Central venous saturation is a predictor of reintubation in difcult-to-wean patients*

Cassiano Teixeira, MD; Nilton Branda o da Silva, PhD; Augusto Savi, RPT; Silvia Regina Rios Vieira, PhD; Luis Anto nio Nasi, MD; Gilberto Friedman, PhD; Roselaine Pinheiro Oliveira, MD; Ricardo Viegas Cremonese, MD; Tu lio Frederico Tonietto, MD; Mathias Azevedo Bastian Bressel, MSc; Juc ara Gasparetto Maccari, MD; Ricardo Wickert, RPT; Luis Guilherme Borges, RPT
Objective: To evaluate the predictive value of central venous saturation to detect extubation failure in difcult-to-wean patients. Design: Cohort, multicentric, clinical study. Setting: Three medical-surgical intensive care units. Patients: All difcult-to-wean patients (dened as failure to tolerate the rst 2-hr T-tube trial), mechanically ventilated for >48 hrs, were extubated after undergoing a two-step weaning protocol (measurements of predictors followed by a T-tube trial). Extubation failure was dened as the need of reintubation within 48 hrs. Interventions: The weaning protocol evaluated hemodynamic and ventilation parameters, and arterial and venous gases during mechanical ventilation (immediately before T-tube trial), and at the 30th min of spontaneous breathing trial. Measurements and Main Results: Seventy-three patients were enrolled in the study over a 6-mo period. Reintubation rate was 42.5%. Analysis by logistic regression revealed that central venous saturation was the only variable able to discriminate outcome of extubation. Reduction of central venous saturation by >4.5% was an independent predictor of reintubation, with odds ratio of 49.4 (95% condence interval 12.1201.5), a sensitivity of 88%, and a specicity of 95%. Reduction of central venous saturation during spontaneous breathing trial was associated with extubation failure and could reect the increase of respiratory muscles oxygen consumption. Conclusions: Central venous saturation was an early and independent predictor of extubation failure and may be a valuable accurate parameter to be included in weaning protocols of difcult-to-wean patients. (Crit Care Med 2010; 38:491 496) KEY WORDS: central venous saturation; mechanical ventilation; extubation; difcult-to-wean

he weaning process comprises progressive withdrawal from the invasive ventilatory support until removal of the endotracheal tube and it could represent approximately 40% of the patients time on mechanical ventilation (MV) (1). A more prolonged time on MV increases the risk of nosocomial pneumonia, traumatic airway injury, sepsis, and bleeding of digestive stress ulcers (2 4). Furthermore,

failure in this process increases the risk of nosocomial pneumonia and mortality (5, 6). Success of weaning depends on improvement of the acute illness, adequate oxygenation and ventilatory parameters, hemodynamic stability, adequate mentation and cough, and normal acid base and electrolytes values (1). Extubation is performed after the decision has been made to disconnect the patient from MV and after the patient has tolerated a

*See also p. 708. From the Intensive Care Unit (CT, NBdS, AS, RPO, RVC, TFT, MABB, JGM, RW, LGB), Moinhos de Vento Hospital, Porto Alegre, Brazil; Central-Intensive Care Unit (CT, GF, RPO), Santa Casa Hospital, Porto Alegre, Brazil; and the Intensive Care Unit (SRRV, LAN, GF, MABB), Clnicas Hospital, Porto Alegre, Brazil. Gau cho Weaning Study Group: Kamile Borba Pinto, RPT; Fernanda Callefe Moreira, RPT; Eubrando Silvestre Oliveira, MD; Flavio Cardona Alves, MD; Jorge Amilton Ho her, MD; Cristiane Trevisan, RPT; Se rgio Fernando Monteiro Brodt, MD; Jose Herve Diel Barth, MD; Andre Santana Machado, MD; Fabiano Leichsenring, RPT; Patrcia de Campos Balzano, MD; Luciano Marques Furlanetto, MD; Jose Fernando Pires, MD; Eduardo Monteiro da Silva, MD; Re gis Bueno Albuquerque, MD; Daniele Munareto Dallegrave, MD; Marcelo Jeffman, MD; Sandro Cadaval Gonc alves, MD; Eduardo

de Oliveira Fernandes, PhD; Marcelo Garcia da Rocha, MD; Maicon Becker, MD; Sergio Pinto Ribeiro, PhD; Alexandre Cordella da Costa, MD; Marcelo de Mello Rieder, RPT; Marisa Helena Pilenghi Correa, MD; Cristiane Magalha es Siqueira de Campos Morais, MD; Paulo Jose Zimmermann Teixeira, PhD; Ma rcio Pereira Hetzel, MD; Andre Petit Torelly, MD; Roger Weingartner, MD; Patrcia Pickersgill de Leon, MD; Joyce Michele Silva, RPT. The authors have not disclosed any potential conicts of interest. For information regarding this article, E-mail: cassiano.rush@terra.com.br Copyright 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3181bc81ec

