78 [0.68-0.91], P<0.01) were increased. Extubation on high-dose vasopressors (>0.1 µg/kg/min) was associated with a greater hazard of reintubation (SHR 2.25 [1.01-4.98], P=0.046) compared to extubation after vasopressor discontinuation. Meanwhile, extubation on low-dose vasopressors (≤0.1 µg/kg/min) was associated with a lower mortality (HR 0.69 [0.51-0.91], P=0.01) and a shorter ICU LOS (SHR 1.34 [1.09-1.65], P<0.01), but no difference in reintubation or hospital LOS as compared to those weaned off vasopressors. CONCLUSIONS Extubation while receiving high-dose but not low-dose vasopressors was associated with an increased risk of reintubation.
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Affiliation(s)
- Baharan Zarrabian
- University of Miami Miller School of Medicine, 12235, Department of Medicine, Miami, Florida, United States;
| | - Hannah Wunsch
- Sunnybrook Health Sciences Centre, 71545, Department of Critical Care Medicine, Toronto, Ontario, Canada.,University of Toronto, 7938, Department of Anesthesiology and Critical Care, Toronto, Ontario, Canada
| | - Henry T Stelfox
- University of Calgary Cumming School of Medicine, 70401, Department of Critical Care Medicine, Calgary, Alberta, Canada.,University of Calgary Cumming School of Medicine, 70401, Department of Community Health Sciences, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, 157746, Calgary, Alberta, Canada.,Alberta Health Services, 3146, Edmonton, Alberta, Canada
| | - Theodore J Iwashyna
- University of Michigan, 1259, Department of Internal Medicine, Ann Arbor, Michigan, United States.,VA Ann Arbor Healthcare System, 20034, VA Center for Clinical Management Research, Ann Arbor, Michigan, United States.,University of Michigan, 1259, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, United States.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan, United States
| | - Hayley B Gershengorn
- University of Miami School of Medicine, 12235, Division of Pulmonary, Critical Care, and Sleep Medicine, Miami, Florida, United States.,Albert Einstein College of Medicine, 2006, Division of Critical Care Medicine, Bronx, New York, United States
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26
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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.
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27
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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.
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28
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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.
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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
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29
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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.
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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
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Dres M, Rozenberg E, Morawiec E, Mayaux J, Delemazure J, Similowski T, Demoule A. Diaphragm dysfunction, lung aeration loss and weaning-induced pulmonary oedema in difficult-to-wean patients. Ann Intensive Care 2021; 11:99. [PMID: 34181105 PMCID: PMC8237539 DOI: 10.1186/s13613-021-00886-6] [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: 03/06/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background Diaphragm dysfunction and weaning-induced pulmonary oedema are commonly involved during weaning failure, but their physiological interactions have been poorly reported. Our hypothesis was that diaphragm dysfunction is not particularly associated with weaning-induced pulmonary oedema. Methods It was a single-centre and physiological study conducted in patients who had failed a first spontaneous breathing trial and who underwent a second trial. The diaphragm function was evaluated by measuring the tracheal pressure generated in response to a bilateral magnetic phrenic nerves stimulations. Weaning-induced pulmonary oedema was diagnosed in case of failure of the spontaneous breathing trial if patients exhibited signs of plasma concentration or echocardiographic diagnosis of pulmonary artery occlusion pressure elevation. Results Fifty-three patients were included and 31/53 (58%) failed the spontaneous breathing trial, including 24/31 (77%) patients with weaning-induced pulmonary oedema. Diaphragm dysfunction was present in 33/53 (62%) patients. Diaphragm dysfunction or weaning-induced pulmonary oedema were present in 26/31 (84%) of the patients who failed the spontaneous breathing trial. Weaning-induced pulmonary oedema occurred in 20/33 (61%) patients with a diaphragm dysfunction and in 4/20 (20%) patients without (p = 0.005). Conclusion Weaning-induced pulmonary oedema was three times more frequent in case of diaphragm dysfunction. Even in case of diaphragm dysfunction, physicians might be encouraged to investigate the presence of weaning-induced pulmonary oedema during weaning failure.
