ROLE OF LUNG ULTRASOUND DURING WEANING IN PATIENT WITH MITRAL REGURGITATION POST ANGIOPLASTY
Keywords:acute coronary syndrome, mechanical ventilation, mitral regurgitation, lung ultrasound, spontaneous breathing trial, respiratory failure
AbstractBackground: We hypothesize that a change in lung ultrasound score (LUS) can assist in the early diagnosis of weaning-induced respiratory failure (RF). The objective of this study was to determine the utility of LUS in weaning patients with mitral regurgitation (MR) from mechanical ventilation (MV). Methods: This prospective observational study included patients with acute coronary syndrome (ACS) who required invasive MV after angiography/angioplasty. Echocardiography was performed and MR was recorded. When the patient was considered ready for extubation, a spontaneous breathing trial (SBT) was performed and pre- and post-SBT LUS was calculated. Patients who successfully passed the SBT were extubated and followed up for 48 hours for the signs of RF and outcomes. Results: We enrolled 215 patients, out of which MR occurred in 51(23.7%) patients. On post-SBT lung ultrasound, patients with MR were more likely to have B2 lines compared to those without MR; 15.7% vs. 3.7%; p=0.002 and mean LUS was significantly higher for patients with MR as compared to patients without MR; 2.75±3.21 vs. 1.37± 2.02; p<0.001. Post-extubation RF and mean CCU stay were significantly higher in MR patients, 49.0% (25) vs. 32.3% (53); p=0.030 and 3.53±1.54 days vs. 2.41±1.1 days; p<0.001 respectively. However, re-intubation and coronary care unit (CCU) mortality rate were not significantly different between patients with and without MR; 7.8% (4/51) vs. 3.7% (6/164); p=0.215, and 5.9% (3/51) vs. 3% (5/164); p=0.35 respectively. Conclusions: Bedside LU is a convenient tool to detect changes in cardiopulmonary interactions during weaning for patients with MR post-ACS.
Piérard LA, Carabello BA. Ischaemic mitral regurgitation: Pathophysiology, outcomes and the conundrum of treatment. Eur Heart J 2010;31(24):2996–3005.
Chaput M, Handschumacher MD, Tournoux F, Hua L, Guerrero JL, Vlahakes GJ, et al. Mitral leaflet adaptation to ventricular remodeling: Occurrence and adequacy in patients with functional mitral regurgitation. Circulation 2008;118(8):845–52.
Bursi F, Enriquez-Sarano M, Nkomo VT, Jacobsen SJ, Weston SA, Meverden RA, et al. Heart failure and death after myocardial infarction in the community: The emerging role of mitral regurgitation. Circulation 2005;111(3):295–301.
Thille AW, Richard JCM, Brochard L. The decision to extubate in the intensive care unit. Am J Respir Crit Care Med 2013;187(12):1294–302.
Lemaire F, Teboul JL, Cinotti L, Giotto G, Abrouk F, Steg G, et al. Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 1988;69(2):171–9.
Teboul JL. Weaning‑induced cardiac dysfunction: where are we today? Intensive Care Med 2014;40(8):1069–79.
Dres M, Teboul JL, Anguel N, Guerin L, Richard C, Monnet X. Passive leg raising performed before a spontaneous breathing trial predicts weaning‑induced cardiac dysfunction. Intensive Care Med 2015;41(4):487–94.
Vallabhajosyula S, Kashani K, Dunlay SM, Vallabhajosyula S, Vallabhajosyula S, Sundaragiri PR, et al. Acute respiratory failure and mechanical ventilation in cardiogenic shock complicating acute myocardial infarction in the USA, 2000–2014. Ann Intensive Care 2019;9(1):96.
Lamas GA, Mitchell GF, Flaker GC, Smith SC, Jr, Gersh BJ, Basta L, et al. Clinical significance of mitral regurgitation after acute myocardial infarction. Survival and ventricular enlargement investigators. Circulation 1997;96(3):827–33.
Bellone A, Barbieri A, Ricci C, Iori E, Donateo M, Massobrio M, et al. Acute effects of non-invasive ventilatory support on functional mitral regurgitation in patients with exacerbation of congestive heart failure. Intensive Care Med 2002;28(9):1348–50.
Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005;366(9484):472–7.
Al-Kharrat T, Zarich S, Amoateng-Adjepong Y, Manthous CA. Analysis of observer variability in measurement of pulmonary artery occlusion pressures. Am J Respir Crit Care Med 1999;160(2):415–20.
Ait-Oufella H, Tharaux PL, Baudel JL, Vandermeersch S, Meyer P, Tonnellier M, et al. Variation in natriuretic peptides and mitral flow indexes during successful ventilatory weaning: a preliminary study. Intensive Care Med 2007;33(7):1183–6.
Gerbaud E, Erickson M, Grenouillet-Delacre M, Beauvieux MC, Coste P, Durrieu-Jaïs C, et al. Echocardiographic evaluation and N-terminal pro-brain natriuretic peptide measurement of patients hospitalized for heart failure during weaning from mechanical ventilation. Minerva Anestesiol 2012;78(4):415–25.
Caille V, Amiel JB, Charron C, Belliard G, Vieillard-Baron A, Vignon P. Echocardiography: a help in the weaning process. Crit Care 2010;14(3):1–7.
Ferré A, Guillot M, Lichtenstein D, Mezière G, Richard C, Teboul JL, et al. Lung ultrasound allows the diagnosis of weaning-induced pulmonary oedema. Intensive Care Med 2019;45(5):601–8.
Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, et al. Bedside lung ultrasound in the assessment of alveolar‑interstitial syndrome. Am J Emerg Med 2006;24(6):689–96.
Fernandez MM, González-Castro A, Magret M, Bouza MT, Ibañez M, García C, et al. Reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial reduces reintubation in critically ill patients. Intensive Care Med 2017;43(11):1660–7.
Soummer A, Perbet S, Brisson H, Arbelot C, Constantin JM, Lu Q, et al. Lung Ultrasound Study Group. Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress. Crit Care Med 2012;40(7):2064–72.
Richard C, Teboul JL. Weaning failure from cardiovascular origin. Intensive Care Med 2005;31(12):1605–7.
Vignon P. Ventricular diastolic abnormalities in the critically ill. Curr Opin Crit Care 2013;19(3):242–9.
Ruiz-Bailén M, Cobo-Molinos J, Castillo-Rivera A, Pola-Gallego-de-Guzmán MD, Cárdenas-Cruz A, Martínez-Amat A, et al. Stress echocardiography in patients who experienced mechanical ventilation weaning failure. J Crit Care 2017;39:66–71.
Rasanen J, Howie MB. Mitral regurgitation during withdrawal of mechanical ventilatory support. J Cardiothorac Anesth 1988;2(1):60–3.
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.