spontaneous breathing trial (SBT). However, extubation failure (EF) occurs in approximately 14% to 32% of the patients meeting these criteria, indicating that the traditional two-step weaning protocol (evaluation of predictors followed by Ttube trial) does not adequately detect failure in difcult-to-wean patients (failure to tolerate their rst SBT) patients (59). Presence of cardiovascular dysfunction can contribute to weaning failure by increasing loads and reducing neuromuscular capacity. Although respiratory muscles do not develop fatigue, they perform a huge workload. Thus, they rely on efcient oxygen transport by the cardiovascular system (10). Jubran et al (11) examined the hemodynamics and mixed venous saturation (SvO2) in patients during weaning trials. Patients who failed weaning also O 2) failed to increase oxygen delivery (D to the tissues, in part due to elevated right and left ventricular afterloads. Central venous oxygen saturation (ScvO2), although less accurate than SvO2, has been successfully used as an
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adequate resuscitation goal in critical illness (10, 12). Earlier authors (1315) had demonstrated adequate correlation between ScvO2 and SvO2, however, not in critically ill patients. As such, in the weaning process (recovery stage from critical disease), measurement of ScvO2 could potentially be a reliable and convenient tool to warn rapidly about acute changes in the oxygen supply and demand of these patients. Given the hypothesis that changes in ScvO2 during SBT could predict EF, a multicentric study was conducted to evaluate the predictive value of measurements of ScvO2 in difcult-to-wean patients submitted to a standard twostep weaning protocol and extubated after successful SBT.

Mechanical ventilated patients (n= 768)

Excluded by: - MV < 48hs (n=102) - Tracheostomy (n= 54) - Death before SBT (n= 124) - Patients with no VCL (n= 98) - Negative for informed consent (n= 86)

Eligible for the study (n= 304)

Success 1st SBT (n= 231)

Failure 1st SBT (n= 73)

Daily SBT until success

METHODS Design
This is a cohort, multicentric, clinical study performed in three medical-surgical intensive care units (ICUs), and approved by the Ethic Research Committees of the three institutions. The informed consent was obtained from all patients or next-of-kin.

Extubation success (n=42)

Extubation failure (n=31)

Figure 1. Enrollment. MV, mechanical ventilation; SBT, spontaneous breathing trial.

Weaning Protocol
Patients meeting these criteria were then weaned in a semirecumbent position, using a two-step weaning protocol (measurements of predictors followed by a T-tube trial during 30 mins). In spontaneous breathing, frequency to tidal volume index (f/VT) was calculated by the respiratory rate (RR) and VT ratio measured, using an electronic respirometer (295, Ainca, San Marcos, CA) spirometer monitored during 1 min. Maximal inspiratory pressure (MIP) and maximal expiratory pressure were measured with a manometer (Support Famabra, Sa o Paulo, Brazil) and dened as the most negative and positive values, respectively, produced by three consecutive inspiratory and expiratory trials against a unidirectional valve during 20 secs (16). Those with f/VT 105 were submitted to spontaneous breathing on the T piece for 30 mins (dened as SBT) with supplementary humidied oxygen (4 7 L/min) to achieve arterial oxygen saturation 90% as measured by pulse oximetry. Patients with intolerance to SBT, dened by: RR 35 breaths/min, oxygen saturation by pulse oximetry (SpO2) 90%, heart rate 130 beats/min or changes 20%, change in mental status (drowsiness, coma, agitation, anxiety), worsened discomfort, diaphoresis or signs of increased work of breathing (use of accessory respiratory muscles or thoracoabdominal paradox) were returned to MV and underwent new evaluation on the day after. At this point, patients were selected for entry in the study.