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Affiliation(s)
- Martin Dres
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France. .,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.
| | - Emmanuel Rozenberg
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Elise Morawiec
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Julien Mayaux
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Julie Delemazure
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Thomas Similowski
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Alexandre Demoule
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
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Fayssoil A, De Carnavalet MCDC, Mansencal N, Lofaso F, Davido B. Cardiopulmonary Pathophysiological Aspects in the Context of COVID-19 and Obesity. ACTA ACUST UNITED AC 2021; 3:1848-1857. [PMID: 34151188 PMCID: PMC8200316 DOI: 10.1007/s42399-021-00995-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 12/15/2022]
Abstract
Obesity is a significant public health concern associated with high morbidity. Obese patients are at risk of severe COVID-19 infection, and obesity is a high-risk factor for admission to the intensive care unit. We aimed to write a narrative review of cardiac and pulmonary pathophysiological aspects of obese patients in the context of COVID-19 infection. Obesity affects lung volume, with a decrease in expiratory reserve volume, which is associated with a decrease in lung and chest wall compliance, an increase in airway resistance, and an increase in work of breathing. Obesity affects cardiac structure and hemodynamics. Obesity is a risk factor for hypertension and cardiovascular disorders. Moreover, obesity is associated with a low-grade inflammatory state, endothelial dysfunction, hyperinsulinemia, and metabolic disorders. Obesity is associated with severe COVID-19 and invasive mechanical ventilation. These previous cardiopulmonary pathological aspects may explain the clinical severity in obese patients with COVID-19. Obese patients are at risk of severe COVID-19 infection. Understanding cardiorespiratory pathophysiological aspects may help physicians manage patients in hospitals.
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Affiliation(s)
- Abdallah Fayssoil
- Service de Cardiologie, Hôpital Raymond Poincaré, APHP, Garches, France.,Service de Cardiologie, Centre de Référence des Cardiomyopathies et des Troubles du Rythme Cardiaque Héréditaires ou Rares, Hôpital Ambroise Paré, AP-HP, Université Paris Saclay/UFR Simone Veil-Santé-Université de Versailles Saint Quentin en Yvelines, Boulogne-Billancourt, France.,INSERM U1179, END-ICAP, Montigny-le-Bretonneux, France
| | | | - Nicolas Mansencal
- Service de Cardiologie, Centre de Référence des Cardiomyopathies et des Troubles du Rythme Cardiaque Héréditaires ou Rares, Hôpital Ambroise Paré, AP-HP, Université Paris Saclay/UFR Simone Veil-Santé-Université de Versailles Saint Quentin en Yvelines, Boulogne-Billancourt, France.,INSERM U-1018, CESP, Clinical Epidemiology, UVSQ, Villejuif, France
| | - Frederic Lofaso
- Service de Physiologie - Explorations fonctionnelles, Hôpital Raymond Poincaré, APHP, Université Paris Saclay/UFR Simone Veil-Santé-Université de Versailles Saint Quentin en Yvelines, Garches, France
| | - Benjamin Davido
- Service de maladies infectieuses, Hôpital Raymond Poincaré, APHP, AP-HP, Université Paris Saclay/UFR Simone Veil-Santé-Université de Versailles Saint Quentin en Yvelines, Garches, France
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Porto DB, Beltrão BA, Medeiros FS, Pellegrini JAS, Boniatti MM. Preload Independence Is Associated with Extubation Failure in Simple Weaning Patients: A Multicenter Cohort Study. Am J Respir Crit Care Med 2021; 203:916-918. [PMID: 33347386 DOI: 10.1164/rccm.202008-3250le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lassola S, Miori S, Sanna A, Cucino A, Magnoni S, Umbrello M. Central venous pressure swing outperforms diaphragm ultrasound as a measure of inspiratory effort during pressure support ventilation in COVID-19 patients. J Clin Monit Comput 2021; 36:461-471. [PMID: 33635495 PMCID: PMC7908005 DOI: 10.1007/s10877-021-00674-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/12/2021] [Indexed: 12/19/2022]
Abstract
Purpose The COVID-19-related shortage of ICU beds magnified the need of tools to properly titrate the ventilator assistance. We investigated whether bedside-available indices such as the ultrasonographic changes in diaphragm thickening ratio (TR) and the tidal swing in central venous pressure (ΔCVP) are reliable estimates of inspiratory effort, assessed as the tidal swing in esophageal pressure (ΔPes). Methods Prospective, observational clinical investigation in the intensive care unit of a tertiary care Hospital. Fourteen critically-ill patients were enrolled (age 64 ± 7 years, BMI 29 ± 4 kg/m2), after 6 [3; 9] days from onset of assisted ventilation. A three-level pressure support trial was performed, at 10 (PS10), 5 (PS5) and 0 cmH2O (PS0). In each step, the esophageal and central venous pressure tidal swing were recorded, as well as diaphragm ultrasound. Results The reduction of pressure support was associated with an increased respiratory rate and a reduced tidal volume, while minute ventilation was unchanged. ΔPes significantly increased with reducing support (5 [3; 8] vs. 8 [14; 13] vs. 12 [6; 16] cmH2O, p < 0.0001), as did the diaphragm TR (9.2 ± 6.1 vs. 17.6 ± 7.2 vs. 28.0 ± 10.0%, p < 0.0001) and the ΔCVP (4 [3; 7] vs. 8 [5; 9] vs. 10 [7; 11] cmH2O, p < 0.0001). ΔCVP was significantly associated with ΔPes (R2 = 0.810, p < 0.001), as was diaphragm TR, albeit with a lower coefficient of determination (R2 = 0.399, p < 0.001). Conclusions In patients with COVID-19-associated respiratory failure undergoing assisted mechanical ventilation, ΔCVP is a better estimate of inspiratory effort than diaphragm ultrasound. Supplementary Information The online version contains
supplementary material available at 10.1007/s10877-021-00674-4.
