Dres Martin, Teboul Jean-Louis, Anguel Nadia, Guerin Laurent, Richard Christian, Monnet Xavier
1Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France. 2EA4533, Université Paris-Sud, Le Kremlin-Bicêtre, France.
Crit Care Med. 2014 Aug;42(8):1882-9. doi: 10.1097/CCM.0000000000000295.
We tested whether the changes in extravascular lung water indexed for ideal body weight could detect weaning-induced pulmonary edema. We also studied the diagnostic value of blood volume contraction indices and B-type natriuretic peptide variations.
Prospective study.
Twenty-one patients who failed a first spontaneous breathing trial.
None.
We performed a second 60-minute T-tube spontaneous breathing trial. Before and at the end of spontaneous breathing trial, we recorded pulmonary artery occlusion pressure, the extravascular lung water indexed for ideal body weight, plasma B-type natriuretic peptide level, hemoglobin, and plasma protein concentrations. Weaning-induced pulmonary edema was defined by the association of signs of clinical intolerance and a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg at the end of spontaneous breathing trial. Because some patients performed several spontaneous breathing trial, a primary analysis included all spontaneous breathing trial and a secondary analysis included only the first spontaneous breathing trial of each patient. In primary analysis, 36 spontaneous breathing trials were analyzed, 21 spontaneous breathing trial with weaning-induced pulmonary edema and 15 without. During spontaneous breathing trial, extravascular lung water indexed for ideal body weight increased only in cases with weaning-induced pulmonary edema (25% ± 23%). Plasma protein concentration, hemoglobin concentration, and B-type natriuretic peptide also significantly increased only in cases with weaning-induced pulmonary edema (9% ± 3%, 9% ± 4%, 21% ± 23%, respectively). The areas under the receiver operating characteristics curves to detect weaning-induced pulmonary edema were 0.89 (95% CI, 0.78-0.99) for extravascular lung water indexed for ideal body weight, 0.97 (0.93-1.01) for spontaneous breathing trial-induced changes in plasma protein concentration, 0.96 (0.90-1.01) for changes in hemoglobin concentration, and 0.76 (0.60-0.93) for changes in B-type natriuretic peptide. An increase in extravascular lung water indexed for ideal body weight greater than or equal to 14% diagnosed weaning-induced pulmonary edema with a sensitivity of 67% (95% CI, 43-85%) and a specificity of 100% (95% CI, 78-100%). The secondary analysis confirmed these results.
Spontaneous breathing trial-induced increases in extravascular lung water indexed for ideal body weight, plasma protein concentrations, hemoglobin concentration, and B-type natriuretic peptide are reliable alternatives to the pulmonary artery catheter for diagnosing weaning-induced pulmonary edema.
我们测试了以理想体重校正的血管外肺水变化是否能检测出撤机诱发的肺水肿。我们还研究了血容量收缩指标和B型利钠肽变化的诊断价值。
前瞻性研究。
重症监护病房患者：21例首次自主呼吸试验失败的患者。
无。
我们进行了第二次60分钟的T管自主呼吸试验。在自主呼吸试验前及试验结束时，我们记录了肺动脉闭塞压、以理想体重校正的血管外肺水、血浆B型利钠肽水平、血红蛋白及血浆蛋白浓度。撤机诱发的肺水肿定义为自主呼吸试验结束时出现临床不耐受体征且肺动脉闭塞压大于或等于18 mmHg。由于部分患者进行了多次自主呼吸试验，主要分析纳入了所有自主呼吸试验，次要分析仅纳入了每位患者的首次自主呼吸试验。在主要分析中，共分析了36次自主呼吸试验，其中21次试验出现撤机诱发的肺水肿，15次未出现。在自主呼吸试验期间，仅在出现撤机诱发肺水肿的病例中，以理想体重校正的血管外肺水增加（25%±23%）。血浆蛋白浓度、血红蛋白浓度及B型利钠肽也仅在出现撤机诱发肺水肿的病例中显著增加（分别为9%±3%、9%±4%、21%±23%）。用于检测撤机诱发肺水肿的受试者工作特征曲线下面积，以理想体重校正的血管外肺水为0.89（95%CI，0.78 - 0.99），血浆蛋白浓度因自主呼吸试验诱发的变化为0.97（0.93 - 1.01），血红蛋白浓度变化为0.96（0.90 - 1.01），B型利钠肽变化为0.76（0.60 - 0.93）。以理想体重校正的血管外肺水增加大于或等于14%可诊断撤机诱发的肺水肿，敏感性为67%（95%CI，43 - 85%），特异性为100%（95%CI，78 - 100%）。次要分析证实了这些结果。
自主呼吸试验诱发的以理想体重校正的血管外肺水、血浆蛋白浓度、血红蛋白浓度及B型利钠肽增加，是诊断撤机诱发肺水肿的可靠方法，可替代肺动脉导管检查。
