Pneumologie 2009; 63(5): 276-281
DOI: 10.1055/s-0028-1119719
Serie: Intensiv- und Beatmungsmedizin

© Georg Thieme Verlag KG Stuttgart · New York

Herz und Weaning

The Heart and WeaningF.  J.  Meyer1 , B.  Schönhofer2
  • 1Abt. Innere Medizin III, Kardiologie, Angiologie, Pneumologie, Universitätsklinikum, Heidelberg
  • 2Klinikum der Region Hannover, Krankenhaus Oststadt-Heidehaus, Abt. Pneumologie und internistische Intensivmedizin, Hannover
Further Information

Publication History

Publication Date:
15 April 2009 (online)

Zusammenfassung

Der Beginn einer maschinellen Beatmung und die Rückkehr zur Spontanatmung (Weaning) induzieren erhebliche Änderungen des intrathorakalen Drucks mit Konsequenzen für die Herz-Kreislauf-Funktion. Trotz dieser bekannten pathophysiologischen Zusammenhänge wird die kardiovaskuläre Situation der Patienten häufig vor und beim Weaning nicht ausreichend beachtet. Die publizierten und in Leitlinien empfohlenen Kriterien für Beginn des Weanings, Extubation und Reintubation sind notgedrungen allgemein gehalten. Die Erkenntnis, dass eine kardiale Dysfunktion ein erfolgreiches Weaning verhindern kann, basiert auf Studien bei Patienten mit bekannter kardiovaskulärer Erkrankung. Tatsächlich haben viele Intensivpatienten eine latente oder noch nicht diagnostizierte kardiale Dysfunktion. Zudem limitiert die intensivmedizinische Grunderkrankung häufig die kardiovaskulären Kompensationsoptionen. Daher scheitert das Weaning bei nicht wenigen Intensivpatienten an einer ungenügenden hämodynamischen Reserve. Diese Arbeit stellt die klinisch relevanten Grundlagen für das erfolgreiche Weaning mit besonderer Berücksichtigung der kardiovaskulären Situation des Patienten dar.

Abstract

The initiation of and weaning from mechanical ventilation with extubation cause significant changes in intrathoracic pressures and have profound consequences for the cardiovascular function. However, in spite of the known pathophysiological relationships, frequently little attention is paid to the cardiovascular situation during the weaning period. The currently available guidelines concerning weaning and extubation/reintubation are based on only limited evidence and are thus rather general. Moreover, recommendations for the cardiovascular management during weaning reflect mainly the pathophysiological rationale. In patients with known cardiac disease, studies have demonstrated the necessity for a prolonged weaning process. On the contrary, many intensive care patients have subclinical or undiagnosed cardiac disease, and cardiovascular compensation mechanisms are frequently hampered by the underlying critical illness. Therefore, in a significant proportion of patients, weaning and extubation attempts fail due to the patient’s limited cardiovascular reserves. This review summarises the relevant information for a successful weaning and extubation with special respect to the cardiovascular function.