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Affiliation(s)
- Sergio Lassola
- SC Anestesia e Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Sara Miori
- SC Anestesia e Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Andrea Sanna
- SC Anestesia e Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Alberto Cucino
- SC Anestesia e Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Sandra Magnoni
- SC Anestesia e Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Michele Umbrello
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano, Italy.
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Tavares CAM, Bailey MA, Girardi ACC. Biological Context Linking Hypertension and Higher Risk for COVID-19 Severity. Front Physiol 2020; 11:599729. [PMID: 33329052 PMCID: PMC7710931 DOI: 10.3389/fphys.2020.599729] [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: 09/02/2020] [Accepted: 10/28/2020] [Indexed: 01/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), represents a public health crisis of major proportions. Advanced age, male gender, and the presence of comorbidities have emerged as risk factors for severe illness or death from COVID-19 in observation studies. Hypertension is one of the most common comorbidities in patients with COVID-19. Indeed, hypertension has been shown to be associated with increased risk for mortality, acute respiratory distress syndrome, need for intensive care unit admission, and disease progression in COVID-19 patients. However, up to the present time, the precise mechanisms of how hypertension may lead to the more severe manifestations of disease in patients with COVID-19 remains unknown. This review aims to present the biological plausibility linking hypertension and higher risk for COVID-19 severity. Emphasis is given to the role of the renin-angiotensin system and its inhibitors, given the crucial role that this system plays in both viral transmissibility and the pathophysiology of arterial hypertension. We also describe the importance of the immune system, which is dysregulated in hypertension and SARS-CoV-2 infection, and the potential involvement of the multifunctional enzyme dipeptidyl peptidase 4 (DPP4), that, in addition to the angiotensin-converting enzyme 2 (ACE2), may contribute to the SARS-CoV-2 entrance into target cells. The role of hemodynamic changes in hypertension that might aggravate myocardial injury in the setting of COVID-19, including endothelial dysfunction, arterial stiffness, and left ventricle hypertrophy, are also discussed.
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Affiliation(s)
- Caio A M Tavares
- Geriatric Cardiology Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Matthew A Bailey
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Adriana C C Girardi
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
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How to ventilate obstructive and asthmatic patients. Intensive Care Med 2020; 46:2436-2449. [PMID: 33169215 PMCID: PMC7652057 DOI: 10.1007/s00134-020-06291-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/12/2020] [Indexed: 11/11/2022]
Abstract
Exacerbations are part of the natural history of chronic obstructive pulmonary disease and asthma. Severe exacerbations can cause acute respiratory failure, which may ultimately require mechanical ventilation. This review summarizes practical ventilator strategies for the management of patients with obstructive airway disease. Such strategies include non-invasive mechanical ventilation to prevent intubation, invasive mechanical ventilation, from the time of intubation to weaning, and strategies intended to prevent post-extubation acute respiratory failure. The role of tracheostomy, the long-term prognosis, and potential future adjunctive strategies are also discussed. Finally, the physiological background that underlies these strategies is detailed.
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Bac NH, Dinh NH, Binh TQ, Khoi LM. Severe aortic regurgitation following blunt chest trauma due to home accident. Asian Cardiovasc Thorac Ann 2020; 29:414-416. [PMID: 33153276 DOI: 10.1177/0218492320972227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aortic valve rupture is a rare manifestation in comparison to cardiac rupture or contusion following blunt chest trauma. We report a case of aortic valve leaflet rupture with severe aortic regurgitation after a fall from a ladder. The aortic valve rupture had been missed in the emergency ultrasound and was only detected on comprehensive echocardiography after failure of weaning from a mechanical ventilator. The patient underwent aortic bioprosthetic valve replacement that dramatically changed the clinical course.
