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Poddighe D, Van Hollebeke M, Choudhary YQ, Campos DR, Schaeffer MR, Verbakel JY, Hermans G, Gosselink R, Langer D. Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis. Crit Care 2024; 28:70. [PMID: 38454487 PMCID: PMC10919035 DOI: 10.1186/s13054-024-04823-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures. METHODS Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients. RESULTS Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01). CONCLUSIONS DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted. TRIAL REGISTRATION PROSPERO CRD42020209295, October 15, 2020.
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Affiliation(s)
- Diego Poddighe
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yasir Qaiser Choudhary
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Débora Ribeiro Campos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Prêto, Brazil
| | - Michele R Schaeffer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, EPI-Centre, KU Leuven, Leuven, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Health and Rehabilitation Sciences, Faculty of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
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Mesquida J, Gruartmoner G, Espinal C, Masip J, Sabatier C, Villagrá A, Gómez H, Pinsky M, Baigorri F, Artigas A. Thenar oxygen saturation (StO 2) alterations during a spontaneous breathing trial predict extubation failure. Ann Intensive Care 2020; 10:54. [PMID: 32394211 PMCID: PMC7214564 DOI: 10.1186/s13613-020-00670-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/26/2020] [Indexed: 01/05/2023] Open
Abstract
Background Weaning from mechanical ventilation (MV) is a cardiovascular stress test. Monitoring the regional oxygenation status has shown promising results in predicting the tolerance to spontaneously breathe in the process of weaning from MV. Our aim was to determine whether changes in skeletal muscle oxygen saturation (StO2) measured by near-infrared spectroscopy (NIRS) on the thenar eminence during a vascular occlusion test (VOT) can be used to predict extubation failure from mechanical ventilation. Methods We prospectively studied 206 adult patients with acute respiratory failure receiving MV for at least 48 h from a 30-bed mixed ICU, who were deemed ready to wean by their physicians. Patients underwent a 30-min spontaneous breathing trial (SBT), and were extubated according to the local protocol. Continuous StO2 was measured non-invasively on the thenar eminence. A VOT was performed prior to and at 30 min of the SBT (SBT30). The rate of StO2 deoxygenation (DeO2), StO2 reoxygenation (ReO2) rate and StO2 hyperemic response to ischemia (HAUC) were calculated. Results Thirty-six of the 206 patients (17%) failed their SBT. The remainder 170 patients (83%) were extubated. Twenty-three of these patients (13.5%) needed reinstitution of MV within 24 h. Reintubated patients displayed a lower HAUC at baseline, and higher relative changes in their StO2 deoxygenation rate between baseline and SBT30 (DeO2 Ratio). A logistic regression-derived StO2 score, combining baseline StO2, HAUC and DeO2 ratio, showed an AUC of 0.84 (95% CI 0.74–0.91) for prediction of extubation failure. Conclusions Extubation failure was associated to baseline and dynamic StO2 alterations during the SBT. Monitoring StO2-derived parameters might be useful in predicting extubation outcome.
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Affiliation(s)
- Jaume Mesquida
- Critical Care Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT), Parc Taulí, 1, 08208, Sabadell, Spain. .,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain.
| | - Guillem Gruartmoner
- Critical Care Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT), Parc Taulí, 1, 08208, Sabadell, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Cristina Espinal
- Critical Care Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT), Parc Taulí, 1, 08208, Sabadell, Spain
| | - Jordi Masip
- Critical Care Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT), Parc Taulí, 1, 08208, Sabadell, Spain
| | - Caroline Sabatier
- Critical Care Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT), Parc Taulí, 1, 08208, Sabadell, Spain.,Réanimation Polyvalente, Centre Hospitalier de Pau, Pau, France
| | - Ana Villagrá
- Critical Care Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT), Parc Taulí, 1, 08208, Sabadell, Spain.,Critical Care Department, Osakidetza Basque Health Service, Alava University Hospital, Vitoria-Gasteiz, Spain
| | - Hernando Gómez
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Pinsky
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Francisco Baigorri
- Critical Care Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT), Parc Taulí, 1, 08208, Sabadell, Spain
| | - Antonio Artigas
- Critical Care Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT), Parc Taulí, 1, 08208, Sabadell, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain.,CIBER de Enfermedades Respiratorias, Sabadell, Spain