Literatur

  • 1 Boles J M, Bion J, Connors A. et al . Weaning from mechanical ventilation.  Eur Respir J. 2007;  29 1033-1056
  • 2 MacIntyre N R, Cook D J, Ely E W. et al . Evidence-based guidelines for weaning and discontinuing ventilatory support.  Chest. 2001;  120 375S-395S
  • 3 Pinsky M R. Cardiovascular issues in respiratory care.  Chest. 2005;  128 592S-597S
  • 4 Jubran A, Mathru M, Dries D. et al . Continuous recordings of mixed venous oxygen saturation during weaning from mechanical ventilation and the ramifications thereof.  Am J Resp Crit Care Med. 1998;  158 1763-1769
  • 5 Lemaire F, Teboul J L, Cinotti L. et al . Acute Left-Ventricular Dysfunction During Unsuccessful Weaning from Mechanical Ventilation.  Anesthesiology. 1988;  69 171-179
  • 6 Chatila W, Ani S, Guaglianone D. et al . Cardiac ischemia during weaning from mechanical ventilation.  Chest. 1996;  109 1577-1583
  • 7 Mohsenifar Z, Hay A, Hay J. et al . Gastric Intramural Ph As A Predictor of Success Or Failure in Weaning Patients from Mechanical Ventilation.  Ann Int Med. 1993;  119 794-798
  • 8 Roussos C, Macklem P R. The respiratory muscles.  N Engl J Med. 1982;  307 786-797
  • 9 Mohsenifar Z, Hay A, Hay J. et al . Gastric Intramural Ph As A Predictor of Success Or Failure in Weaning Patients from Mechanical Ventilation.  Ann Int Med. 1993;  119 794-798
  • 10 Rudiger A, Singer M. Mechanisms of sepsis-induced cardiac dysfunction.  Crit Care Med. 2007;  35 1599-1608
  • 11 Adamopoulos C, Tsagourias M, Arvaniti K. et al . Weaning failure from mechanical ventilation due to hypertrophic obstructive cardiomyopathy.  Intensive Care Med. 2005;  31 734-737
  • 12 Srivastava S, Chatila W, Amoateng-Adjepong Y, Kanagasegar S, Jacob B, Zarich S, Manthous C A. Myocardial ischemia and weaning failure in patients with coronary artery disease: An update.  Crit Care Med. 1999;  27 2109-2112
  • 13 Scheinhorn D J, Hassenpflug M S, Votto J J. et al . Ventilator-dependent survivors of catastrophic illness transferred to 23 long-term care hospitals for weaning from prolonged mechanical ventilation.  Chest. 2007;  131 76-84
  • 14 Lapinsky S E, Mount D B, Mackey D. et al . Management of acute respiratory failure due to pulmonary edema with nasal positive pressure support.  Chest. 1994;  105 229-231
  • 15 Naughton M T, Rahman M A, Hara K. et al . Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure.  Circulation. 1995;  91 1725-1731
  • 16 Vital F MR, Saconato H, Ladeira M T. et al .Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema. Cochrane Database of Systematic Reviews
  • 17 Dickstein K, Cohen S olal, Filippatos G. et al . ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure.  Eur Heart J. 2008;  29 2388-2442
  • 18 MacNee W, Maclay J, McAllister D. Cardiovascular injury and repair in chronic obstructive pulmonary disease.  Proc Am Thorac Soc. 2008;  5 824-833
  • 19 Wise R A, Robotham J L, Summer W R. Effects of spontaneous ventilation on the circulation.  Lung. 1981;  159 175-186
  • 20 Zakynthinos S, Routsi C, Vassilakopoulos T. et al . Differential cardiovascular responses during weaning failure: effects on tissue oxygenation and lactate.  Intensive Care Med. 2005;  31 1634-1642
  • 21 Mohsenifar Z, Hay A, Hay J. et al . Gastric Intramural Ph As A Predictor of Success Or Failure in Weaning Patients from Mechanical Ventilation.  Ann Int Med. 1993;  119 794-798
  • 22 Monnet X, Teboul J L, Richard C. Cardiopulmonary interactions in patients with heart failure.  Curr Opin Crit Care. 2007;  13 6-11
  • 23 Richard C, Teboul J L, Archambaud F. et al . Left-Ventricular Function During Weaning of Patients with Chronic Obstructive Pulmonary-Disease.  Intensive Care Med. 1994;  20 181-186
  • 24 Shen H N, Lin L Y, Chen K Y. et al . Changes of heart rate variability during ventilator weaning.  Chest. 2003;  123 1222-1228
  • 25 Hurford W E, Favorite F. Association of Myocardial-Ischemia with Failure to Wean from Mechanical Ventilation.  Crit Care Med. 1995;  23 1475-1480
