Top

The Ultrasound Journal

Published in:

Open Access 01-12-2018 | Original article

Lung and diaphragm ultrasound as predictors of success in weaning from mechanical ventilation

Authors: Eva Tenza-Lozano, Ana Llamas-Alvarez, Enrique Jaimez-Navarro, Javier Fernández-Sánchez

Published in: The Ultrasound Journal | Issue 1/2018

Abstract

Background

Lung and diaphragm ultrasound methods have recently been introduced to predict the outcome of weaning from mechanical ventilation (MV). The aim of this study is to assess the reliability and accuracy of these techniques for predicting successful weaning in critically ill adults.

Methods

We conducted two studies: a cross-sectional interobserver agreement study between two sonographers and a prospective cohort study to assess the accuracy of lung and diaphragm ultrasound for predicting weaning and extubation outcome. For the interobserver agreement study, we included 50 general critical care patients who were consecutively admitted to the ICU. For the predictive accuracy study, we included consecutively 69 patients on MV who were ready for weaning. We assessed interobserver agreement of ultrasound measurements, using the weighted kappa coefficient for LUSm score (modified lung ultrasound score) and the intraclass correlation coefficient (ICC) and Bland–Altman method for TI (diaphragm thickening index). We assessed the predictive value of LUSm and TI in weaning outcome by plotting the corresponding ROC curves.

Results

We found adequate interobserver agreement for both LUSm (weighted kappa 0.95) and TI (ICC 0.78, difference according to Bland–Altman analysis ± 12.5%). LUSm showed good-moderate discriminative power for successful weaning and extubation (area under the ROC curve (AUC) for successful weaning 0.80, and sensitivity and specificity at optimal cut-off point 0.76 and 0.73, respectively; AUC for successful extubation 0.78, and optimal sensitivity and specificity 0.76 and 0.47, respectively. TI was more sensitive but less specific for predicting successful weaning (AUC 0.71, optimal sensitivity and specificity 0.93 and 0.48) and successful extubation (AUC 0.76, optimal sensitivity and specificity 0.93 and 0.58). The area under the ROC curve for predicting weaning success was 0.83 for both ultrasound measurements together.

Conclusions

Interobserver agreement was excellent for LUSm and moderate-good for TI. A low TI value or high LUSm value indicates high risk of weaning failure.

Available only for authorised users

Peñuelas O, Frutos-Vivar F, Fernández C, Anzueto A, Epstein SK, Apezteguía C et al (2011) Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med 184(4):430–437CrossRefPubMed

Powers SK, Kavazis ANLS (2009) Prolonged mechanical ventilation alters diaphragmatic structure and function. Crit Care Med 37(10 suppl):S347–S353CrossRefPubMedPubMedCentral

Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, Zhu J, Sachdeva R, Sonnad S, Kaiser LR, Rubinstein NA, Powers SKSJ (2008) Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 358(13):1327–1335CrossRefPubMed

Béduneau G, Pham T, Schortgen F, Piquilloud L, Zogheib E, Jonas M, Grelon F, Runge I, Terzi N, Grangé S, Barberet G, Guitard PG, Frat JP, Constan A, Chretien JM, Mancebo J, Mer BL (2016) Epidemiology of weaning outcome according to a new definition. The WIND study. Am J Respir Crit Care Med 195(6):772–783CrossRef

Funk GC, Anders S, Breyer MK, Burghuber OC, Edelmann G, Heindl W et al (2010) Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J 35(1):88–94CrossRefPubMed

Savi A, Teixeira C, Silva JM, Borges LG, Pereira PA, Pinto KB et al (2012) Weaning predictors do not predict extubation failure in simple-to-wean patients. J Crit Care 27(2):221-e1–221-e8. https://doi.org/10.1016/j.jcrc.2011.07.079 CrossRef

Bouhemad B, Liu ZH, Arbelot C, Zhang M, Ferarri F, Le-Guen M, Girard M, Lu QRJ (2010) Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia. Crit Care Med 38(1):84–92CrossRefPubMed

Soummer A, Perbet S, Brisson H, Arbelot C, Constantin J-M, Lu Q et al (2012) Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress. Crit Care Med 40(7):2064–2072CrossRefPubMed

Binet C, Neron L, Rochart N, Cousson J, Floch T, Charbit B et al (2014) Validation d’un indice échographique prédictif d’échec de sevrage de la ventilation mécanique. Ann Fr Anesth Reanim 33:A383CrossRef

10.

