Cardiac dysfunction induced by weaning from mechanical ventilation: incidence, risk factors, and effects of fluid removal.
BACKGROUND
Weaning-induced pulmonary oedema (WiPO) is a well-recognised cause of failure of weaning from mechanical ventilation, but its incidence and risk factors have not been reliably described. We wanted to determine the incidence and risk factors in a population of critically ill patients. In addition, we wanted to describe the effects of diuretics when they are administered in this context.


METHODS
We monitored 283 consecutive spontaneous breathing trials (SBT; T-piece trial) performed in 81 patients. In cases with cardiac output monitoring (n = 85, 29 patients), a passive leg raising (PLR) test was performed before SBT. Three experts established the diagnosis of WiPO based on various patient characteristics.


RESULTS
SBT failed in 128 cases (45 % of all SBT). WiPO occurred in 59 % of these failing cases. Compared to patients without WiPO (n = 52), patients with at least one WiPO (n = 29) had a higher prevalence of chronic obstructive pulmonary disease (COPD) (38 % vs. 12 %, respectively; p < 0.01), previous "structural" cardiopathy (dilated and/or hypertrophic and/or hypokinetic cardiopathy and/or significant valvular disease, 9 % vs. 25 %, respectively; p < 0.01), obesity (45 % vs. 17 %, respectively; p < 0.01), and low left ventricular ejection fraction (55 % vs. 21 %, respectively; p = 0.01). At logistic regression, COPD (odds ratio (OR) 8.7, 95 % confidence interval (CI) 2.0-37.3), previous structural cardiopathy (OR 4.5, 95 % CI 1.4-14.1), and obesity (OR 3.6, 95 % CI 1.2-12.6) were independent risk factors for experiencing at least one episode of WiPO. In 16 cases with WiPO and a negative PLR at baseline, treatment including diuretics was started. In 9 of these cases, the PLR remained negative before the following SBT. A new episode of WiPO occurred in 7 of these instances, while the two other were extubated. In 7 other cases, the PLR became positive before the following SBT. WiPO did not occur anymore in 6 of these 7 patients who were extubated, while the remaining one was not.


CONCLUSIONS
In our population of critically ill patients, WiPO was responsible for 59 % of weaning failures. COPD, previous "structural" cardiopathy, and, to a lesser extent, obesity were the main risk factors. When a treatment including fluid removal had changed preload-independence to preload-dependence, the following SBT was very likely to succeed.
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.|AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.|Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.|Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Jinglun
J
Liu
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.|AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.|Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.|Department of Critical Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, China.
Feng
F
Shen
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.|AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.|Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
Jean-Louis
JL
Teboul
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.|AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.|Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
Nadia
N
Anguel
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.|AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.|Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
Alexandra
A
Beurton
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.|AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.|Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
Nadia
N
Bezaz
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.|AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.|Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
Christian
C
Richard
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France. xavier.monnet@aphp.fr.|AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France. xavier.monnet@aphp.fr.|Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France. xavier.monnet@aphp.fr.
Xavier
X
Monnet
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006331:Heart Diseases / Q000175:diagnosis / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D011654:Pulmonary Edema / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D012121:Respiration, Artificial / Q000009:adverse effects* / Q000379:methods; D012307:Risk Factors; D013815:Thermodilution / Q000379:methods; D016896:Treatment Outcome; D015300:Ventilator Weaning / Q000009:adverse effects* / Q000379:methods
COPD; Diuretics; Heart-lung interactions; Mechanical ventilation; Pulmonary oedema; Weaning