WeaningWeaning failure of cardiac origin failure of cardiac origin

Prof. Jean-Louis TEBOULProf. Jean-Louis TEBOUL

Medical ICU

Bicetre Hospital

University Paris-South

France

TREATMENT OF SEVERE CARDIOGENIC PULMONARY EDEMA WITH CONTINUOUSPOSITIVE AIRWAY PRESSURE DELIVERED BY FACE MASK

Invasive or non invasive positive pressure ventilation positive pressure ventilation is an established treatmenttreatment

of severe cardiogenic pulmonary edema cardiogenic pulmonary edema

Weaning-induced pulmonary edemaWeaning-induced pulmonary edema

may develop

and may be a cause of weaning failurecause of weaning failure

in predisposed patients

PAOPtm

mmHg

SBSBMVMV

6060

5050

4040

3030

2020

00

1010

Weaning-induced increase in PAOPWeaning-induced increase in PAOP

LV end diastolic volume

LV end diastolic pressure

AB

C

D

Radionuclide Radionuclide

angiocardiographyangiocardiography

during weaningduring weaning

in COPD patientsin COPD patients

without CADwithout CAD

Left ventricular function during weaning of patients with COPD Richard C, Teboul JL, Archambaud F et al.

Intensive Care Med 1994; 20 : 181-6

LVEF (%)

MV1 SV MV2

LV end diastolic volume

LV end diastolic pressure

normal compliance

reduced compliance

A

C

B

Who are the patients at risk of weaning failure Who are the patients at risk of weaning failure

from from cardiac origin cardiac origin ??

Patients with LV disease (CAD) and associated COPD

• biventricular interdependence

Deep inspiratory fall in intrathoracic pressure and elevated WOB

• airway obstruction

Increased Increased RVRV and LV preloadLV preload

and increased increased LV afterloadLV afterload

Increased cardiac work Increased cardiac work

and thus, increasedincreased

riskrisk of myocardial ischemia myocardial ischemia

Decreased LV compliance Decreased LV compliance

When should cardiac-related weaning failure When should cardiac-related weaning failure be suspected?be suspected?

. . whenwhen CHF CHF andand COPD COPD coexistcoexist

. when other. when other obvious causes obvious causes of weaning failure of weaning failure have beenhave been discarded discarded

How to diagnose weaning-induced pulmonary edema?How to diagnose weaning-induced pulmonary edema?

Weaning trialWeaning trial: T-piece T-piece or low levellow level of Pressure supportPressure support

• PA catheter ?

increase in PAOP

How to diagnose weaning-induced pulmonary edema?How to diagnose weaning-induced pulmonary edema?

• Transpulmonary thermodilution?

Weaning trial: T-piece or low level of Pressure support

• PA catheter ?

Elevation of EVLW

Cut-off: 6%

Crit Care Med 2014

AUC = 0.89

How to diagnose weaning-induced pulmonary edema?How to diagnose weaning-induced pulmonary edema?

• Doppler-echo ?

E/A and E/E’ assumed to reflect PAOP

Weaning trial: T-piece or low level of Pressure support

• PA catheter ?• Transpulmonary thermodilution?

Pulsed waveDoppler

Tissue Doppler

Apical 4-chamber view

or

E

A

E’A’

or

E

A

E’ A’

determinantsLV relaxation

LV filling pressure

determinant LV relaxation reflects

LV filling pressure

E

E’

Can E/A and E/E’ at the end of a

Spontaneous Breathing Trial

identify weaning failure from cardiac origin

defined as a weaning-induced increase

in PAOP > 18 mmHg?

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

PE - PE +

E/A at the end of the SBT

20

18

16

14

12

10

8

6

4

2

PE - PE +

E/E’ at the end of the SBT

0.95

8.5

The predictive value

of each of these variables

was not sufficiently acceptable

to diagnose weaning-induced

pulmonary edema

-1 0 1 2 3 4

20

18

16

14

12

10

8

6

4

2

E/A at the end of the SBT

E/E’

at

the

end

of th

e SB

T

8.5

0.95

-1 0 1 2 3 4

20

18

16

14

12

10

8

6

4

2

E/A at-1 0 1 2 3 4

20

18

16

14

12

10

8

6

4

2

PE +

PE - Se = 82%

Sp = 91%

PPV = 88%

NPV = 87%

Combination ofCombination of E/A > 0.95 E/A > 0.95 and and E/E’ > 8.5 E/E’ > 8.5

at the end of a SBT

predicted weaning-induced pulmonary edemapredicted weaning-induced pulmonary edema

with a high accuracy

defined as a PAOP > 18 mmHg at the end of a SBT

How to diagnose weaning-induced pulmonary edema?How to diagnose weaning-induced pulmonary edema?