  • 26 Frazier S K, Brom H, Widener J. et al . Prevalence of myocardial ischemia during mechanical ventilation and weaning and its effects on weaning success.  Heart & Lung. 2006;  35 363-373
  • 27 Teboul J L, Richard C. How to diagnose weaning-induced pulmonary edema?.  Intensive Care Med. 2006;  32 938
  • 28 Mueller C, Breidthardt T, Laule-Kilian K. et al . The integration of BNP and NT-proBNP into clinical medicine.  Swiss Medical Weekly. 2007;  137 4-12
  • 29 Mekontso-Dessap A, De Prost N, Girou E. et al . B-type natriuretic peptide and weaning from mechanical ventilation.  Intensive Care Med. 2006;  32 1529-1536
  • 30 Ait-Oufella H, Tharaux P L, Baudel J L. et al . Variation in natriuretic peptides and mitral flow indexes during successful ventilatory weaning: a preliminary study.  Intensive Care Med. 2007;  33 1183-1186
  • 31 Chien J Y, Lin M S, Huang Y CT. et al . Changes in B-type natriuretic peptide improve weaning outcome predicted by spontaneous breathing trial.  Crit Care Med. 2008;  36 1421-1426
  • 32 Grasso S, Leone A, DeMichele M. et al . Use of N-terminal pro-brain natriuretic peptide to detect acute cardiac dysfunction during weaning failure in difficult-to-wean patients with chronic obstructive pulmonary disease.  Crit Care Med. 2007;  35 96-105
  • 33 Upadya A, Tilluckdharry L, Muralidharan V. et al . Fluid balance and weaning outcomes.  Intensive Care Med. 2005;  31 1643-1647
  • 34 Streba M, Banerjee A, Mudaliar Y. Prospective observational study of levosimendan and weaning of difficult-to-wean ventilator dependent intensive care patients.  Crit Care Resusc. 2008;  10 182-186
  • 35 Schönhofer B, Wenzel M, Geibel M. et al . Blood transfusion and lung function in chronically anemic patients with severe chronic obstructive pulmonary disease.  Crit Care Med. 1998;  26 1824-1828
  • 36 Schönhofer B, Bohrer H, Kohler D. Blood transfusion facilitating difficult weaning from the ventilator.  Anaesthesia. 1998;  53 181-184
  • 37 Schönhofer B, Sonneborn M, Haidl P. et al . Nocturnal mechanical ventilation after long-term mechanical ventilation.  Med Klin. 1996;  91 27-30
  • 38 Ferrer M, Esquinas A, Arancibia F. et al . Noninvasive ventilation during persistent weaning failure - A randomized controlled trial.  Am J Resp Crit Care Med. 2003;  168 70-76
  • 39 Nava S, Ambrosino N, Clini E. et al . Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease – A randomized, controlled trial.  Ann Int Med. 1998;  128 721-728
  • 40 Carlucci A, Gregoretti C, Squadrone V. et al . Preventive use of non-invasive mechanical ventilation to avoid post-extubation respiratory failure: a randomised controlled study.  Eur Respir J. 2001;  18 Suppl 306
  • 41 Ferrer M, Valencia M, Nicolas J M. et al . Early noninvasive ventilation averts extubation failure in patients at risk – A randomized trial.  Am J Resp Crit Care Med. 2006;  173 164-170
  • 42 Hilbert G, Gruson D, Portel L. et al . Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency.  Eur Respir J. 1998;  11 1349-1353
  • 43 Nava S, Gregoretti C, Fanfulla F. et al . Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients.  Crit Care Med. 2005;  33 2465-2470
  • 44 Gray A, Goodacre S, Newby D E. et al . Noninvasive ventilation in acute cardiogenic pulmonary edema.  N Engl J Med. 2008;  359 142-151
  • 45 Winck J C, Azevedo L F, Costa-Pereira A. et al . Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema – a systematic review and meta-analysis.  Crit Care. 2006;  10 R69
  • 46 Meyer F J, Borst M M, Zugck C. et al . Respiratory muscle dysfunction in congestive heart failure: clinical correlation and prognostic significance.  Circulation. 2001;  103 2153-2158
  • 47 Meyer F J, Lossnitzer D, Kristen A V. et al . Respiratory muscle dysfunction in idiopathic pulmonary arterial hypertension.  Eur Respir J. 2005;  25 125-130

Priv.-Doz. Dr. med. F. Joachim Meyer

Abt. Innere Medizin III
Universitätsklinikum

Im Neuenheimer Feld 410
69120 Heidelberg

Email: Joachim.Meyer@med.uni-heidelberg.de