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Louvaris Z, Van Hollebeke M, Dhaenens A, Vanhemelen M, Meersseman P, Wauters J, Gosselink R, Wilmer A, Langer D, Hermans G. Cerebral cortex and respiratory muscles perfusion during spontaneous breathing attempts in ventilated patients and its relation to weaning outcomes: a protocol for a prospective observational study. BMJ Open 2019; 9:e031072. [PMID: 31676653 PMCID: PMC6830828 DOI: 10.1136/bmjopen-2019-031072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In addition to the well-documented factors that contribute to weaning failure, increased energy demands of the respiratory muscles during spontaneous breathing trials (SBTs) might not be met by sufficient increases in energy supplies. This discrepancy may deprive blood and oxygen of other tissues. In this context, restrictions in perfusion of splanchnic organs and non-working muscles during SBT have been associated with weaning failure. However, alterations in perfusion of the brain during the weaning process are less well understood. OBJECTIVE AND HYPOTHESIS To investigate whether cerebral cortex perfusion evolves differentially during the transition from mechanical ventilation (MV) to spontaneous breathing between patients failing or succeeding the SBT. We hypothesise that patients failing the SBT will exhibit reduced cerebral cortex perfusion during the transition from MV to spontaneous breathing as compared with patients succeeding the SBT. METHODS AND ANALYSIS This single-centre, prospective, observational study will be conducted in a medical Intensive Care unit of University Hospital Leuven, Belgium in ready to wean patients. Blood flow index in the cerebral cortex (prefrontal area), inspiratory (scalene) and expiratory muscle (upper rectus abdominis) and a non-working muscle (thenar eminence) will be simultaneously assessed by near-infrared spectroscopy (NIRS) using the tracer indocyanine green dye. Measurements will be performed on the same day during MV and during SBT. NIRS-derived tissue oxygenation index and cardiac output (by pulse contour analyses) will be recorded continuously. Twenty patients failing an SBT are estimated to be sufficient for detecting a significant difference in the change of cerebral cortex perfusion from MV to SBT (primary outcome) between SBT failure and success patients. ETHICS AND DISSEMINATION Ethics approval was obtained from the local ethical committee (Ethische Commissie Onderzoek UZ/KU Leuven protocol ID: S60516). Results from this study will be presented at scientific meetings and congresses and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03240263; Pre-results.
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Affiliation(s)
- Zafeiris Louvaris
- Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Rehabilitation for Internal Disorders Research Group, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Rehabilitation for Internal Disorders Research Group, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Dhaenens
- Department of General Internal Medicine, University Hospitals Leuven, Medical Intensive Care Unit, Leuven, Belgium
| | - Maarten Vanhemelen
- Department of General Internal Medicine, University Hospitals Leuven, Medical Intensive Care Unit, Leuven, Belgium
| | - Philippe Meersseman
- Department of General Internal Medicine, University Hospitals Leuven, Medical Intensive Care Unit, Leuven, Belgium
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, University Hospitals Leuven, Laboratory for Clinical Infectious and Inflammatory Disorders, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Rehabilitation for Internal Disorders Research Group, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Wilmer
- Department of General Internal Medicine, University Hospitals Leuven, Medical Intensive Care Unit, Leuven, Belgium
| | - Daniel Langer
- Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Rehabilitation for Internal Disorders Research Group, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Department of General Internal Medicine, University Hospitals Leuven, Medical Intensive Care Unit, Leuven, Belgium
- Division of Cellular and Molecular Medicine, Laboratory of Intensive Care Medicine, KU Leuven, Leuven, Belgium
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4
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Research in Latin America: opportunities and challenges. Intensive Care Med 2016; 42:1045-7. [PMID: 27043235 DOI: 10.1007/s00134-016-4342-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 03/22/2016] [Indexed: 12/21/2022]
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Abstract
Weaning patients from mechanical ventilation has been compared to a cardiac stress test. Weaning failure (WF) from a cardiac origin can be common in patients with limited cardiac reserve. Diuretic and vasodilator therapies are indicated for WF due to excessive preload, afterload, or myocardial ischemia. Alteration in intrathoracic pressure and lung volumes may also impact weaning process in a patient with poor cardiac function. Noninvasive ventilation decreases cardiac stress load and should be utilized in weaning patients with poor cardiac reserves. In fact, positive pressure therapy is now the standard of care for treating a patient with acute pulmonary edema and to decrease afterload (Frazier et al. Biol Res Nurs 2000; 1(4): 253-264; Pinsky MR. Chest 2005; 128(5 Suppl 2): 592S-597S.). Recently, biomarkers and echocardiography have been utilized to assess weaning success during spontaneous breathing trials. In this article, we describe the physiological alterations in cardiac and pulmonary systems during the weaning process and its impact on weaning outcome.
