The impact of heart, lung and diaphragmatic ultrasound on prediction of failed extubation from mechanical ventilation in critically ill patients: a prospective observational pilot study

Abstract

BackgroundFailed extubation from mechanical ventilation in critically ill patients is multifactorial, complex and not well understood. We aimed to identify whether combined transthoracic echocardiography, lung and diaphragmatic ultrasound can predict extubation failure in critically ill patients.ResultsFifty-three participants who were intubated > 48 h and deemed by the treating intensivist ready for extubation underwent a 60-min pre-extubation weaning trial (pressure support ≤ 10 cmH2O and positive end expiratory pressure 5 cmH2O). Prior to extubation, data collected included ultrasound assessment of left ventricular ejection fraction, left atrial area, early diastolic trans-mitral flow velocity wave (E), early diastolic trans-mitral flow velocity wave/late diastolic trans-mitral flow velocity wave (E/A), early diastolic trans-mitral flow velocity wave/early diastolic mitral annulus velocity (E/E′), interatrial septal motion, lung loss of aeration score and diaphragm movement. At the end of the weaning trial, the rapid shallow breathing index and serum B-type natriuretic peptide concentration were measured. Success and failure of weaning was assessed by defined criteria. Decision to extubate was at the discretion of the treating intensivist. Failure of extubation was defined as re-intubation, non-invasive ventilation or death within 48 h after extubation. Of 53 extubated participants, 11 failed extubation. Failed extubation was associated with diabetes, ischaemic heart disease, higher E/E′ (OR 1.27, 95% CI 1.05–1.54), left atrial area (OR 1.14, CI 1.02–1.28), fixed rightward curvature of the interatrial septum (OR 12.95, CI 2.73–61.41), and higher loss of aeration score of anterior and lateral regions of the lungs (OR 1.41, CI 1.01–1.82).ConclusionsFailed extubation in mechanically ventilated patients is more prevalent if markers of left ventricular diastolic dysfunction and loss of lung aeration are present.

Lung ultrasound score before and after extubation for predicting weaning outcome

“…LUS can aid to assess lung water volume overload in a timely manner and non-invasive, quick way to predict post-extubation failure. 9 LUS finding in our study prior to extubation was normal with no other associated pathological signs. Mean LUS score before and after extubation was highly significant except in one failed extubation case.…”

Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 2

“…The association between lung de-recruitment and weaning failure was emphasized by Jabaudon et al who found a loss of aerated lung mass to be the only predictor of weaning failure [13]. In addition to corroborating all of the above, Haji et al also pointed out the clinical relevance of LUS examination in predicting weaning outcome [14].…”

Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management

“…Bouhemad showed to be accurate the use of the lung ultrasound reaeration score for the use of antibiotics in ventilator-associated pneumonia [ 60 ]. Haji et al showed parameters lung (loss of aeration score of the left and right anterior and lateral regions) and parameters cardiac through diastolic dysfunction (left atrial area, E/E′, interatrial septal rightward fixed curvature) to help predict failed extubation [ 49 ]. Echocardiography should be further explored in this population because the risk of swings and changes in heart-lung interaction can influence the success of weaning from MV [ 38 , 78 ].…”