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Affiliation(s)
- Nguyen Hoang Bac
- University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Hoang Dinh
- University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Truong Quang Binh
- University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Le Minh Khoi
- University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
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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.
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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
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Sanfilippo F, Murabito P, La Rosa V, Oliveri F, Astuto M. Successful spontaneous breathing trial, early reintubation and mechanisms of weaning failure. Intensive Care Med 2020; 46:1960-1961. [PMID: 32661616 PMCID: PMC7358284 DOI: 10.1007/s00134-020-06176-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U., "Policlinico-Vittorio Emanuele" University Hospital, Catania, Italy.
| | - Paolo Murabito
- Department of Anaesthesia and Intensive Care, A.O.U., "Policlinico-Vittorio Emanuele" University Hospital, Catania, Italy.,Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Valeria La Rosa
- School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy
| | - Francesco Oliveri
- Department of Anaesthesia and Intensive Care, A.O.U., "Policlinico-Vittorio Emanuele" University Hospital, Catania, Italy
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care, A.O.U., "Policlinico-Vittorio Emanuele" University Hospital, Catania, Italy.,Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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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.
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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.
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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]
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Zawadka M, Marchel M, Andruszkiewicz P. Diastolic dysfunction of the left ventricle - a practical approach for an anaesthetist. Anaesthesiol Intensive Ther 2020; 52:237-244. [PMID: 32419432 PMCID: PMC10172939 DOI: 10.5114/ait.2020.94486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/21/2020] [Indexed: 01/06/2024] Open
Abstract
Bedside point-of-care echocardiography is being increasingly incorporated in peri-operative assessment and in intensive care units. Because of availability of tissue Doppler imaging in the modern ultrasound machines there has been an increased interest in research of diastolic function of left ventricle. The diastolic function is crucial for the hemodynamically effective function of the heart. Diastolic dysfunction is a well-established risk factor of the major adverse cardiac events during perioperative period, complications during weaning from ventilator and prognostic factor of mortality in septic shock.
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Affiliation(s)
- Mateusz Zawadka
- 2 Department of Anaestesiology and Intensive Therapy, Medical University of Warsaw, Warsaw, Poland
| | - Michał Marchel
- 1 Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Andruszkiewicz
- 2 Department of Anaestesiology and Intensive Therapy, Medical University of Warsaw, Warsaw, Poland
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Dubo S, Valenzuela ED, Aquevedo A, Jibaja M, Berrutti D, Labra C, Lagos R, García MF, Ramírez V, Tobar M, Picoita F, Peláez C, Carpio D, Alegría L, Hidalgo C, Godoy K, Bruhn A, Hernández G, Bakker J, Castro R. Early rise in central venous pressure during a spontaneous breathing trial: A promising test to identify patients at high risk of weaning failure? PLoS One 2019; 14:e0225181. [PMID: 31805071 PMCID: PMC6894783 DOI: 10.1371/journal.pone.0225181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/30/2019] [Indexed: 11/19/2022] Open
Abstract
Background The spontaneous breathing trial (SBT) assesses the risk of weaning failure by evaluating some physiological responses to the massive venous return increase imposed by discontinuing positive pressure ventilation. This trial can be very demanding for some critically ill patients, inducing excessive physical and cardiovascular stress, including muscle fatigue, heart ischemia and eventually cardiac dysfunction. Extubation failure with emergency reintubation is a serious adverse consequence of a failed weaning process. Some data suggest that as many as 50% of patients that fail weaning do so because of cardiac dysfunction. Unfortunately, monitoring cardiovascular function at the time of the SBT is complex. The aim of our study was to explore if central venous pressure (CVP) changes were related to weaning failure after starting an SBT. We hypothesized that an early rise on CVP could signal a cardiac failure when handling a massive increase on venous return following a discontinuation of positive pressure ventilation. This CVP rise could identify a subset of patients at high risk for extubation failure. Methods Two-hundred and four mechanically ventilated patients in whom an SBT was decided were subjected to a monitoring protocol that included blinded assessment of CVP at baseline, and at 2 minutes after starting the trial (CVP-test). Weaning failure was defined as reintubation within 48-hours following extubation. Comparisons between two parametric or non-parametric variables were performed with student T test or Mann Whitney U test, respectively. A logistic multivariate regression was performed to determine the predictive value on extubation failure of usual clinical variables and CVP at 2-min after starting the SBT. Results One-hundred and sixty-five patients were extubated after the SBT, 11 of whom were reintubated within 48h. Absolute CVP values at 2-minutes, and the change from baseline (dCVP) were significantly higher in patients with extubation failure as compared to those successfully weaned. dCVP was an early predictor for reintubation (OR: 1.70 [1.31,2.19], p<0.001). Conclusions An early rise in CVP after starting an SBT was associated with an increased risk of extubation failure. This might represent a warning signal not captured by usual SBT monitoring and could have relevant clinical implications.