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Affiliation(s)
- Jahan Porhomayon
- VA Western New York Healthcare System, Division of Critical Care Medicine, Department of Anesthesiology and Medicine, State University of New York, Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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Abstract
PURPOSE OF REVIEW Mechanical ventilation is a cornerstone of ICU treatment. Because of its interaction with blood flow and intra-abdominal pressure, mechanical ventilation has the potential to alter hepato-splanchnic perfusion, abdominal organ function and thereby outcome of the most critically ill patients. RECENT FINDINGS Mechanical ventilation can alter hepato-splanchnic perfusion, but the effects are minimal (with moderate inspiratory pressures, tidal volumes, and positive end-expiratory pressure levels) or variable (with high ones). Routine nursing procedures may cause repeated episodes of inadequate hepato-splanchnic perfusion in critically ill patients, but an association between perfusion and multiple organ dysfunction cannot yet be determined. Clinical research continues to be challenging as a result of difficulties in measuring hepato-splanchnic blood flow at the bedside. SUMMARY Mechanical ventilation and attempts to improve oxygenation such as intratracheal suctioning and recruitment maneuvers, may have harmful consequences in patients with already limited cardiovascular reserves or deteriorated intestinal perfusion. Due to difficulties in assessing hepato-splanchnic perfusion, such effects are often not detected.
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7
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Failed weaning from mechanical ventilation and cardiac dysfunction. Crit Care Res Pract 2012; 2012:173527. [PMID: 22991658 PMCID: PMC3443576 DOI: 10.1155/2012/173527] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 08/03/2012] [Indexed: 11/17/2022] Open
Abstract
Failure to transition patient from controlled mechanical ventilation to spontaneous breathing trials (SBTs) in a timely fashion is associated with significant morbidity and mortality in the intensive care unit. In addition, weaning failures are common in patients with limited cardiac reserves. Recent advances in cardiac echocardiography and laboratory measurement of serum biomarkers to assess hemodynamic response to SBT may provide additional information to guide clinicians to predict weaning outcome.
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8
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Hamzaoui O, Monnet X, Teboul JL. Sevrage difficile d’origine cardiaque. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0342-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Teixeira C, Tonietto TF, Gonçalves SC, Cremonese RV, De Oliveira RP, Savi A, Oliveira ES, Alves FAC, Brodt SFM, Barth JHD, Machado AS, de Campos Balzano P, Maccari JG, da Silva NB. Noradrenaline Use is Not Associated with Extubation Failure in Septic Patients. Anaesth Intensive Care 2008; 36:385-90. [DOI: 10.1177/0310057x0803600310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Standard clinical practice recommends minimal doses of vasoactive drugs during weaning of patients from mechanical ventilation. However, there are currently no clinical data to inform clinicians about whether the use of noradrenaline during weaning predisposes to weaning failure. The objective of this study was to evaluate whether the necessity of the vasopressor noradrenaline in mechanically ventilated patients recovering from septic shock changed the extubation outcome. A total of 656 patients recovering from septic shock on mechanical ventilation were selected from intensive care units in two university hospitals. Patients receiving noradrenaline at the time of weaning and case-controls not taking noradrenaline were matched for age, gender, haemodynamic and ventilatory parameters, aetiology of respiratory failure and APACHE II score. One hundred and forty-five patients who successfully tolerated a spontaneous breathing trial were extubated while on noradrenaline therapy and the reintubation rate was measured. In the noradrenaline group, the mean dose of noradrenaline during initial shock treatment was 0.52±0.29 μg/kg/min and 0.12±0.10 μg/kg/min during weaning. The reintubation rate was 12/63 (19%) in the noradrenaline group and 15/82 (18.3%) in the control group (P=1.00). Intensive care unit mortality was also similar in both groups (10/63, 15.9%) for noradrenaline patients and (11/82, 13.4%) for control patients (P=0.81). Arterial blood gases and ventilatory and haemodynamic parameters were similar in all patients regardless of weaning success. We did not find that the use of noradrenaline at the time of weaning was associated with extubation failure. Low doses of noradrenaline may not preclude weaning from mechanical ventilation.
