New insights into weaning from mechanical ventilation: left ventricular diastolic dysfunction is a key player

• Published in: Intensive care medicine 2011-12, Vol.37 (12), p.1976-1985
• Main Authors: Papanikolaou, John, Makris, Demosthenes, Saranteas, Theodosios, Karakitsos, Dimitrios, Zintzaras, Elias, Karabinis, Andreas, Kostopanagiotou, Georgia, Zakynthinos, Epaminondas
• Format: Article
• Language: English
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anesthesiology; Biological and medical sciences; Cardiac patients; Cardiovascular disease; Critical Care; Critical Care Medicine; Critical Illness; Doppler effect; Echocardiography, Doppler; Emergency and intensive respiratory care; Emergency Medicine; Female; Hemodynamics; Hemodynamics - physiology; Hospitals; Humans; inflow; Intensive; Intensive care; Intensive care medicine; Logistic Models; Male; Medical colleges; Medical research; Medical sciences; Medicine; Medicine & Public Health; Medicine, Experimental; Middle Aged; Original; Pain Medicine; Patients; Pediatrics; Pneumology/Respiratory System; Prognosis; Prospective Studies; Respiration, Artificial; Respiratory Insufficiency - physiopathology; Respiratory Insufficiency - therapy; Risk Factors; Sensitivity; Velocity; Ventilation; Ventilator Weaning - adverse effects; Ventilator Weaning - methods; Ventilators; Ventricular Dysfunction, Left - diagnostic imaging; Ventricular Dysfunction, Left - physiopathology; Ventricular Function, Left - physiology; Weaning
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-011-2368-0

Purpose To investigate the diagnostic performance of Doppler echocardiography (DE) in predicting the outcome of weaning from mechanical ventilation in patients without overt cardiac disease. Methods Fifty critical care noncardiac patients who fulfilled predetermined criteria for weaning underwent DE before and at the end of spontaneous breathing trial (pre-SBT/end-SBT, respectively). “Conventional” mitral inflow analysis and “advanced” DE parameters [tissue Doppler imaging (TDI)-derived mitral/tricuspid annular velocities and color M-mode Doppler velocity of propagation ( V p )] were used to assess left ventricular (LV) diastolic function/filling pressures. Weaning was considered successful if patients had been extubated after successful SBT and sustained spontaneous breathing for more than 48 h. Results Twenty-eight patients (56%) failed weaning: 23 patients failed SBT and 5 required reintubation within 48 h. Weaning failure was associated with the degree of LV diastolic dysfunction at pre-SBT ( P  = 0.01). Patients who failed weaning presented evidence of increased LV filling pressures at pre-SBT, by demonstrating increased E / E m and E / V p ratios compared with patients with successful outcome ( P  ≤ 0.004); pre-SBT values of lateral E / E m greater than 7.8 and E / V p greater than 1.51 predicted weaning failure with an area under the curve, sensitivity (%), and specificity (%) of 0.86, 79, and 100, and 0.74, 75, and 73, respectively. Lateral E / E m was the only factor independently associated with weaning failure before SBT; OR (95% CI) 5.62 (1.17–26.96), P  = 0.03. Conclusions Our findings suggest that LV diastolic dysfunction is significantly associated with weaning outcome in critically ill patients with preserved LV systolic function. An E / E m ratio greater than 7.8 may identify patients at high risk of weaning failure.