1. Weaning failure of cardiac origin
Prof. Jean-Louis TEBOUL
Medical ICU
Bicetre Hospital
University Paris-South
France

2. Weaning-induced pulmonary edema may develop
Invasive or non invasive positive pressure ventilation
is an established treatment
of severe cardiogenic pulmonary edema
TREATMENT OF SEVERE CARDIOGENIC PULMONARY EDEMA WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DELIVERED BY FACE MASK
Weaning-induced pulmonary edema
may develop
and may be a cause of weaning failure
in predisposed patients

3. PAOPtm
mmHg 60 50 40 30 20 10 MV SB

4. Weaning-induced increase in PAOP

9. LV end diastolic pressureB
LV end diastolic volume

13. Radionuclide angiocardiography
Left ventricular function during weaning of patients with COPD
Richard C, Teboul JL, Archambaud F et al.
Intensive Care Med 1994; 20 : 181-6
LVEF (%)
Radionuclide angiocardiography
during weaning
in COPD patients
without CAD
MV1 SV MV2

15. LV end diastolic pressure
reduced compliance
normal compliance A C B
LV end diastolic volume

20. Who are the patients at risk of weaning failure
from cardiac origin ?
Patients with LV disease (CAD)
Increased RV and LV preload
and increased LV afterload
and associated COPD
Deep inspiratory fall in intrathoracic pressure and elevated WOB
airway obstruction
Increased cardiac work
and thus, increased
risk of myocardial ischemia
biventricular interdependence
Decreased LV compliance

21. When should cardiac-related weaning failure be suspected?
. when CHF and COPD coexist
. when other obvious causes of weaning failure
have been discarded

22. How to diagnose weaning-induced pulmonary edema?
Weaning trial: T-piece or low level of Pressure support
PA catheter ?
increase in PAOP

23. How to diagnose weaning-induced pulmonary edema?
Weaning trial: T-piece or low level of Pressure support
PA catheter ?
Transpulmonary thermodilution?
Elevation of EVLW

24. Crit Care Med 2014
Cut-off: 6%
AUC = 0.89

25. How to diagnose weaning-induced pulmonary edema?
Weaning trial: T-piece or low level of Pressure support
PA catheter ?
Transpulmonary thermodilution?
Doppler-echo ?
E/A and E/E’
assumed to reflect PAOP

26. E A A’ E’ Apical 4-chamber view Pulsed wave Doppler Tissue Doppler or
Doppler criteria for classification of diastolic function. Modified with permission from Redfield et al.15 A’ E’ or 26

27. E E’ E A A’ E’ LV filling pressure determinants LV relaxation reflects
Doppler criteria for classification of diastolic function. Modified with permission from Redfield et al.15 A’ E’ or 27

28. Can E/A and E/E’ at the end of a Spontaneous Breathing Trial
identify weaning failure from cardiac origin
defined as a weaning-induced increase
in PAOP > 18 mmHg?

29. of each of these variables was not sufficiently acceptable
E/A at the end of the SBT
E/E’ at the end of the SBT
The predictive value
of each of these variables
was not sufficiently acceptable
to diagnose weaning-induced
pulmonary edema
4.0 20 18
3.5 16
3.0 14
2.5 12
2.0 10
8.5 8
1.5
0.95 6
1.0 4
0.5 2
PE -
PE +
PE -
PE +

30. Combination of E/A > 0.95 and E/E’ > 8.5 at the end of a SBT
PE +
defined as a PAOP > 18 mmHg at the end of a SBT
Se = 82%
Sp = 91%
PPV = 88%
NPV = 87%
PE - 20 20 20 18 18 18
Combination of E/A > 0.95 and E/E’ > 8.5
at the end of a SBT
predicted weaning-induced pulmonary edema
with a high accuracy 16 16 16 14 14 14
the end of the SBT 12 12 12 10 10 10
8.5 at 8 8 8
E/E’ 6 6 6 4 4 4
0.95 2 2 2 - - - 1 1 1 1 1 1 2 2 2 3 3 3 4 4 4
E/A
E/A at at
the end of the SBT

31. How to diagnose weaning-induced pulmonary edema?
Weaning trial: T-piece or low level of Pressure support
PA catheter ?
Transpulmonary thermodilution ?
Doppler-echo ?
BNP or NT-proBNP ?

32. * MV SB MV SB Crit Care Med 2014 weaning-induced pulmonary edema
no weaning-induced
pulmonary edema

33. Crit Care Med 2014
AUC = 0.76
 BNP

34. How to diagnose weaning-induced pulmonary edema?
Weaning trial: T-piece or low level of Pressure support
PA catheter ?
Transpulmonary thermodilution ?
Doppler-echo ?
BNP or NT-proBNP ?
Hemoconcentration ?

35. Increase in plasma protein concentration during weaning could detect
Hydrostatic pulmonary edema
Increase in plasma protein concentration
during weaning could detect
weaning-induced pulmonary edema
Hemoconcentration

36. 59 52 Weaning-induced PO defined as intolerance to SB
and a PAOP > 18 mmHg 59 52

37. SBT-induced change in plasma protein concentration (%)20 18 16
Se = 85 %
Sp= 100 % 14 12 10 8 6 4 2 -2
No weaning-induced P0
Weaning-induced PO
Anguel et al Intensive Care Med 2008

38. Crit Care Med 2014
 Hb
 Plasma Protein
 EVLW
 BNP

39. Which therapy? Phamacological agents
. Diuretics: if pulmonary edema is assumed to be related to increased preload
secondary to increased venous return

40. Am J Respir Crit Care Med 2012; 186:1256-63

41. Am J Respir Crit Care Med 2012; 186:1256-63

42. Time (hrs) to successful weaning
Am J Respir Crit Care Med 2012; 186:
Time (hrs) to successful weaning

43. Which therapy? Phamacological agents
. Diuretics: if pulmonary edema is assumed to be related to increased preload
secondary to increased venous return
. Nitrates: if suspicion of myocardial ischemia

44. Control day Systolic Arterial Pressure PAOP MV SBTstart SBTend MV
mmHg
Control day MV
SBTstart
SBTend MV
SBTstart
SBTend

45. Control day PAOP mmHg Study day IV nitrates starting at the beginning
Systolic Arterial Pressure
mmHg
SBTstart MV
SBTend
PAOP mmHg
Control day
Study day
IV nitrates starting
at the beginning
of the SBT

46. Which therapy? Phamacological agents
. Diuretics: if pulmonary edema is assumed to be related to increased preload
secondary to increased venous return
. Nitrates: if suspicion of myocardial ischemia
. Vasodilators: if suspicion of increased LV afterload

47. Which therapy? Phamacological agents
. Diuretics: if pulmonary edema is assumed to be related to increased preload
secondary to increased venous return
. Nitrates: if suspicion of myocardial ischemia
. Vasodilators: if suspicion of increased LV afterload
. Inotropes: not logical!

48. PS + PEEP Which therapy? Ventilatory modalities
. Decremental levels of PS
and keeping 5 to 8 cmH2O of PEEP
. Continue after extubation (facial mask)

49. Conclusion weaning failure from cardiac origin is not uncommon
. In case of preexisting cardiac disease,
weaning failure from cardiac origin is not uncommon
. Complex and intricate mechanisms (vicious circle) generated
by marked increased respiratory muscles activity
. Its recognition is important since a specific therapy
(after individualized evaluation) can result in successful weaning
Thank you