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Weaning failure of cardiac origin Prof. Jean-Louis TEBOUL Medical ICU Bicetre Hospital University Paris-South France.

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Presentation on theme: "Weaning failure of cardiac origin Prof. Jean-Louis TEBOUL Medical ICU Bicetre Hospital University Paris-South France."— Presentation transcript:

1 Weaning failure of cardiac origin Prof. Jean-Louis TEBOUL Medical ICU Bicetre Hospital University Paris-South France

2 TREATMENT OF SEVERE CARDIOGENIC PULMONARY EDEMA WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DELIVERED BY FACE MASK positive pressure ventilation Invasive or non invasive positive pressure ventilation treatment is an established treatment cardiogenic pulmonary edema of severe cardiogenic pulmonary edema Weaning-induced pulmonary edema may develop cause of weaning failure and may be a cause of weaning failure in predisposed patients

3 PAOP tm mmHg SB MV

4 Weaning-induced increase in PAOP

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9 LV end diastolic volume LV end diastolic pressure A B C D

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13 Radionuclide angiocardiography during weaning in COPD patients in COPD patients without CAD without CAD Left ventricular function during weaning of patients with COPD Richard C, Teboul JL, Archambaud F et al. Intensive Care Med 1994; 20 : LVEF (%) MV 1 SV MV 2

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15 LV end diastolic volume LV end diastolic pressure normal compliance reduced compliance A C B

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20 Who are the patients at risk of weaning failure from cardiac origin ? Patients with LV disease (CAD) and associated COPD biventricular interdependence Deep inspiratory fall in intrathoracic pressure and elevated WOB airway obstruction Increased RVLV preload Increased RV and LV preload increased LV afterload and increased LV afterload Increased cardiac work increased and thus, increased riskmyocardial ischemia risk of myocardial ischemia Decreased LV compliance

21 When should cardiac-related weaning failure be suspected? When should cardiac-related weaning failure be suspected?. when CHF and COPD coexist. when other obvious causes of weaning failure have been discarded have been discarded

22 How to diagnose weaning-induced pulmonary edema? Weaning trial T-piece low level Pressure support Weaning trial: T-piece or low level of Pressure support PA catheter ?   increase in PAOP

23 How to diagnose weaning-induced pulmonary edema? Transpulmonary thermodilution? Weaning trial: T-piece or low level of Pressure support PA catheter ? Elevation of EVLW

24 Cut-off: 6% Crit Care Med 2014 AUC = 0.89

25 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?

26 Pulsed wave Doppler Tissue Doppler Apical 4-chamber view or E A E’ A’

27 or E A E’ A’ determinants LV relaxation LV filling pressure determinantLV relaxation reflects LV filling pressure E E’

28 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?

29 PE - PE + E/A at the end of the SBT PE - PE + E/E’ at the end of the SBT The predictive value of each of these variables was not sufficiently acceptable to diagnose weaning-induced pulmonary edema

30 E/Aatthe end of the SBT E/E’ at the end of the SBT E/Aat PE + PE - Se = 82% Sp = 91% PPV = 88% NPV = 87% Combination of E/A > 0.95 and E/E’ > 8.5 at the end of a SBT predicted weaning-induced pulmonary edema with a high accuracy defined as a PAOP > 18 mmHg at the end of a SBT

31 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 ?

32 Crit Care Med 2014 * weaning-induced pulmonary edema no weaning-induced pulmonary edema MV SB

33 Crit Care Med 2014  BNP AUC = 0.76

34 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 ?

35 Hydrostatic pulmonary edema Hemoconcentration Increase in plasma protein concentration during weaning could detect weaning-induced pulmonary edema

36 52 59 Weaning-induced PO defined as intolerance to SB and a PAOP > 18 mmHg

37 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

38 Crit Care Med 2014  BNP  Plasma Protein  Hb  EVLW

39 . Diuretics: if pulmonary edema is assumed to be related to increased preload secondary to increased venous return Which therapy? Phamacological agents

40 Am J Respir Crit Care Med 2012; 186:

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42 Time (hrs) to successful weaning Am J Respir Crit Care Med 2012; 186:

43 . Diuretics: if pulmonary edema is assumed to be related to increased preload secondary to increased venous return Which therapy? Phamacological agents. Nitrates: if suspicion of myocardial ischemia

44 PAOPSystolic Arterial Pressure mmHg SBT start MVSBT end SBT start MVSBT end Control day

45 PAOPSystolic Arterial Pressure mmHg SBT start MVSBT end SBT start MVSBT end PAOP mmHg SBT start MVSBT end SBT start MVSBT end mmHg PAOPSystolic Arterial Pressure Control day Study day IV nitrates starting at the beginning of the SBT

46 . Diuretics: if pulmonary edema is assumed to be related to increased preload secondary to increased venous return Which therapy? Phamacological agents. Vasodilators: if suspicion of increased LV afterload. Nitrates: if suspicion of myocardial ischemia

47 . Diuretics: if pulmonary edema is assumed to be related to increased preload secondary to increased venous return Which therapy? Phamacological agents. Inotropes: not logical!. Vasodilators: if suspicion of increased LV afterload. Nitrates: if suspicion of myocardial ischemia

48 PS + PEEP. Decremental levels of PS and keeping 5 to 8 cmH 2 O of PEEP. Continue after extubation (facial mask) Which therapy? Ventilatory modalities

49 Conclusion Conclusion. 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


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