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Affiliation(s)
- Sebastián Dubo
- Departamento de Kinesiología, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
- Programa de Doctorado en Ciencias Médicas, Universidad de la Frontera, Temuco, Chile
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Andrés Aquevedo
- Unidad de Pacientes Críticos, Hospital Dr. Sótero del Río, Santiago, Chile
| | - Manuel Jibaja
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
- Escuela de Medicina, Universidad Internacional de Ecuador, Quito, Ecuador
| | - Dolores Berrutti
- Centro de Terapia Intensiva, Hospital de Clínicas, Universidad de la Republica de Uruguay, Montevideo, Uruguay
| | - Christian Labra
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rossana Lagos
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Vanessa Ramírez
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
| | - Milton Tobar
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
| | - Fabricio Picoita
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
| | - Cristian Peláez
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
| | - David Carpio
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Programa de Doctorado en Ciencias Médicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carolina Hidalgo
- Unidad de Cuidados Intensivos Cardioquirúrgicos, Hospital Guillermo Grant Benavente, Concepción, Chile
| | - Karen Godoy
- Unidad de Cuidados Intensivos Neuroquirúrgicos, Hospital Guillermo Grant Benavente, Concepción, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Pulmonary and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Pulmonary and Critical Care, New York University Medical Center, New York, New York, United States of America
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- * E-mail:
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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.
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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
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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.
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Choi AY, Kim M, Park E, Son MH, Ryu JA, Cho J. Outcomes of mechanical ventilation according to WIND classification in pediatric patients. Ann Intensive Care 2019; 9:72. [PMID: 31250234 PMCID: PMC6597660 DOI: 10.1186/s13613-019-0547-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 06/13/2019] [Indexed: 01/15/2023] Open
Abstract
Background The outcomes of weaning processes are not well known in pediatric patients, and the International Conference Classification on weaning from mechanical ventilation showed limited application. We evaluate the relationship between the new Weaning according to a New Definition (WIND) classification and outcome in pediatric patients.
Methods We conducted a retrospective cohort study in a tertiary pediatric intensive care unit (ICU). We included patients under 18 years of age who received invasive mechanical ventilation for more than 24 h and excluded cases with other than the first ICU admissions, tracheostomy with home ventilation before admission, intubation or weaning processes conducted in other ICU, and weaning with extracorporeal membrane oxygenation. Weaning processes were classified into four groups according to weaning duration after the first separation attempt (SA): no-SA, short weaning (< 24 h), difficult weaning (24 h–7 days), and prolonged weaning (> 7 days). Mortality rates were compared across groups using the Kruskal–Wallis test, and risk factors for the no-SA group were analyzed by multivariate logistic regression tests with age, sex, severity score at admission, admission type, and underlying disease as variables. Results Among 313 patients, 224 were enrolled and had a median age of 2.1 (interquartile range 0.5–6.6) years. Spontaneous breathing tests were done in 70.1% of enrolled patients. The median duration of intubation to the first SA was 4 (range 0–36) days, and 92.8% patients underwent the first SA within 14 days. The mortality rate was 0% in the short (0/99) and difficult (0/53) weaning groups and 17.9% (5/28) in the prolonged weaning group (p < 0.001). The mortality rate of the no-SA group was 93.2% (41/44). Admission severity (hazard ratio 1.036, confidence interval 1.022–1.050) and underlying oncologic disease (hazard ratio 7.341, confidence interval 3.008–17.916) were independent risk factors for lack of SA. Conclusions In conclusion, WIND classification is associated with ICU mortality in pediatric patients. Further studies of this association are required to improve protocols associated with the weaning process and clinical outcomes. Trial registration Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13613-019-0547-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ah Young Choi
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Minji Kim
- Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Esther Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Meong Hi Son
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Abstract
A subset of intubated patients can safely be extubated in the emergency department (ED). The emergency medicine provider should be prepared for both common and life-threatening complications if considering ED extubation. Patients selected for extubation in the ED should have a low or near zero risk of reintubation or extubation failure. Intensive nursing care, close monitoring, and the ability to reintubate are minimum requirements for EDs considering ED extubation. This article provides a framework for determining appropriate patients for extubation and a practical approach on how to safely perform the procedure.
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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: 47] [Impact Index Per Article: 9.4] [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.
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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.
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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: 32] [Impact Index Per Article: 6.4] [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.
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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
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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.
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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
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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.
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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
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