Neuroventilatory efficiency and extubation readiness in critically ill patients

Ling Liu, Huogen Liu, Yi Yang, Yingzi Huang, Songqiao Liu, Jennifer Beck, Arthur S Slutsky, Christer Sinderby, Haibo Qiu, Ling Liu, Huogen Liu, Yi Yang, Yingzi Huang, Songqiao Liu, Jennifer Beck, Arthur S Slutsky, Christer Sinderby, Haibo Qiu

Abstract

Introduction: Based on the hypothesis that failure of weaning from mechanical ventilation is caused by respiratory demand exceeding the capacity of the respiratory muscles, we evaluated whether extubation failure could be characterized by increased respiratory drive and impaired efficiency to generate inspiratory pressure and ventilation.

Methods: Airway pressure, flow, volume, breathing frequency, and diaphragm electrical activity were measured in a heterogeneous group of patients deemed ready for a spontaneous breathing trial. Efficiency to convert neuromuscular activity into inspiratory pressure was calculated as the ratio of negative airway pressure and diaphragm electrical activity during an inspiratory occlusion. Efficiency to convert neuromuscular activity into volume was calculated as the ratio of the tidal volume to diaphragm electrical activity. All variables were obtained during a 30-minute spontaneous breathing trial on continuous positive airway pressure (CPAP) of 5 cm H₂O and compared between patients for whom extubation succeeded with those for whom either the spontaneous breathing trial failed or for those who passed, but then the extubation failed.

Results: Of 52 patients enrolled in the study, 35 (67.3%) were successfully extubated, and 17 (32.7%) were not. Patients for whom it failed had higher diaphragm electrical activity (48%; P < 0.001) and a lower efficiency to convert neuromuscular activity into inspiratory pressure and tidal volume (40% (P < 0.001) and 53% (P < 0.001)), respectively. Neuroventilatory efficiency demonstrated the greatest predictability for weaning success.

Conclusions: This study shows that a mixed group of critically ill patients for whom weaning fails have increased neural respiratory drive and impaired ability to convert neuromuscular activity into tidal ventilation, in part because of diaphragm weakness.

Trial registration: Clinicaltrials.gov identifier NCT01065428.

Figures

Figure 1
Figure 1
Flow chart of the study.
Figure 2
Figure 2
The development of (top to bottom) diaphragm electrical activity (EAdi), neuromechanical efficiency (NVE), and neuroventilatory efficiency (NME) during pressure support of 10 above 5 cm H2O of PEEP (PSV10) and throughout the spontaneous breathing trial (SBT) on CPAP of 5 cm H2O. On the X-axis: T1, T5, T10, T15, T30, and Tend indicate minutes 1, 5, 10, 15, and 30, as well as the last data obtained during the SBT. In the successfully extubated group, n = 35 at all time points. In the group for whom extubation failed, n = 17 at PSV10, T1, and T5; n=16 at T10 and T15; n=14 at T30 (three for whom SBT failed at 30 minutes and 11 who were initially extubated but were later reintubated or provided with noninvasive ventilation or died). Data were obtained for the remaining three patients meeting SBT exclusion criteria at T30. At Tend, n = 17 in the group for whom extubation failed. *Difference (P < 0.05) between failure and successfully extubated groups at the same time point. †Differences (P < 0.05) between PSV10 and other time points in the group for whom extubation failed. ‡Differences (P < 0.05) between PSV10 and other time points in the group that was successfully extubated.
Figure 3
Figure 3
The development of (top to bottom) of tidal volume (Vt), breathing frequency (f), minute ventilation (VE), and the ratio of breathing frequency and tidal volume (f/Vt) during pressure support of 10 above 5 cm H2O of PEEP (PSV10) and throughout the spontaneous breathing trial (SBT) on CPAP of 5 cm H2O. See Figure 2 for more description.
Figure 4
Figure 4
Upper left panel shows the ROC curve (receiver operating characteristic) for neuroventilatory efficiency (NVE) to predict extubation success after 5 minutes of the spontaneous breathing trial (T5). Area under the curve (AUC) was 0.84 (P < 0.001). Upper right panel shows the ROC curve for diaphragm electrical activity (EAdi) to predict extubation failure at T5. AUC was 0.73 (P < 0.009). Lower left panel shows ROC curve for neuromuscular efficiency (NME) to predict extubation success at T5. AUC = 0.70 (P < 0.02).The lower right panel shows the ROC curve for the ratio of breathing frequency and tidal volume (f/Vt) to predict extubation failure at T5. AUC was 0.72 (P = 0.012).

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