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Affiliation(s)
- C. Teixeira
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital and Central ICU Casa Hospital
| | - T. Frederico Tonietto
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - S. Cadaval Gonçalves
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - R. Viegas Cremonese
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - R. Pinheiro De Oliveira
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital and Central ICU Casa Hospital
| | - A. Savi
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - E. Silvestre Oliveira
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensivist
| | - F. André Cardona Alves
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - S. Fernando Monteiro Brodt
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - J. Hervê Diel Barth
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - A. Santana Machado
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - P. de Campos Balzano
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - J. Gasparetto Maccari
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
| | - N. Brandão da Silva
- Intensive Care Unit, Moinhos de Vento Hospital and Central Intensive Care Unit, Santa Casa Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Moinhos de Vento Hospital
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Abstract
Over the past 2 decades, the art of "weaning" from mechanical ventilation has been informed by increasing published basic science and outcomes studies. Although monitoring technologies can provide vast amounts of information before, during, and after liberation from mechanical ventilation, little data exists on how to maximally harness even routinely monitored, basic physiologic parameters. Overdependence on technology and derived variables, without data to demonstrate benefit, may even inhibit the patient's progress if it is used inappropriately. We review the scientific evidence for best using routinely available physiologic data and a few more sophisticated and invasive monitoring technologies during weaning. We also suggest future study designs that would better inform the process of liberation from the ventilator and endotracheal extubation.
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Affiliation(s)
- Jonathan M Siner
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208057, New Haven, CT 06520-8057, USA.
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Abstract
PURPOSE OF REVIEW Tissue dysoxia is now widely regarded as the major factor leading to organ dysfunction in critically ill patients. Recent data suggests that early aggressive resuscitation of critically ill patients, which limits and/or reverses tissue dysoxia may prevent progression to organ dysfunction and improve outcome. The traditional clinical and laboratory markers used to assess tissue dysoxia are, however, insensitive and have numerous limitations. Regional carbon dioxide monitoring appears to be ideally suited to monitoring the adequacy of resuscitation. This review provides an update on this evolving technology. RECENT FINDINGS Gastric intramucosal carbon dioxide as measured by gastric tonometry has proven to be useful as a prognostic marker, in evaluating the response to specific therapeutic interventions and as an end point of resuscitation. Gastric tonometry is, however, cumbersome and has a number of limitations that may have prevented its widespread adoption. The measurement of carbon dioxide in the sublingual mucosa by sublingual capnometry is technically simple, noninvasive, and provides near instantaneous information. Clinical studies have demonstrated a good correlation between gastric intramucosal carbon dioxide and sublingual mucosa carbon dioxide. Sublingual mucosa carbon dioxide responds more rapidly to therapeutic interventions than does gastric intramucosal carbon dioxide and may be a better prognostic marker. SUMMARY Sublingual capnometry may be the ideal technology for guiding early goal directed therapy. This technology may be useful for monitoring tissue oxygenation, titrating therapeutic interventions, and as an end point for resuscitation in critically ill and injured patients.
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Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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Venkatesh B, Morgan TJ, Hall J, Endre Z, Willgoss D. Subcutaneous gas tensions closely track ileal mucosal gas tensions in a model of endotoxaemia without anaerobism. Intensive Care Med 2005; 31:447-53. [PMID: 15703895 DOI: 10.1007/s00134-005-2558-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2003] [Accepted: 01/10/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Few comparative data exist on the responses of the subcutaneous and splanchnic circulations to evolving endotoxic shock. We therefore compared continuous subcutaneous pO(2) (pO(2sc)) and pCO(2) (pCO(2sc)) with simultaneous continuous gut luminal pCO(2) (pCO(2gi)) in an animal model of endotoxaemia and examined whether changes in gas tensions track tissue energy charge (EC). DESIGN Prospective observational study. SUBJECTS Fourteen anaesthetized rats, 7 controls and 7 experimental. INTERVENTIONS Controls were injected with saline, the experimental group with 20 mg/kg Klebsiella endotoxin. pCO(2sc), pO(2sc), and pCO(2gi) were measured continuously. Plasma lactate concentrations were measured at defined periods during the study. After 2 h ileal segments were snap frozen and assayed for tissue EC. MEASUREMENTS AND RESULTS Endotoxaemia resulted in a significant decrease in mean arterial blood pressure (132+/-9 to 71+/-20 mmHg) and pO(2sc) (71+/-23 to 33+/-22 torr) and a significant increase in pCO(2gi) (58+/-10 to 90+/-20 torr) and pCO(2sc) (56+/-6 to 81+/-25 torr). During endotoxaemia pCO(2gi) was directly correlated with pCO(2sc) (R (2)=0.5) and inversely correlated with pO(2sc) (R (2)=0.63). Plasma lactate concentrations were significantly elevated from baseline in the endotoxin limb. The mean EC was not significantly different in the two groups. CONCLUSIONS Both subcutaneous tissue gas tensions and intestinal luminal carbon dioxide tensions are rapidly responsive during evolving hypodynamic endotoxic shock. Alterations in tissue gas tensions were not associated with dysoxia.
