Lung aeration loss as a predictor of reintubation using lung ultrasound in mechanically ventilated patients

ABSTRACT

Optimal time to wean from mechanical ventilation remains a challenge in most critically ill patients. There have been studies looking at the factors that aid weaning from mechanical ventilation; however the results have been variable. Recent evidence suggests lung ultrasound can predict successful weaning from mechanical ventilation. This study assesses the ability of the lung aeration scoring using LUS to predict successful weaning in critically ill patients This prospective, observational and non-interventional study was performed in a general ICU in a large university hospital over a period of 6 months. We included all patients who needed mechanical ventilation for more than 48 hours (n=50) and were eligible for Spontaneous Breathing Trial. LUS was performed during SBT and lung aeration Scoring was calculated in 12 lung regions. Points were allocated according to the worst ultrasound pattern observed: N (normal lung pattern) = 0, B1 lines (multiple well-defined B lines) =1, B2 lines (multiple coalescent B Lines) = 2, c (consolidation or atelectasis) = 3. Relevant data were collected from patients, including demographic and LUS aeration scoring in a standardized case report form. Patients were divided into two groups: Group 1 and Group 2 based on the failure and success in weaning, respectively. The LUS aeration scoring was applied to both groups to assess the predictability of weaning failure. Lung aeration scores were significantly higher in patients in Group F compared to Group S (p<0.01). The sensitivity, specificity for failed extubation for an LUS score of more than 18 is 88.89 and 86.96 respectively Lung aeration score using lung ultrasound can predict weaning failure in critically ill patients. Our study showed that an LUS score of more than 18 has a good prediction value. However larger randomized controlled trials are required to validate this pilot study.

Keywords: lung ultrasound; mechani­cal ventilation; reintubation; weaning; spontaneous breathing trial

REFERENCES

1. Esteban A, Alia I, Ibanez J, Benito S, Tobin MJ. Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. Chest 1994; 106: 1188–93.
2. Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, et al. Mechanical Ventilation International Study Group. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002; 287: 345–55.
3. Bouhemad B, Liu ZH, Arbelot C, Zhang M, Ferarri F, Le-Guen M, et al. Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia. Crit Care Med 2010; 38(1): 84-92.
4. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, et al. International Liaison Committee on Lung Ultrasound (ILC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Int Care Med 2012; 38(4): 577-91.
5. Lamia B, Maizel J, Ochagavia A, et al: Echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation. Crit Care Med 2009; 37:1696–1701.
6. Richard C, Teboul JL: Weaning failure from cardiovascular origin. Intensive Care Med 2005; 31:1605–1607.
7. J-M. Boles*, J. Bion, A. Connors, M. Herridge, B. Marsh, C. Melot, R. Pearl, H. Silverman, M. Stanchina, A. Vieillard-Baron, T. Welte: Weaning failure from mechanical ventilation. Eur Respir J 2007; 29: 1033–1056.
8. Biggerstaff BJ (2000) Comparing diagnostic tests: a simple graphic using likelihood ratios. Stat Med 19:649–663
9. Sateesh Pujari and Estari Mamidala (2015). Anti-diabetic activity of Physagulin-F isolated
   from Physalis angulata fruits. The Ame J Sci & Med Res, 2015,1(1):53-60.
   doi:10.17812/ajsmr2015113.
10. Greiner M, Pfeiffer D, Smith RD (2000) Principles and practical application of the receiver-operating characteristic analysis for diagnostic tests. Prev Vet Med 45:23–41.
11. Jaeschke R, Guyatt GH, Sackett DL (1994) Users’ guides to the medical literature: how to use an article about a diagnostic test; are the results of the study valid? JAMA 271:389–391.
12. Tobin MJ, Alex CG. Discontinuation of mechanical ventilation. In: Tobin MJ, editor. Principles and practice of mechanical ventilation. New York: McGraw Hill; 1994. p. 1177-206
13. Liu Y, Wei LQ, Li GQ, Lv FY, Wang H, Zhang YH, et al. A decision-tree model for predicting extubation outcome in elderly patients after a successful spontaneous breathing trial. Anesth Analg 2010; 111(5):1211–1218.
14. MacIntyre NR, Cook DJ, Ely EW Jr., Epstein SK, Fink JB, Heffner JE, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120(6 Suppl):375S–395S. Also in: Respir Care 2002;47(2):69-90
15. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033-56
16. Lichtenstein DA, Meziere GA, Lagoueyte JF, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. 2009; 17:1014–1020.
17. Philipp Enghard, Sibylle Rademacher, Jens Nee, Dietrich Hasper, Ulrike Engert, Achim Jörres and Jan M Kruse. Simplified lung ultrasound protocol shows excellent prediction of extravascular lung water in ventilated intensive care patients. Critical Care. 2015; 19:36.
18. Mayo JR, Aldrich J, Muller NL: Radiation exposure at chest CT: A statement of the Fleischner Society. Radiology 2003; 228:15–21.
19. Mallamaci F, Benedetto FA, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C. Detection of pulmonary congestion by chest ultrasound in dialysis patients. JACC Cardiovasc Imaging. 2010; 17:586–594.
20. Sergio L Zanotti Cavazzoni* and R Phillip Dellinge. Hemodynamic optimization of sepsis-induced tissue hypoperfusion. Critical Care 2006, 10(Suppl 3):S2.
21. Upadya A1, Tilluckdharry L, Muralidharan V, Amoateng-Adjepong Y, Manthous CA. Fluid balance and weaning outcomes. Intensive Care Med. 2005 Dec;31(12):1643-7. Epub 2005 Sep 29.
22. Voga G: Early and simple detection of diastolic dysfunction during weaning from mechanical ventilation. Critical Care 2012,16:137
23. Marelich GP1, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2000 Aug; 118(2):459-67.