Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients

Intensive Care Medicine - Tập 36 - Trang 1171-1179 - 2010
Belén Cabello1, Arnaud W. Thille2, Ferran Roche-Campo1, Laurent Brochard2, Francisco J. Gómez3, Jordi Mancebo1
1Servei de Medicina Intensiva, Hospital Santa Creu i Sant Pau, Barcelona, Spain
2Medical Intensive Care Unit, AP-HP, Centre Hospitalier Albert Chenevier-Henri Mondor, University of Paris 12, Créteil, France
3Departamento de Medicina, Universidad de Granada, Granada, Spain

Tóm tắt

To compare cardiovascular and respiratory responses to different spontaneous breathing trials (SBT) in difficult-to-wean patients using T-piece and pressure support ventilation (PSV) with or without positive end-expiratory pressure (PEEP). Prospective physiological study. Fourteen patients who were monitored with a Swan-Ganz catheter and had failed a previous T-piece trial were studied. Three SBTs were performed in random order in all patients: PSV with PEEP (PSV-PEEP), PSV without PEEP (PSV-ZEEP), and T-piece. PSV level was 7 cmH2O, and PEEP was 5 cmH2O. Inspiratory muscle effort was calculated, and hemodynamic parameters were measured using standard methods. Most patients succeeded in the PSV-PEEP (11/14) and PSV-ZEEP (8/14) trials, but all failed the T-piece trial. Patient effort was significantly higher during T-piece than during PSV with or without PEEP [esophageal pressure-time product was 292 (238–512), 128 (58–299), and 148 (100–465) cmH2O·s/min, respectively, p < 0.05]. Left ventricular heart failure was observed in 11 of the 14 patients during the T-piece trial. Pulmonary artery occlusion pressure and respiratory rate were significantly higher during T-piece than with PSV-PEEP [21 (18–24) mmHg versus 17 (14–22) mmHg, p < 0.05 and 27 (21–35) breaths/min versus 19 (16–29) breaths/min, p < 0.05 respectively]. Tidal volume was significantly lower during the T-piece trial. In this selected population of difficult-to-wean patients, PSV and PSV plus PEEP markedly modified the breathing pattern, inspiratory muscle effort, and cardiovascular response as compared to the T-piece. Caregivers should be aware of these differences in SBT as they may play an important role in weaning decision-making.