Patients
Over a 6-mo period, we studied prospectively all difcult-to-wean patients (dened as failure to tolerate the rst 2-hr T-tube trial), mechanically ventilated for 48 hrs, in three medical-surgical ICUs (Moinhos de Vento Hospital, Santa Casa Hospital, and Clnicas Hospital, Porto Alegre, Brazil). All patients were ventilated with Servo 900C, and Servo 300 (Siemens-Elema AB, Solna, Sweden) or Evita-4 (Dra ger Medical AG, Lu beck, Germany). They were assessed daily for presence of the following readiness-towean criteria: a) improvement in the underlying condition that leads to acute respiratory failure; b) adequate oxygenation, indicated by PaO2 60 torr (8 kPa) on FIO2 0.4 and positive end-expiratory pressure 8 cm H 2 O; c) cardiovascular stability (heart rate 130 beats/min and no or minimal pressors); d) afebrile; e) adequate hemoglobin (8 g/dL); f) adequate mental status (arousal, Glasgow Coma Scale score of 13, and no continuous sedative infusions); g) effective cough; and (h) normal acid base and electrolytes (1). Exclusion criteria were: a) tracheotomized patients; b) patients with no central venous catheter; c) negative for informed consent; d) weaned successfully in the rst weaning trial; and e) dead before weaning trial (Fig. 1).

After successful completion of an SBT, patients were extubated, and followed for presence of postextubation respiratory distress during 48 hrs. EF was dened as need of reintubation in 48 hrs. Noninvasive ventilation was used to prevent respiratory distress after extubation in all patients with chronic obstructive pulmonary disease (COPD).

Measurements
Measurements of ventilatory parameters were recorded at 1st min and at 30th min of SBT. Respiratory compliance, RR, oxygenation and pressure index (CROP) were measured immediately before SBT (during MV support) and calculated by the formula: [Cdyn MIP (Pa O 2/P AO 2)]/RR, where Cdyn stands for dynamic compliance, PAO2 for alveolar oxygen pressure, and RR for respiratory rate. Arterial and venous blood samples were collected immediately before SBT (during MV support) and at 30th min of SBT. Hemodynamic variables (heart rate and arterial blood pressure), demographic data, Acute Physiology and Chronic Health Evaluation (APACHE II) score (17) at rst 24 hrs of ICU stay, ICU admission diagnosis, comorbidities, Glasgow Coma Scale score, days in ICU, MV days, drugs used (neuromuscular blocking agents, benzodiazepines, opioids, adrenocortical steroids) were also registered. The ScvO 2 and arterial blood were sampled by central venous access (placed in the internal jugular or subclavic vein) and radial artery, respectively, and were analyzed immediately, using a blood

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gas analyzer (ABL 520 Radiometer, Copenhagen, Denmark). Oxygen extraction ratio (O2ER) was calculated by the formula: (SaO2 ScvO2)/SaO2.

Table 1. Demographic characteristics, clinical parameters, drug use, and ventilatory settings All Patients (n 73) 57 19 39 (53) 17 6 14 2 9.8 1.5 36 (49) 8 (11) 5 (6) 4 (5) 4 (5) 1 (1) 30 (41) 12 (16) 2.5 1.5 79 53 14 13 51 17 4 545 134 50 22 289 100 Extubation Success (n 42) 55 20 22 (56) 16 5 14 2 10.1 1.8 23 (55) 3 (7) 4 (9) 3 (7) 3 (7) 0 17 (40) 3 (7) 32 43 43 10 6 51 17 5 567 126 52 18 292 92 Extubation Failure (n 31) 59 18 17 (44) 20 7 13 3 9.4 1.2 13 (42) 5 (16) 1 (3) 1 (3) 1 (3) 1 (3) 13 (42) 9 (29) 22 10 13 63 18 18 51 18 4 513 140 48 27 285 111

Variables Age, yr Male, % Admission APACHE II GCS at extubation Hemoglobin concentration, g/dL ICU admission, % Sepsis Stroke Postoperative Exacerbation of asthma Acute pulmonary edema Exacerbation of COPD Comorbidities, % Heart disease COPD Drug use, days Neuromuscular antagonists Opioids Benzodiazepines Adrenocortical steroids Ventilatory settings at weaning trial PEEP, cm H2O Inspiratory pressure, cm H2O VT (mL) Cdyn (mL/cm H2O) PaO2/FIO2

pa .34 .83 .006 .13 .81 .35 .23 .38 .63 .42 NA .54 .02 .51 .41 .08 .69 .96 .71 .08 .45 .77

Statistical Analysis
All data were expressed as mean standard deviation for continuous variables and percentages for categorical variables. Differences between the two groups at baseline were analyzed with the use of Students t test or Mann-Whitney U test for continuous variable and chi-square test for categorical variable, including the Fisher test. Logistic regression was performed for multivariable analysis for all univariate relevant variables that discriminate EF for extubation success (ES) patients. The Pearson test and Spearman test were used to determine correlations of parametric and nonparametric variables, respectively. Incremental analysis of the area under the receiver operating characteristic curve was performed to quantify ScvO2 differences between MV and the 30th min of SBT. Statistical analysis was performed by a statistician, using the commercially available software (Statistical Package for Social Science - SPSS 11.0, Chicago, IL). Statistical signicance was set at p .05.

