Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review

Abstract

Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.

Linking preoperative and early intensive care unit data for prolonged intubation prediction

“…The model underwent evaluation through an internal validation set (5,429 patients) and an external validation set using a separate cohort (2,938 patients, 28 hospitals). In our study, the incidence rates of PI in the training, internal validation, and external validation cohorts were 11.8%, 12.1%, and 17.5%, respectively, consistent with other reports ( 10 ). Across all study cohorts, the discriminatory ability and clinical decision-making advantages of the model were consistently favorable ( Figure 4 and Supplementary Figure S3 ).…”

“…The model was based on merged multicenter datasets from the MIMIC and eICU-CRD. Previous studies have primarily focused on identifying risk factors for PI, predominantly analyzing preoperative and intraoperative variables ( 4 , 10 ). However, they rarely incorporated early postoperative physiological data, such as measurements taken shortly after ICU admission.…”

“…Assessing the risk of PI in patients is of interest to clinicians and patients alike. While previous studies have identified numerous risk factors ( 4 , 10 ), it is important to note that CS encompasses varied surgical techniques, cardiopulmonary bypass methods, and surgical access types, each exerting distinct effects on postoperative outcomes and clinical trajectories, potentially prolonging the intubation duration ( 29 , 30 ). Furthermore, advancements in modern cardiac anesthesia practices, such as optimized intraoperative temperature management, fast-track anesthesia, and ventilator protocols ( 31 ), indisputably impact the postoperative intubation duration ( 9 ).…”

Risk factors of ventilation dependency following cardiac surgery for infective endocarditis: focus on preoperative aortic insufficiency

“…[9][10][11] Data of predictors of ventilation dependency following cardiac surgery for infective endocarditis is rare. [12,13] We hypothesized that identifying modi able risk factors of ventilation dependency following cardiac surgery and optimization of pre-, peri-, and postoperative factors that can reduce mechanical ventilation, therefore, contribute to a better postoperative and long-term outcome.…”

Prediction of ventilator weaning failure in postoperative cardiac surgery patients using vasoactive-ventilation-renal score and nomogram analysis

“…Therefore, after cardiac surgery, patients usually undergo a SBT and removal of the tracheal tube while receiving vasoactive drugs. According to the literature, the weaning failure rate in patients undergoing post-cardiac surgery varies significantly, ranging from 2.6%–22.7%, one of the most common risk factors for weaning failure is the need for vasoactive drugs ( 5 ). Therefore, we believe that the dose of vasoactive drugs used during weaning is crucial for weaning outcomes in patients after cardiac surgery.…”