Shoaeir M, Noeam KMA (2016) Lung aeration loss as a predictor of reintubation using lung ultrasound in mechanically ventilated patients. Biolife 4(3):514–520

11.

Osman AM, Hashim RM (2017) Diaphragmatic and lung ultrasound application as new predictive indices for the weaning process in ICU patients. Egypt J Radiol Nucl Med 48:61–66CrossRef

12.

DiNino E, Gartman EJEJ, Sethi JMJM, McCool FDD (2014) Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation. Thorax 69(5):423–427. https://doi.org/10.1136/thoraxjnl-2013-204111 CrossRefPubMed

13.

Ferrari G, De Filippi G, Elia F, Panero F, Volpicelli GAF (2014) Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J. 6(1):8CrossRefPubMedPubMedCentral

14.

Blumhof S, Wheeler D, Thomas K, McCool FD, Mora J (2016) Change in diaphragmatic thickness during the respiratory cycle predicts extubation success at various levels of pressure support ventilation. Lung 194(4):519–525CrossRefPubMed

15.

Fayed AM, Abd El Hady MA, Shaaban MSFD (2016) Use of ultrasound to assess diaphragmatic thickness as a weaning parameter in invasively ventilated chronic obstructive pulmonary disease patients. J Am Sci. 12(6):96–105

16.

Farghaly S, Hasan AA (2015) Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients. Aust Crit Care. https://doi.org/10.1016/j.aucc.2016.03.004 CrossRefPubMed

17.

Jung B, Moury PH, Mahul M, de Jong A, Galia F, Prades A et al (2016) Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on extubation failure. Intensive Care Med 42(5):853–861CrossRefPubMed

18.

Baess AI, Abdallah TH, Emara DM, Hassan M (2016) Diaphragmatic ultrasound as a predictor of successful extubation from mechanical ventilation: thickness, displacement, or both? Egypt J Bronchiol 10(2):162–166CrossRef

19.

Umbrello M, Formenti P (2016) Ultrasonographic assessment of diaphragm function in critically ill subjects. Respir Care 61(4):542–555CrossRefPubMed

20.

Ali ER, Mohamad AM (2016) Diaphragm ultrasound as a new functional and morphological index of outcome, prognosis and discontinuation from mechanical ventilation in critically ill patients and evaluating the possible protective indices against VIDD. Egypt J Chest Dis Tuberc. https://doi.org/10.1016/j.ejcdt.2016.10.006 CrossRef

21.

Zambon M, Greco M, Bocchino S, Cabrini L, Beccaria PF, Zangrillo A (2016) Assessment of diaphragmatic dysfunction in the critically ill patient with ultrasound: a systematic review. Intensive Care Med 43(1):29–38CrossRefPubMed

22.

Palkar A, Narasimhan M, Greenberg H, Singh K, Koenig S, Mayo P et al (2018) Diaphragm excursion-time index: a new parameter using ultrasonography to predict extubation outcome. Chest 153(5):1213–1220. https://doi.org/10.1016/j.chest.2018.01.007 CrossRefPubMed

23.

Dubé B-P, Dres M, Mayaux J, Demiri S, Similowski T, Demoule A (2017) Ultrasound evaluation of diaphragm function in mechanically ventilated patients: comparison to phrenic stimulation and prognostic implications. Thorax. https://doi.org/10.1136/thoraxjnl-2016-209459 PubMedCrossRef

24.

Llamas-Alvarez AM, Tenza-Lozano EM, Latour-Perez J (2017) Diaphragm and lung ultrasound to predict weaning outcome: systematic review and meta-analysis. Chest 152(6):1140–1150CrossRefPubMed

25.

Bouhemad B, Zhang M, Lu QRJ (2007) Clinical review: bedside lung ultrasound in critical care practice. Crit Care 11(1):205. https://doi.org/10.1186/cc5668 CrossRefPubMedPubMedCentral

26.

Lichtenstein DAMG (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 134(1):117–125CrossRefPubMedPubMedCentral

27.

