Left ventricular overloading identified by critical care echocardiography is key in weaning-induced pulmonary edema

Abstract

To assess the role of left ventricular overload and cumulated fluid balance in the development weaninginduced pulmonary edema (WIPO). Methods: Ventilated patients in sinus rhythm with COPD and/or heart failure (ejection fraction ≤ 40%) were studied. Echocardiography was performed immediately before and during a 30-min spontaneous breathing trial (SBT) using a T-tube. Patients who failed were treated according to echocardiography results before undergoing a second SBT. Results: Twelve of 59 patients failed SBT, all of them developing WIPO. Patients who succeeded SBT had lower body weight (− 2.5 kg [− 4.8; − 1] vs. + 0.75 kg [− 2.95; + 5.57]: p = 0.02) and cumulative fluid balance (− 2326 ml [− 3715; + 863] vs. + 143 ml [− 2654; + 4434]: p = 0.007) than those who developed WIPO. SBT-induced central hemodynamic changes were more pronounced in patients who developed WIPO, with higher E wave velocity (122 cm/s [92; 159] vs. 93 cm/s [74; 109]: p = 0.017) and E/A ratio (2.1 [1.2; 3.6] vs. 0.9 [0.8; 1.4]: p = 0.001), and shorter E wave deceleration time (85 ms [72; 125] vs. 147 ms [103; 175]: p = 0.004). After echocardiography-guided treatment, all patients who failed the first SBT were successfully extubated. Fluid balance was then negative (− 2224 ml [− 7056; + 100] vs. + 146 ml [− 2654; + 4434]: p = 0.005). Left ventricular filling pressures were lower (E/

Left ventricular overloading is the leading mechanism in extubation failure of patients at high-risk of weaning-induced pulmonary edema

“…Again, no significant difference was observed for the E ′ wave maximal velocity and E / E ′ ratio (Table 1 ). These data confirm those reported initially when dichotomizing patients according to passed or failed SBT [ 2 ].…”

“…We read with interest the correspondence by Sanfilippo et al [ 1 ] who suggest performing further analysis for our recently reported study [ 2 ]. As per their thoughtful suggestion, we first redefined the two study groups as “weaning success” ( n = 43) when the patient could be extubated without reinstitution of ventilator support within 48 h after extubation, and as “weaning failure” ( n = 16) whenever one the following occurred: (i) failed spontaneous breathing trial (SBT) ( n = 12); (ii) reintubation and/or resumption of ventilator support within 48 h after extubation ( n = 3); or (iii) death in the 48 h after extubation ( n = 1) [ 3 ].…”

Successful spontaneous breathing trial, early reintubation and mechanisms of weaning failure

“…We read with great interest the elegant study recently published by the group of Goudelin et al [ 1 ] where authors studied weaning from mechanical ventilation (MV) in a population with chronic-obstructive pulmonary disease (COPD) and/or heart failure with reduced ejection fraction (HFrEF). The authors confirmed that left ventricular (LV) overloading is a key aspect of weaning-induced pulmonary oedema (WiPO).…”

“…In this interesting study published in the journal [ 1 ], the authors showed that 47 out of 59 patients successfully passed their first SBT, while 12 had failed. Noteworthy, four patients “passing the SBT” subsequently met the criteria of “extubation failure within 48 h”, but they were still analysed as “successful SBT”.…”

“…Finally, the study population included a mixture of COPD and HFrEF patients [ 1 ], but they have different cardiovascular profiles on the systolic/diastolic function of both ventricles. A sub-group analysis may be very intriguing for readers as the mechanisms of weaning failure could be profoundly different.…”