Extravascular Lung Water, B-Type Natriuretic Peptide, and Blood Volume Contraction Enable Diagnosis of Weaning-Induced Pulmonary Edema
Extravascular Lung Water, B-Type Natriuretic Peptide, and Blood Volume Contraction Enable Diagnosis of Weaning-Induced Pulmonary Edema
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DOI：
10.1097/ccm.0000000000000295
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发表时间：
2014-08-01
影响因子：
8.8
通讯作者：
Monnet, Xavier
中科院分区：
文献类型：
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作者：
Dres, Martin;Teboul, Jean-Louis;Monnet, Xavier
目的：探讨以理想体重为指标的血管外肺水变化是否能检测出脱机所致肺水肿。探讨了血容量收缩指标和b型利钠肽变化的诊断价值。设计：前瞻性研究。设置:ICU。患者：21例首次自主呼吸试验失败的患者。干预措施:没有。测量和主要结果：我们进行了第二次60分钟的t管自主呼吸试验。在自主呼吸试验前和结束时，我们记录肺动脉闭塞压、理想体重指标血管外肺水、血浆b型利钠肽水平、血红蛋白和血浆蛋白浓度。脱机性肺水肿的定义是临床不耐受体征与自主呼吸试验结束时肺动脉闭塞压大于或等于18 mm Hg的相关性。由于一些患者进行了多次自主呼吸试验，初级分析包括所有的自主呼吸试验，二级分析只包括每个患者的第一次自主呼吸试验。初步分析36例自发性呼吸试验，其中21例有脱机肺水肿，15例无脱机肺水肿。在自主呼吸试验中，理想体重的血管外肺水指数仅在脱机肺水肿病例中增加（25% +/- 23%）。血浆蛋白浓度、血红蛋白浓度和b型利钠肽也仅在脱机肺水肿病例中显著升高（分别为9% +/- 3%、9% +/- 4%、21% +/- 23%）。以理想体重为指标的血管外肺水检测脱机所致肺水肿的受试者工作特征曲线下面积为0.89 (95% CI, 0.78-0.99)，自主呼吸试验所致血浆蛋白浓度变化0.97(0.93-1.01)，血红蛋白浓度变化0.96 (0.90-1.01)，b型利钠肽变化0.76（0.60-0.93）。以理想体重为指标的血管外肺水增加大于或等于14%，诊断为脱机所致肺水肿，敏感性为67% (95% CI, 43-85%)，特异性为100% （95% CI, 78-100%）。二次分析证实了这些结果。结论：自主呼吸试验诱导的血管外肺水增加（以理想体重、血浆蛋白浓度、血红蛋白浓度和b型利钠肽为指标）是诊断脱机肺水肿可靠的替代肺动脉导管。
Objective: We tested whether the changes in extravascular lung water indexed for ideal body weight could detect weaning-induced pulmonary edema. We also studied the diagnostic value of blood volume contraction indices and B-type natriuretic peptide variations.Design: Prospective study.Setting: ICU.Patients: Twenty-one patients who failed a first spontaneous breathing trial.Interventions: None.Measurements and Main Results: We performed a second 60-minute T-tube spontaneous breathing trial. Before and at the end of spontaneous breathing trial, we recorded pulmonary artery occlusion pressure, the extravascular lung water indexed for ideal body weight, plasma B-type natriuretic peptide level, hemoglobin, and plasma protein concentrations. Weaning-induced pulmonary edema was defined by the association of signs of clinical intolerance and a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg at the end of spontaneous breathing trial. Because some patients performed several spontaneous breathing trial, a primary analysis included all spontaneous breathing trial and a secondary analysis included only the first spontaneous breathing trial of each patient. In primary analysis, 36 spontaneous breathing trials were analyzed, 21 spontaneous breathing trial with weaning-induced pulmonary edema and 15 without. During spontaneous breathing trial, extravascular lung water indexed for ideal body weight increased only in cases with weaning-induced pulmonary edema (25% +/- 23%). Plasma protein concentration, hemoglobin concentration, and B-type natriuretic peptide also significantly increased only in cases with weaning-induced pulmonary edema (9% +/- 3%, 9% +/- 4%, 21% +/- 23%, respectively). The areas under the receiver operating characteristics curves to detect weaning-induced pulmonary edema were 0.89 (95% CI, 0.78-0.99) for extravascular lung water indexed for ideal body weight, 0.97 (0.93-1.01) for spontaneous breathing trial-induced changes in plasma protein concentration, 0.96 (0.90-1.01) for changes in hemoglobin concentration, and 0.76 (0.60-0.93) for changes in B-type natriuretic peptide. An increase in extravascular lung water indexed for ideal body weight greater than or equal to 14% diagnosed weaning-induced pulmonary edema with a sensitivity of 67% (95% CI, 43-85%) and a specificity of 100% (95% CI, 78-100%). The secondary analysis confirmed these results.Conclusions: Spontaneous breathing trial-induced increases in extravascular lung water indexed for ideal body weight, plasma protein concentrations, hemoglobin concentration, and B-type natriuretic peptide are reliable alternatives to the pulmonary artery catheter for diagnosing weaning-induced pulmonary edema.