comparison between extravascular lung water, b-type natriuretic peptide and blood volume contraction...
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Comparison between Extravascular lung water, B-type natriuretic peptide and blood volume
contraction to detect weaning-induced pulmonary edema
M. Dres, J-L. Teboul, N. Anguel, L. Guerin, C. Richard, X. Monnet
Service de réanimation médicale, Hôpitaux universitaires Paris-Sud, Hôpital de BicêtreEA4533, Université Paris-Sud, Le Kremlin-Bicêtre, France
Prs Xavier Monnet and Jean-Louis Teboul: members of the Medical Advisory Board of Pulsion Medical System
Conflict of interest
Background Methods Results Discussion
Weaning of mechanical ventilationWeaning induced pulmonary edema : frequent and treatable
Teboul JL et al. Crit Care 2010
• Clinical examination• Echocardiography• Biological : Blood volume contraction
B-type natriuretic peptide• Hemodynamic (right heart
catheter)
IND
IREC
TD
IREC
T
• Measure of extravascular lung water
DiscussionBackground Methods Results
Transpulmonary Thermodilution
Cold bolus
EVLWGEDVPVPI…
time
ΔTemp
Background Methods Results Discussion
To detect weaning induced pulmonary edema by showing an increase in extravascular lung water
Hypothesis:
1
To confirm the ability of an increase in BNP and in plasma protein concentration and hemoglobin to diagnose weaning induced pulmonary edema
2
Background Methods Results Discussion
During a SBT performed
24 hours after the failure of a first SBT
Patients with right heart catheter
1.
2.
3.
Patients ready to be weaned
Measurement of EVLW BNPPlasma protein concentration hemoglobin PAOP
Weaning induced pulmonary edema : clinical intolerance + PAOP ≥18 mmHg
SBT on T-tube during 60 minutes
Baseline End of SBT
Background Methods Results Discussion
36 SBTs
Primary analysis
Background Methods Results Discussion
Changes in EVLW during spontaneous breathing trial
Background Methods Results Discussion
Changes in plasma protein concentration during spontaneous breathing trial
Background Methods Results Discussion
Changes in hemoglobin during spontaneous breathing trial
Background Methods Results Discussion
Changes in B-type natriuretic peptide during spontaneous breathing trial
Background Methods Results Discussion
Diagnostic performance for the detection of weaning induced pulmonary edema
Weaning-induced changes inplasma protein concentration
Weaning-induced changes inhemoglobin concentration
Weaning-induced changes inextravascular lung water
Weaning-induced changes inB-type natriuretic peptide
0 20 40 60 80 1000
20
40
60
80
100
100 - Specificity
Sens
iti vit y
0 20 40 60 80 1000
20
40
60
80
100
100 - Specificity
Sens
iti vit y
0 20 40 60 80 1000
20
40
60
80
100
100 - Specificity
Sens
iti vit y
0 20 40 60 80 1000
20
40
60
80
100
100- Specificity
Sens
iti vit y
AUC 0.96
AUC 0.76
6%
14%
AUC 0.97
AUC 0.89
Background Methods Results Discussion
Limits of the study
Performance of BNP : pro-BNP?
Strengths of the study
Gold standard method to diagnose weaning induced pulmonary edema
Confirmation of the physiological approach by showing blood volume contraction
SBT on T-tube. Pressure support level?
Transpulmonary thermodilution enables to detect
increase in extravascular lung water
during weaning induced pulmonary edema
Blood volume contraction confirmed its relevance as an
Non invasive alternative tool in this context
Conclusion
Background Methods Results Discussion
12%
Background Methods Results Discussion
Weaning induced PE +
Weaning induced PE -