• Doppler-echo ?

Weaning trial: T-piece or low level of Pressure support

• PA catheter ?• Transpulmonary thermodilution ?

• BNP or NT-proBNP ?

Crit Care Med 2014

*

weaning-induced pulmonary edema

no weaning-induced pulmonary edema

MV MVSB SB

Crit Care Med 2014

BNP

AUC = 0.76

How to diagnose weaning-induced pulmonary edema?How to diagnose weaning-induced pulmonary edema?

• Doppler-echo ?

Weaning trial: T-piece or low level of Pressure support

• PA catheter ?• Transpulmonary thermodilution ?

• BNP or NT-proBNP ?

• Hemoconcentration ?

Hydrostatic pulmonary edema

Hemoconcentration

Increase in plasma protein concentration

during weaning could detect

weaning-induced pulmonary edema

52

59Weaning-induced PO defined as intolerance to SB and a PAOP > 18 mmHg

-2

0

2

4

6

8

10

12

14

16

18

20

Weaning-induced PO No weaning-induced P0

SBT-induced change in plasma protein concentration (%)

Se = 85 %Sp= 100 %

Anguel et al Intensive Care Med 2008 Anguel et al Intensive Care Med 2008

Crit Care Med 2014

BNP

Plasma Protein Hb

EVLW

. Diuretics: if pulmonary edema is assumed to be related to increased preload secondary to increased venous return

Which therapy? Which therapy? Phamacological agentsPhamacological agents

Am J Respir Crit Care Med 2012; 186:1256-63Am J Respir Crit Care Med 2012; 186:1256-63

Am J Respir Crit Care Med 2012; 186:1256-63Am J Respir Crit Care Med 2012; 186:1256-63

Time (hrs) to successful weaning

Am J Respir Crit Care Med 2012; 186:1256-63Am J Respir Crit Care Med 2012; 186:1256-63

. Diuretics: if pulmonary edema is assumed to be related to increased preload secondary to increased venous return

Which therapy? Which therapy? Phamacological agentsPhamacological agents

. Nitrates: if suspicion of myocardial ischemia

PAOPSystolic Arterial PressuremmHg

SBTstartMV SBTend SBTstartMV SBTend

Control day

PAOPSystolic Arterial PressuremmHg

SBTstartMV SBTend SBTstartMV SBTend

PAOP mmHg

SBTstartMV SBTend SBTstartMV SBTend

mmHg PAOPSystolic Arterial Pressure

Control day

Study day

IV nitrates starting at the beginning

of the SBT

. Diuretics: if pulmonary edema is assumed to be related to increased preload secondary to increased venous return

Which therapy? Which therapy? Phamacological agentsPhamacological agents

. Vasodilators: if suspicion of increased LV afterload

. Nitrates: if suspicion of myocardial ischemia

. Diuretics: if pulmonary edema is assumed to be related to increased preload secondary to increased venous return

Which therapy? Which therapy? Phamacological agentsPhamacological agents

. Inotropes: not logical!

. Vasodilators: if suspicion of increased LV afterload

. Nitrates: if suspicion of myocardial ischemia

PS + PEEP

. Decremental levels of PS

and keeping 5 to 8 cmH2O of PEEP

. Continue after extubation (facial mask)

Which therapy? Which therapy? Ventilatory modalitiesVentilatory modalities

ConclusionConclusion

. In case of preexisting cardiac disease, weaning failure from cardiac origin is not uncommon

. Its recognition is important since a specific therapy (after individualized evaluation) can result in successful weaning

. Complex and intricate mechanisms (vicious circle) generated by marked increased respiratory muscles activity

Thank you