RESULTS
From of July 2005 to January 2006 (6 mos), 768 patients were submitted to MV in the three study ICUs: 124 died before weaning trial, 251 had been MV dependent for 48 hrs, 86 declined consent, 98 patients had no central venous catheter at the moment of weaning trial, and 54 were submitted to early tracheotomy. Seventy-three consecutive MV patients were enrolled in the study (Fig. 1). The mean age of these ptients was 57 19 yrs, mean APACHE II score in rst 24 hrs of ICU stay was 17 6, and 53.4% were male. The most frequent diagnosis at the time of ICU admission was sepsis (49%) and ICU sample mortality rate was 18%. All patients underwent a two-step weaning protocol, but the intubation rate was 42.5%. The number of failed SBT before a successful SBT was equal in ES and EF groups (1.2 0.5 vs. 1.3 0.5, p .92). Patient characteristics, ventilatory settings, ventilatory and hemodynamic parameters are shown in Table 1.

APACHE II, Acute Physiology and Chronic Health Evaluation; ICU, intensive care unit; MV, mechanical ventilation; GCS, Glasgow Coma Scale; COPD, chronic obstructive pulmonary disease; PEEP, positive end-expiratory pressure; VT, tidal volume; Cdyn, dynamic compliance; PaO2/FIO2, arterial pressure/oxygen fraction ratio; NA, not analyzed. a Comparing extubation failure to extubation success.

than at MV measurements (92 24 torr [12 3.2 kPa] vs. 103 35 torr [13.7 4.7 kPa], p .001; 95 3% vs. 97 2%, p .001; 66 9% vs. 69 7%, p .001, respectively) (Table 2). Heart rate increased signicantly at the 30th min of SBT (95 19 beats/min to 98 19 beats/min, p .009) and mean arterial pressure remained stable (92 14 mm Hg to 95 13 mm Hg, p .42) when compared with MV measurement. Ventilatory parameters as well as other hemodynamic parameters and blood gas measurements were similar during MV and at 30th min of SBT.

Extubation Outcome (Comparing Extubation Failure and Extubation Success)

Admission APACHE II, COPD diagnosis, SaO2, ScvO2, and O2ER at the 30th min of SBT were associated with EF (Tables 1 and 2). However, multivariate analysis demonstrated that only ScvO2 (ES 70 7 vs. EF 60 8; p .009) and O2ER (ES 27 7 vs. EF 36 8, p .003) at the 30th min of SBT could discriminate EF from ES (Table 3).

The PaO2, SaO2, ScvO2, and O2ER measurements between ES and EF from MV to 30th min of SBT are shown in Figure 2 and Table 2. A 4.5% reduction of ScvO2 was associated with greater risk for reintubation (odds ratio 49.5, 95% condence interval 12.1201.5, p .0001). A receiver operating characteristic curve was obtained with this value and demonstrated 90% of sensitivity, 84% of specicity, positive predictive value of 0.86, and negative predictive value of 0.88 for EF (Fig. 3). In our study, a reduction of 17% in ScvO2 predicted 100% of EF. Mortality rate, ICU stay, and days on MV were signicantly higher in the EF group than in the ES group (Table 4).

DISCUSSION
A greater risk of reintubation was associated with a 4.5% reduction in ScvO2 (88% sensitivity, 95% of specicity, positive predictive value of 0.93, and negative predictive value of 0.90), and with a higher calculated O2ER in difcult-to-wean patients.
493

All Patients (Comparing MV and 30th Minute of SBT)

In the sample, PaO2, SaO2, and ScvO2 evaluated at 30th min of SBT were lower
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Table 2. Ventilatory and hemodynamic parameters, and arterial and central venous blood gases data during MV and at 30th min of SBT All Patients (n 73) Extubation Success (n 42) Extubation Failure (n 31)

Variable During mechanical ventilation Blood gases pH PaCO2, torr PaO2, torr SaO2, % ScvO2, % O2ER, % Ventilatory parameters measured at 1st min of SBT f/VT, breath/min/L RR, beat/min MIP, cm H2O MEP, cm H2O CROP index Hemodynamic parameters HR, beat/min SAP, mm Hg DAP, mm Hg MAP, mm Hg At 30th min SBT Blood gases pH PaCO2, torr PaO2, torr SaO2, % ScvO2, % O2ER, % Ventilatory parameters f/VT, breath/min/L RR, beat/min MIP, cm H2O MEP, cm H2O Hemodynamic parameters HR, beat/min SAP, mm Hg DAP, mm Hg MAP, mm Hg

pa

7.39 0.9 35 11 103 35 97 2 69 7 28.8 7 73 27 28 6 41 13 30 11 41 35 95 18 132 21 72 14 92 14 7.38 0.6 35 11 92 24b 95 3b 65 9b 31.2 8 80 36 28 7 39 14 30 10 98 19c 135 20 75 13 95 13