Tài liệu tham khảo

Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, Johnson MM, Browder RW, Bowton DL, Haponik EF (1996) Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 335:1864–1869 Tobin MJ, Jubran A (2006) Variable performance of weaning-predictor tests: role of Bayes’ theorem and spectrum and test-referral bias. Intensive Care Med 32:2002–2012 Buda AJ, Pinsky MR, Ingels NB Jr, Daughters GT 2nd, Stinson EB, Alderman EL (1979) Effect of intrathoracic pressure on left ventricular performance. N Engl J Med 301:453–459 Lemaire F, Teboul JL, Cinotti L, Giotto G, Abrouk F, Steg G, Macquin-Mavier I, Zapol WM (1988) Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 69:171–179 Lamia B, Maizel J, Ochagavia A, Chemla D, Osman D, Richard C, Teboul JL (2009) Echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation. Crit Care Med 37:1696–1701 Brochard L, Rauss A, Benito S, Conti G, Mancebo J, Rekik N, Gasparetto A, Lemaire F (1994) Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 150:896–903 Esteban A, Frutos F, Tobin MJ, Alia I, Solsona JF, Valverdu I, Fernandez R, de la Cal MA, Benito S, Tomas R et al (1995) A comparison of four methods of weaning patients from mechanical ventilation Spanish Lung Failure Collaborative Group. N Engl J Med 332:345–350 Esteban A, Alia I, Gordo F, Fernandez R, Solsona JF, Vallverdu I, Macias S, Allegue JM, Blanco J, Carriedo D, Leon M, de la Cal MA, Taboada F, Gonzalez de Velasco J, Palazon E, Carrizosa F, Tomas R, Suarez J, Goldwasser RS (1997) Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 156:459–465 Ezingeard E, Diconne E, Guyomarc’h S, Venet C, Page D, Gery P, Vermesch R, Bertrand M, Pingat J, Tardy B, Bertrand JC, Zeni F (2006) Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing. Intensive Care Med 32:165–169 Sassoon CS, Light RW, Lodia R, Sieck GC, Mahutte CK (1991) Pressure-time product during continuous positive airway pressure, pressure support ventilation, and T-piece during weaning from mechanical ventilation. Am Rev Respir Dis 143:469–475 Koh Y, Hong SB, Lim CM, Lee SD, Kim WS, Kim DS, Kim WD (2000) Effect of an additional 1-hour T-piece trial on weaning outcome at minimal pressure support. J Crit Care 15:41–45 Kuhlen R, Max M, Dembinski R, Terbeck S, Jurgens E, Rossaint R (2003) Breathing pattern and workload during automatic tube compensation, pressure support and T-piece trials in weaning patients. Eur J Anaesthesiol 20:10–16 Cabello B, Mancebo J (2006) Cardiovascular and Respiratory Alterations during Different Spontanous Breathing Trials The role of congestive heart failure. Am J Respir Crit Care Med 3:A40 Girault C, Breton L, Richard JC, Tamion F, Vandelet P, Aboab J, Leroy J, Bonmarchand G (2003) Mechanical effects of airway humidification devices in difficult to wean patients. Crit Care Med 31:1306–1311 Vallverdu I, Calaf N, Subirana M, Net A, Benito S, Mancebo J (1998) Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med 158:1855–1862 Fishman A (1985) Pulmonary Circulation Handbook of physiology. The respiratory system Vol I. Circulation and nonrespiratory functions. American Physiological Society, Bethesda, pp 93–166 Baydur A, Behrakis PK, Zin WA, Jaeger MJ, Milic-Emili J (1982) A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis 126:788–791 Cabello B, Mancebo J (2006) Work of breathing. Intensive Care Med 32:1311–1314 Mancebo J, Albaladejo P, Touchard D, Bak E, Subirana M, Lemaire F, Harf A, Brochard L (2000) Airway occlusion pressure to titrate positive end-expiratory pressure in patients with dynamic hyperinflation. Anesthesiology 93:81–90 Fleury B, Murciano D, Talamo C, Aubier M, Pariente R, Milic Emili J (1985) Work of breathing in patients with chronic obstructive pulmonary disease in acute respiratory failure. Am Rev Respir Dis 131:822–827 Brochard L, Harf A, Lorino H, Lemaire F (1989) Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis 139:513–521 El-Khatib MF, Zeineldine SM, Jamaleddine GW (2008) Effect of pressure support ventilation and positive end expiratory pressure on the rapid shallow breathing index in intensive care unit patients. Intensive Care Med 34:505–510 Brochard L, Pluskwa F, Lemaire F (1987) Improved efficacy of spontaneous breathing with inspiratory pressure support. Am Rev Respir Dis 136:411–415 Epstein SK, Ciubotaru RL (1996) Influence of gender and endotracheal tube size on preextubation breathing pattern. Am J Respir Crit Care Med 154:1647–1652 Smith TC, Marini JJ (1988) Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol 65:1488–1499 Richard C, Teboul JL, Archambaud F, Hebert JL, Michaut P, Auzepy P (1994) Left ventricular function during weaning of patients with chronic obstructive pulmonary disease. Intensive Care Med 20:181–186 Lenique F, Habis M, Lofaso F, Dubois-Rande JL, Harf A, Brochard L (1997) Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure. Am J Respir Crit Care Med 155:500–505 Pierard LA, Lancellotti P (2004) The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 351:1627–1634 Jubran A, Tobin MJ (1997) Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med 155:906–915 Jubran A, Mathru M, Dries D, Tobin MJ (1998) Continuous recordings of mixed venous oxygen saturation during weaning from mechanical ventilation and the ramifications thereof. Am J Respir Crit Care Med 158:1763–1769 Zile MR, Gaasch WH, Carroll JD, Feldman MD, Aurigemma GP, Schaer GL, Ghali JK, Liebson PR (2001) Heart failure with a normal ejection fraction: is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure? Circulation 104:779–782 Zile MR, Baicu CF, Gaasch WH (2004) Diastolic heart failure-abnormalities in active relaxation and passive stiffness of the left ventricle. N Engl J Med 350:1953–1959 Gandhi SK, Powers JC, Nomeir AM, Fowle K, Kitzman DW, Rankin KM, Little WC (2001) The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med 344:17–22 Richard C, Teboul JL (2005) Weaning failure from cardiovascular origin. Intensive Care Med 31:1605–1607 Zakynthinos S, Routsi C, Vassilakopoulos T, Kaltsas P, Zakynthinos E, Kazi D, Roussos C (2005) Differential cardiovascular responses during weaning failure: effects on tissue oxygenation and lactate. Intensive Care Med 31:1634–1642 Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R (1994) The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824 Pinsky MR (2003) Clinical significance of pulmonary artery occlusion pressure. Intensive Care Med 29:175–178 Hoyt JD, Leatherman JW (1997) Interpretation of the pulmonary artery occlusion pressure in mechanically ventilated patients with large respiratory excursions in intrathoracic pressure. Intensive Care Med 23:1125–1131 Feihl F, Broccard AF (2009) Interactions between respiration and systemic hemodynamics, part I: basic concepts. Intensive Care Med 35:45–54 Feihl F, Broccard AF (2009) Interactions between respiration and systemic hemodynamics, part II: practical implications in critical care. Intensive Care Med 35:198–205 Frutos-Vivar F, Ferguson ND, Esteban A, Epstein SK, Arabi Y, Apezteguía C, González M, Hill NS, Nava S, D’Empaire G, Anzueto A (2006) Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 130:1664–1671 Upadya A, Tilluckdharry L, Muralidharan V, Amoateng-Adjepong Y, Manthous CA (2005) Fluid balance and weaning outcomes. Intensive Care Med 31:1643–1647 Straus C, Louis B, Isabey D, Lemaire F, Harf A, Brochard L (1998) Contribution of the endotracheal tube and the upper airway to breathing workload. Am J Respir Crit Care Med 157:23–30 Epstein SK, Ciubotaru RL, Wong JB (1997) Effect of failed extubation on the outcome of mechanical ventilation. Chest 112:186–192 Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame F, Navalesi P (2005) Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 33:2465–2470 Ferrer M, Sellares J, Valencia M, Carrillo A, Gonzalez G, Badia JR, Nicolas JM, Torres A (2009) Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet 374:1082–1088