Matamis D, Soilemezi E, Tsagourias M, Akoumianaki E, Dimassi S, Boroli F et al (2013) Sonographic evaluation of the diaphragm in critically ill patients. Technique and clinical applications. Intensive Care Med 39(5):801–810. https://doi.org/10.1007/s00134-013-2823-1 CrossRefPubMed

28.

Boles J-M, Bion J, Connors A, Herridge M, Marsh B, Melot C et al (2007) Weaning from mechanical ventilation. Eur Respir J 29(5):1033–1056. https://doi.org/10.1183/09031936.00010206 CrossRefPubMed

29.

Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, Benito S, Epstein SK, Apezteguía C, Nightingale P, Arroliga AC, Tobin MJ (2002) Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 287(3):345CrossRefPubMed

30.

Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Peñuelas O, Abraira V et al (2013) Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med 188(2):220–230CrossRefPubMed

31.

Figueroa-Casas JB, Broukhim A, Vargas A, Milam L, Montoya R (2014) Inter-observer agreement of spontaneous breathing trial outcome. Respir Care 59(9):1324–1328CrossRefPubMed

32.

Esteban A, Alía I, Tobin MTA et al (1999) Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Am J Resp Crit Care Med 159:512–518CrossRefPubMed

33.

Frutos-Vivar F, Esteban A, Apezteguia C, González M, Arabi Y, Restrepo MI et al (2011) Outcome of reintubated patients after scheduled extubation. J Crit Care 26(5):502–509. https://doi.org/10.1016/j.jcrc.2010.12.015 CrossRefPubMed

34.

Tonnelier A, Tonnelier JM, Nowak E, Gut-Gobert C, Prat G, Renault A et al (2011) Clinical relevance of classification according to weaning difficulty. Respir Care 56(5):583–590CrossRefPubMed

35.

Sellares J, Ferrer M, Cano E, Loureiro H, Valencia M, Torres A (2011) Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU. Intensive Care Med 37(5):775–784CrossRefPubMed

36.

Thille AW, Boissier F, Ben-Ghezala H, Razazi K, Mekontso-Dessap A, Brun-Buisson C et al (2016) Easily identified at-risk patients for extubation failure may benefit from noninvasive ventilation: a prospective before-after study. Crit Care 20(1):48CrossRefPubMedPubMedCentral

37.

Ferrer M, Esquìnas A, Arancibia F, Thomas Bauer T, Gonzalez G, Carrillo A et al (2003) Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med 168(1):70–76CrossRefPubMed

38.

Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame FNP (2005) Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 33(11):2465–2470CrossRefPubMed

39.

Esteban A, Alía I, Gordo FFR et al (1997) Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. Am J Respir Crit Care Med 156:459–465CrossRefPubMed

40.

Thille AW, Harrois A, Schortgen F, Brun-Buisson C, Brochard L (2011) Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med 39(12):2612–2618CrossRefPubMed

Title: Lung and diaphragm ultrasound as predictors of success in weaning from mechanical ventilation
Authors: Eva Tenza-Lozano
Ana Llamas-Alvarez
Enrique Jaimez-Navarro
Javier Fernández-Sánchez
Publication date: 01-12-2018
Publisher: Springer Milan
Published in: The Ultrasound Journal / Issue 1/2018
Electronic ISSN: 2524-8987
DOI: https://doi.org/10.1186/s13089-018-0094-3

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Lung and diaphragm ultrasound as predictors of success in weaning from mechanical ventilation

Abstract

Background

Methods

Results

Conclusions

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2018

Strain analysis for the identification of hypertensive cardiac end-organ damage in the emergency department

Early abnormal transient hyperemic response test can predict delayed ischemic neurologic deficit in subarachnoid hemorrhage

Diagnosis of diastolic dysfunction in the emergency department: really at reach for minimally trained sonologists? A call for a wise approach to heart failure with preserved ejection fraction diagnosis in the ER

Mitral valve velocity time integral and passive leg raise as a measure of volume responsiveness

Application of robotic transcranial Doppler for extended duration recording in moderate/severe traumatic brain injury: first experiences

Emergency physician use of tissue Doppler bedside echocardiography in detecting diastolic dysfunction: an exploratory study

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page