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Affiliation(s)
- Bala Venkatesh
- Department of Intensive Care, University of Queensland, Princess Alexandra Hospital, Woolloongabba and Wesley Hospital, Australia.
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Fournell A, Schwarte LA, Kindgen-Milles D, Müller E, Scheeren TWL. Assessment of microvascular oxygen saturation in gastric mucosa in volunteers breathing continuous positive airway pressure. Crit Care Med 2003; 31:1705-10. [PMID: 12794408 DOI: 10.1097/01.ccm.0000063281.47070.53] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Adequate oxygenation of the gastrointestinal mucosa to preserve its barrier function is a basic objective in the prevention of multiple organ failure. Sustaining a positive airway pressure during the entire respiratory cycle remains a cornerstone in the therapeutic regimen to improve systemic oxygenation. Whereas increased systemic oxygenation during breathing continuous positive airway pressure has been shown, the impact of continuous positive airway pressure on regional oxygenation in the gastrointestinal tract has not yet been evaluated. We hypothesized that continuous positive airway pressure decreases microvascular oxygen saturation in gastric mucosa. DESIGN Prospective, randomized study. SETTING University department of anesthesiology. PARTICIPANTS Twelve healthy volunteers. INTERVENTIONS Incremental increases of continuous positive airway pressure (0, 5, and 10 cm H(2)O) and subsequent release of continuous positive airway pressure. MEASUREMENTS AND MAIN RESULTS We continuously measured microvascular oxygen saturation in gastric mucosa by reflectance spectrophotometry. Systemic oxygen saturation, end-tidal Pco(2), respiratory rate, heart rate, and arterial blood pressure were obtained noninvasively. In every volunteer, microvascular oxygen saturation in gastric mucosa was reduced corresponding to the level of continuous positive airway pressure, although systemic variables, especially systemic oxygen saturation, did not change. Continuous positive airway pressure reduced microvascular oxygen saturation in gastric mucosa from 59 +/- 7% (baseline with 0 cm H(2)O continuous positive airway pressure, mean +/- sd) to 54 +/- 8% (p <.05) during 5 cm H(2)O continuous positive airway pressure and to 50 +/- 9% (p <.05) during 10 cm H(2)O continuous positive airway pressure, returning to 59 +/- 7% during spontaneous breathing with 0 cm H(2)O continuous positive airway pressure. End-tidal Pco(2), respiratory rate, as well as hemodynamic variables, remained stable. CONCLUSIONS Reflectance spectrophotometry meticulously monitored changes in microvascular oxygen saturation in gastric mucosa during breathing continuous positive airway pressure. Microvascular oxygen saturation in gastric mucosa decreased with increasing levels of continuous positive airway pressure despite steady systemic variables. These results suggest that the impact of altering airway pressures on splanchnic oxygenation is not mirrored necessarily by concomitant changes in systemic circulation. Moreover, if these findings also apply to critically ill patients, monitoring microvascular oxygen saturation in gastric mucosa would be useful to further optimize the setting of ventilation variables.
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Affiliation(s)
- Artur Fournell
- Department of Anesthesiology, Heinrich-Heine-University, Düsseldorf, Germany
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15
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Abstract
The study of patients being weaned from mechanical ventilation has offered new insights into the physiology of respiratory failure. Assessment of the balance between respiratory muscle strength, work and central drive is essential if difficulty in weaning occurs, and optimisation of these elements may improve the success of weaning. Psychological support of patients and the creation of units specialising in weaning have also resulted in a higher success rate.
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Affiliation(s)
- J Goldstone
- Department of Intensive Care Medicine, University College London Hospitals, The Middlesex Hospital, London, UK.
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16
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Abstract
Inadequate splanchnic perfusion is associated with increased morbidity and mortality, particularly if liver dysfunction coexists. Heart failure, increased intra-abdominal pressure, haemodialysis and the presence of obstructive sleep apnoea are among the multiple clinical conditions that are associated with impaired splanchnic perfusion in critically ill patients. Total liver blood flow is believed to be relatively protected when gut blood flow decreases, because hepatic arterial flow increases when portal venous flow decreases (the hepatic arterial buffer response [HABR]). However, there is evidence that the HABR is diminished or even abolished during endotoxaemia and when gut blood flow becomes very low. Unfortunately, no drugs are yet available that increase total hepato-splanchnic blood flow selectively and to a clinically relevant extent. The present review discusses old and new concepts of splanchnic vasoregulation from both experimental and clinical viewpoints. Recently published trials in this field are discussed.
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Affiliation(s)
- Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital, Bern, Switzerland.
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