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The Ultrasound Journal

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Open Access 01-12-2018 | Original article

The impact of heart, lung and diaphragmatic ultrasound on prediction of failed extubation from mechanical ventilation in critically ill patients: a prospective observational pilot study

Authors: Kavi Haji, Darsim Haji, David J. Canty, Alistair G. Royse, Cameron Green, Colin F. Royse

Published in: The Ultrasound Journal | Issue 1/2018

Abstract

Background

Failed extubation from mechanical ventilation in critically ill patients is multifactorial, complex and not well understood. We aimed to identify whether combined transthoracic echocardiography, lung and diaphragmatic ultrasound can predict extubation failure in critically ill patients.

Results

Fifty-three participants who were intubated > 48 h and deemed by the treating intensivist ready for extubation underwent a 60-min pre-extubation weaning trial (pressure support ≤ 10 cmH₂O and positive end expiratory pressure 5 cmH₂O). Prior to extubation, data collected included ultrasound assessment of left ventricular ejection fraction, left atrial area, early diastolic trans-mitral flow velocity wave (E), early diastolic trans-mitral flow velocity wave/late diastolic trans-mitral flow velocity wave (E/A), early diastolic trans-mitral flow velocity wave/early diastolic mitral annulus velocity (E/E′), interatrial septal motion, lung loss of aeration score and diaphragm movement. At the end of the weaning trial, the rapid shallow breathing index and serum B-type natriuretic peptide concentration were measured. Success and failure of weaning was assessed by defined criteria. Decision to extubate was at the discretion of the treating intensivist. Failure of extubation was defined as re-intubation, non-invasive ventilation or death within 48 h after extubation. Of 53 extubated participants, 11 failed extubation. Failed extubation was associated with diabetes, ischaemic heart disease, higher E/E′ (OR 1.27, 95% CI 1.05–1.54), left atrial area (OR 1.14, CI 1.02–1.28), fixed rightward curvature of the interatrial septum (OR 12.95, CI 2.73–61.41), and higher loss of aeration score of anterior and lateral regions of the lungs (OR 1.41, CI 1.01–1.82).

Conclusions

Failed extubation in mechanically ventilated patients is more prevalent if markers of left ventricular diastolic dysfunction and loss of lung aeration are present.

Boles JM, 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

Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L et al (2008) Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med 177(2):170–177. https://doi.org/10.1164/rccm.200706-893oc CrossRefPubMed

Esteban A, Alia I, Tobin MJ, Gil A, Gordo F, Vallverdu I et al (1999) Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 159(2):512–518. https://doi.org/10.1164/ajrccm.159.2.9803106 CrossRefPubMed

Hurford WE, Favorito F (1995) Association of myocardial ischemia with failure to wean from mechanical ventilation. Crit Care Med 23(9):1475–1480CrossRefPubMed

Jubran A, Lawm G, Duffner LA, Collins EG, Lanuza DM, Hoffman LA et al (2010) Post-traumatic stress disorder after weaning from prolonged mechanical ventilation. Intensive Care Med 36(12):2030–2037. https://doi.org/10.1007/s00134-010-1972-8 CrossRefPubMedPubMedCentral

Lemaire F, Teboul JL, Cinotti L, Giotto G, Abrouk F, Steg G et al (1988) Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 69(2):171–179CrossRefPubMed

Mekontso-Dessap A, de Prost N, Girou E, Braconnier F, Lemaire F, Brun-Buisson C et al (2006) B-type natriuretic peptide and weaning from mechanical ventilation. Intensive Care Med 32(10):1529–1536. https://doi.org/10.1007/s00134-006-0339-7 CrossRefPubMed

Caille V, Amiel JB, Charron C, Belliard G, Vieillard-Baron A, Vignon P (2010) Echocardiography: a help in the weaning process. Crit Care 14(3):R120. https://doi.org/10.1186/cc9076 CrossRefPubMedPubMedCentral

Papanikolaou J, Makris D, Saranteas T, Karakitsos D, Zintzaras E, Karabinis A et al (2011) New insights into weaning from mechanical ventilation: left ventricular diastolic dysfunction is a key player. Intensive Care Med. https://doi.org/10.1007/s00134-011-2368-0 PubMedCrossRef

10.

Moschietto S, Doyen D, Grech L, Dellamonica J, Hyvernat H, Bernardin G (2012) Transthoracic echocardiography with Doppler tissue imaging predicts weaning failure from mechanical ventilation: evolution of the left ventricle relaxation rate during a spontaneous breathing trial is the key factor in weaning outcome. Crit Care 16(3):R81. https://doi.org/10.1186/cc11339 CrossRefPubMedPubMedCentral

11.

