Cardiovascular failure and weaning

Cardiac patients are at high risk of weaning failure due to the abrupt burden to the cardiovascular system resulting from the transition from positive-pressure ventilation to spontaneous breathing. Similarly, numerous patients with borderline cardiac function, left ventricular diastolic dysfunction, chronic obstructive pulmonary disease, especially with associated fluid overload or cumulative positive fluid balance, are at high risk of weaning failure of cardiac origin. The diagnosis of weaning-induced pulmonary oedema (WiPO) relies on the measurement of elevated left ventricular filling pressure, or on the presence of a surrogate reflecting pulmonary or cardiac congestion. Plasma concentration of B-type natriuretic peptide and N-terminal proBNP, biological signs of hemoconcentration (increased circulating protein or hemoglobin levels), or measurement of extravascular pulmonary lung water using transpulmonary thermodilution have been proved valuable surrogates for the identification of weaning failure. Nevertheless, studies have not yet compared these indirect methods to precisely determine their respective diagnostic values for the identification of WiPO, especially in heart failure patients. In addition, none of these approaches directly assess left ventricular filling pressure and the mechanism of WiPO. In contrast, critical care echocardiography is ideally suited to establish the diagnosis of weaning failure of cardiac origin. It allows identifying the high-risk population, monitoring hemodynamically the patient at risk, depicting an abrupt increase of left ventricular filling pressure consistent with WiPO when the patient fails weaning, identifying the underlying mechanism of WiPO, and finally it allows tailoring the therapeutic management of the patient who failed weaning. The impact on patient-centered outcomes of such integrated management strategy based on critical care echocardiography deserves to be prospectively tested in a large population of patients at high risk of weaning failure of cardiac origin.