Introduction
Pathophysiological considerations
Identification of patients at high risk of weaning failure of cardiovascular origin
Diagnostic methods to detect cardiovascular dysfunction in patients with difficult weaning
Pulmonary artery catheterization
Critical care echocardiography
Transthoracic echocardiography
Chest ultrasonography
Electrocardiogram
Biochemical indices of weaning-induced cardiovascular dysfunction
Blood volume contraction markers
Extravascular lung water
Passive leg raising
Treatment strategies in weaning failure of cardiovascular origin
Study (References) | No. of patients | Study population diagnosis | Agent (class) | Indication given for | Effect | Main findings/comments |
---|---|---|---|---|---|---|
Lemaire et al. [6] | 15 | COPD with concomitant cardiovascular disease | Furosemide (loop of Henle diuretic) | Increased preload/fluid management/Hypervolemia | Preload reduction | 9/15 patients were successfully weaned |
Aubier et al. [81] | 8 | COPD | Dopamine (catecholamine) 10 µg/kg | Impaired diaphragmatic function | Some vasopressor, increase splanchnic blood flow | Results of weaning outcome not reported |
Valtier et al. [21] | 6 | Coronary artery disease | Enoximone (phosphodiesterase -3 inhibitor) | LV dysfunction | Prevention of weaning-induced LV dysfunction | 5/6 patients were successfully weaned |
Paulus et al. [20] | 9 | LV failure after cardiac surgery | Enoximone (phosphodiesterase -3 inhibitor) 30 µg/kg/min followed by 10 µg/kg/min | LV failure | Increase in cardiac index, no change in PAOP | 7/9 patients were successfully weaned |
Duane et al. [99] | 1 | Trauma patient with coronary artery disease | Esmolol IV (beta-blockers) 500 µg followed by 50–100 µg/kg/min | Tachycardia, hypertension and pulmonary edema upon spontaneous breathing | Normal heart rate and systolic blood pressure | Successfully weaned |
Adamopoulos et al. [98] | 2 | Postoperative patients with hypertrophic obstructive cardiomyopathy | Atenolol 200 mg/day (beta-blockers) + Diltiazem 300 mg/day (calcium channel blocker) | hypertrophic obstructive cardiomyopathy | Decreased dynamic LV obstruction (induced by catecholamines), improved LV compliance | Successfully weaned |
Ng et al. [95] | 1 | Secondary pulmonary hypertension and RV dysfunction | Sildenafil (Phosphodiesterase-5 inhibitor) 12.5–25 mg 3 times/day | severe pulmonary hypertension | Decrease in PAP and PVR | Successfully weaned from INO and mechanical ventilation |
Stanopoulos et al. [19] | 3 | COPD | Sildenafil (Phosphodiesterase-5 inhibitor) 50 mg | Pulmonary hypertension | Decrease in PAP and PAOP | Successfully weaned |
Sterba et al. [17] | 12 | Patients with LVEF < 40% | Levosimendan (Calcium sensitizer) 0.108–0.21 μg/kg/min, loading dose 12 µg/kg in 6 patients | Impaired LVEF | Increase in LVEF | 7/12 successfully weaned |
Meaudre et al. [88] | 1 | Dilatated cardiomyopathy | Levosimendan (Calcium sensitizer) loading dose 12 µg/kg followed by 0.1 µg/kg/min × 24 h | Impaired LVEF High LV filling pressures | Increase in LVEF and a decrease in cardiac filling pressures | Successfully weaned |
Routsi et al. [18] | 12 | COPD exhibiting systemic arterial hypertension during SBT | Nitroglycerin (vasodilator) 40–600 µg/min | Increased LV afterload | Decrease in LV filling pressures and afterload | 10/12 patients successfully weaned |
Ouanes-Besbe et al. [83] | 10 | COPD and normal LVEF | Dobutamine (beta-agonist) 7µ/kg/min followed by Levosimendan (Calcium sensitizer) 0.2µ/kg/min × 24 h | PAOP increase ≥ 10 mmHg during SBT | PAOP and PAP increased to a lesser extent with Levosimendan than with Dobutamine | Successfully weaned Dobutamine increased the rate-pressure product (No indication according to guidelines [39],(see text) |
Elias et al. [94] | 1 | Interstitial lung disease, pulmonary hypertension | Sildenafil (Phosphodiesterase-5 inhibitor) 20–30 mg3 times/day | Severe pulmonary hypertension and a patent foramen ovale | Decrease in PAP | Successfully weaned from INO and mechanical ventilation |
Mekontso Dessap et al. [65]a | 304 | General ICU patients eligible for weaning. BNP-driven or physician-driven fluid management | Furosemide (loop of Henle diuretic) ± Acetazolamide sodium (carbonic anhydrase inhibitor) | Fluid overload | More negative fluid balance in BNP-guided group | Shorter duration of MV in BNP-guided approach. Strongest effect in patients with LV systolic dysfunction |
Cateano et al. [89] | 1 | Aortic stenosis, LV systolic dysfunction | Levosimendan (Calcium sensitizer) 0.1 µg/kg/min × 24 h | LV systolic dysfunction | LV systolic function and mean aortic gradient increased | Successfully weaned |
Mongodi et al. [56] | 1 | COPD, arterial hypertension, rheumatoid arthritis | Ramipril (angiotensin-converting enzyme inhibitors) 2.5 mg/die, Nebivolol (beta-blockers) 5 mg/die)and mild negative water balance | LV diastolic dysfunction, LUS consistent with increased EVLW | Reduced LV filling pressures and normal LUS | Successfully weaned |