Soummer A, Perbet S, Brisson H, Arbelot C, Constantin JM, Lu Q et al (2012) Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress*. Crit Care Med 40(7):2064–2072. https://doi.org/10.1097/CCM.0b013e31824e68ae CrossRefPubMed

12.

Frutos-Vivar F, Ferguson ND, Esteban A, Epstein SK, Arabi Y, Apezteguia C et al (2006) Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 130(6):1664–1671. https://doi.org/10.1378/chest.130.6.1664 CrossRefPubMed

13.

Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM (2011) Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med 39(12):2627–2630. https://doi.org/10.1097/CCM.0b013e3182266408 CrossRefPubMed

14.

Bien Udos S, Souza GF, Campos ES, Farah de Carvalho E, Fernandes MG, Santoro I et al (2015) Maximum inspiratory pressure and rapid shallow breathing index as predictors of successful ventilator weaning. J Phys Ther Sci 27(12):3723–3727. https://doi.org/10.1589/jpts.27.3723 CrossRefPubMed

15.

Mayo P, Volpicelli G, Lerolle N, Schreiber A, Doelken P, Vieillard-Baron A (2016) Ultrasonography evaluation during the weaning process: the heart, the diaphragm, the pleura and the lung. Intensive Care Med 42(7):1107–1117. https://doi.org/10.1007/s00134-016-4245-3 CrossRefPubMed

16.

Esteban A, Alia I, Gordo F, Fernandez R, Solsona JF, Vallverdu I et al (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(2 Pt 1):459–465. https://doi.org/10.1164/ajrccm.156.2.9610109 CrossRefPubMed

17.

Tseng YH, Tseng YC, Hsu HS, Chang SC (2015) Different spontaneous breathing trials in patients with atrial fibrillation. Rev Port Pneumol (2006) 21(5):245–252. https://doi.org/10.1016/j.rppnen.2015.04.007 CrossRef

18.

Koksal GM, Sayilgan C, Sen O, Oz H (2004) The effects of different weaning modes on the endocrine stress response. Crit Care 8(1):R31–R34. https://doi.org/10.1186/cc2413 CrossRefPubMed

19.

Ladeira MT, Vital FM, Andriolo RB, Andriolo BN, Atallah AN, Peccin MS (2014) Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev 5:CD006056. https://doi.org/10.1002/14651858.cd006056.pub2 CrossRef

20.

Perrigault PF, Pouzeratte YH, Jaber S, Capdevila XJ, Hayot M, Boccara G et al (1999) Changes in occlusion pressure (P01) and breathing pattern during pressure support ventilation. Thorax 54(2):119–123CrossRefPubMedPubMedCentral

21.

Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA et al (2002) The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166(10):1338–1344. https://doi.org/10.1164/rccm.2107138 CrossRefPubMed

22.

Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28(1):1–39.e14. https://doi.org/10.1016/j.echo.2014 CrossRefPubMed

23.

Kusumoto FM, Muhiudeen IA, Kuecherer HF, Cahalan MK, Schiller NB (1993) Response of the interatrial septum to transatrial pressure gradients and its potential for predicting pulmonary capillary wedge pressure: an intraoperative study using transesophageal echocardiography in patients during mechanical ventilation. J Am Coll Cardiol 21(3):721–728CrossRefPubMed

24.

Royse CF, Royse AG, Soeding PF, Blake DW (2001) Shape and movement of the interatrial septum predicts change in pulmonary capillary wedge pressure. Ann Thorac Cardiovasc Surg 7(2):79–83PubMed

25.

Haji DL, Ali MM, Royse A, Canty DJ, Clarke S, Royse CF (2014) Interatrial septum motion but not Doppler assessment predicts elevated pulmonary capillary wedge pressure in patients undergoing cardiac surgery. Anesthesiology 121(4):719–729. https://doi.org/10.1097/aln.0000000000000392 CrossRefPubMed

26.

Gargani L, Volpicelli G (2014) How I do it: lung ultrasound. Cardiovasc Ultrasound 12:25. https://doi.org/10.1186/1476-7120-12-25 CrossRefPubMedPubMedCentral

27.

Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38(4):577–591. https://doi.org/10.1007/s00134-012-2513-4 CrossRefPubMed

28.

Volpicelli G, Skurzak S, Boero E, Carpinteri G, Tengattini M, Stefanone V et al (2014) Lung ultrasound predicts well extravascular lung water but is of limited usefulness in the prediction of wedge pressure. Anesthesiology 121(2):320–327. https://doi.org/10.1097/aln.0000000000000300 CrossRefPubMed

29.

Ferrari G, De Filippi G, Elia F, Panero F, Volpicelli G, Apra F (2014) Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J 6(1):8. https://doi.org/10.1186/2036-7902-6-8 CrossRefPubMedPubMedCentral

30.

Haji K, Royse A, Tharmaraj D, Haji D, Botha J, Royse C (2015) Diaphragmatic regional displacement assessed by ultrasound and correlated to subphrenic organ movement in the critically ill patients—an observational study. J Crit Care 30(2):439.e7–439.e13. https://doi.org/10.1016/j.jcrc.2014.10.028 CrossRef

31.

Boussuges A, Gole Y, Blanc P (2009) Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest 135(2):391–400. https://doi.org/10.1378/chest.08-1541 CrossRefPubMed

32.

Nava S, Hill N (2009) Non-invasive ventilation in acute respiratory failure. Lancet 374(9685):250–259. https://doi.org/10.1016/s0140-6736(09)60496-7 CrossRefPubMedPubMedCentral

33.

Glossop AJ, Shephard N, Bryden DC, Mills GH (2012) Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth 109(3):305–314. https://doi.org/10.1093/bja/aes270 CrossRefPubMed

34.

Lamia B, Maizel J, Ochagavia A, Chemla D, Osman D, Richard C et al (2009) Echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation. Crit Care Med 37(5):1696–1701. https://doi.org/10.1097/ccm.0b013e31819f13d0 CrossRefPubMed

35.

Temporelli PL, Scapellato F, Eleuteri E, Imparato A, Giannuzzi P (2010) Doppler echocardiography in advanced systolic heart failure: a noninvasive alternative to Swan-Ganz catheter. Circ Heart Fail 3(3):387–394. https://doi.org/10.1161/circheartfailure.108.809590 CrossRefPubMed

36.

Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA (1997) Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 30(6):1527–1533CrossRefPubMed

37.

Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA et al (2009) Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr 10(2):165–193. https://doi.org/10.1093/ejechocard/jep007 CrossRefPubMed

38.

Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ (2004) Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 100(1):9–15CrossRefPubMed

39.

Haddam M, Zieleskiewicz L, Perbet S, Baldovini A, Guervilly C, Arbelot C et al (2016) Lung ultrasonography for assessment of oxygenation response to prone position ventilation in ARDS. Intensive Care Med 42(10):1546–1556. https://doi.org/10.1007/s00134-016-4411-7 CrossRefPubMed

40.

Vassilakopoulos T (2008) Ventilator-induced diaphragm dysfunction: the clinical relevance of animal models. Intensive Care Med 34(1):7–16. https://doi.org/10.1007/s00134-007-0866x CrossRefPubMed

41.

Hussain SNA, Mofarrahi M, Sigala I, Kim HC, Vassilakopoulos T, Maltais F et al (2010) Mechanical ventilation-induced diaphragm disuse in humans triggers autophagy. Am J Respir Crit Care Med. 82(11):1377–1386. https://doi.org/10.1164/rccm.201002-0234OC CrossRef

42.

Jiang J, Tsai T, Jerng J, Yu C, Wu H, Yang P (2004) Ultrasonic evaluation of liver/spleen movements and extubation outcome. Chest 126:179–185. https://doi.org/10.1378/chest.126.1.179 CrossRefPubMed

43.

Tobin MJ, Perez W, Guenther SM, Semmes BJ, Mador MJ, Allen SJ et al (1986) The pattern of breathing during successful and unsuccessful trials of weaning from mechanical ventilation. Am Rev Respir Dis 134(6):1111–1118. https://doi.org/10.1164/arrd.1986.134.6.1111 PubMedCrossRef

44.

Lara TM, Hajjar LA, de Almeida JP, Fukushima JT, Barbas CS, Rodrigues AR et al (2013) High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery. Clinics (Sao Paulo) 68(1):33–38CrossRef

Title: The impact of heart, lung and diaphragmatic ultrasound on prediction of failed extubation from mechanical ventilation in critically ill patients: a prospective observational pilot study
Authors: Kavi Haji
Darsim Haji
David J. Canty
Alistair G. Royse
Cameron Green
Colin F. Royse
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/s13089-018-0096-1

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Abstract

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