7.38 0.9 34 9 103 32 97 2 69 7 28.6 7 68 21 29 5 42 12 32 10 47 41 93 16 131 19 72 13 91 13 7.38 0.5 34 9 94 24 96 3 70 7 27.1 7 73 24 27 6 41 14 31 9 95 14 131 17 75 12 94 12

7.4 0.8 37 13 103 39 96 3 68 8 29.3 9 78 25 26 7 41 15 27 10 36 29 98 21 134 23 71 16 92 15 7.37 0.7 39 13 88 24 94 4 60 8 37 8 89 18 29 8 36.8 13 27 11 102 23 139 23 75 14 97 15

.42 .22 .41 .46 .36 .1

.45 .17 .37 .05 .09 .21 .49 .92 .78

.69 .09 .31 .02 .0001 .0001 .52 .16 .16 .15 .15 .12 .85 .36

MV, mechanical ventilation; SBT, spontaneous breathing trial; PaCO2, carbon dioxide arterial pressure; HCO3 arterial bicarbonate; PaO2 oxygen arterial pressure; SaO2 arterial oxygen saturation; ScvO2 central venous oxygen saturation; O2ER, oxygen extraction rate; f/VT, frequency to tidal volume index; RR, respiratory rate; MIP, maximal inspiratory pressure; MEP, maximal expiratory pressure; HR, heart rate; SAP, systolic blood pressure; DAP, diastolic blood pressure; MAP, mean arterial blood pressure. a Comparing extubation failure and extubation success; bp .01 compared with MV measurements; c p .05 compared with MV measurements.

Table 3. Results of univariate and multivariate analyses for sample weaning predictors Extubation Success (n 42) 16 5 3 (7) 96 3 70 7 27.4 7 Extubation Failure (n 31) 20 7 9 (29) 94 4 60 8 36.1 8 Univariate Analysis .006 .02 .02 .0001 .0001 Multivariate Analysis .08 .08 .34 .009 .003

Variable Admission APACHE II COPD, % SaO2 at 30th min of SBT, % ScvO2 at 30th min of SBT, % O2ER at 30th min of SBT, %

APACHE, Acute Physiology and Chronic Health Evaluation; COPD, chronic obstructive pulmonary disease; SaO2 on SBT, arterial oxygen saturation measured at 30th min of spontaneous breathing trial; ScvO2, central venous oxygen saturation measured at 30th min of spontaneous breathing trial; O2ER, oxygen extraction rate measured at 30th min of spontaneous breathing trial.

Several investigators (1, 8, 18 21) reported that formalizing weaning steps into a protocol might improve the outcome. However, approximately 25% of patients have EF when followed during 48 hrs to 72 hrs (1). Our patients were extubated based on a rigid two-step weaning institutional protocol, but the reintubation rate was high (42.5%). Our patients already had failed in previous SBT, placing them in a subgroup of difcultto-wean patients (1, 2224). According to the Fick principle, ox O2) depends on D O2 and ygen uptake (V O2ER (10, 25). Jubran et al (11) showed that successfully weaned patients had an increase in cardiac index between MV and end of the trial. This was not found in the failure group. The combination of greater venous admixture and low SvO2 can lead to rapid arterial desaturation and a relative decrease of oxygen supplied to the tissues (26). In O2 was not measured, but our study, D similar results between groups (EF and ES) were been estimated based on the same hemoglobin level, hemodynamic parameters, and SaO2 and PaO2. Therefore, we believe that the drop in ScvO2 could reect the increase of respiratory O2 observed in EF patients muscles V during the SBT (11, 26). Use of SvO2 during the weaning period has been previously studied (10, 19 23). Jubran et al (11) demonstrated that SvO2 decreased in weaning failure patients, probably due to increased respiratory muscles O2ER. Noll and Byes (27) showed correlation of SvO2, vital signs, and arterial blood gases in 30 consecutive postoperative coronary artery bypass graft cases, but only SpO2 and respiratory rate correlated with weaning failure. Cason et al (28), in ten postoperative coronary artery bypass graft patients, evaluated SvO2 and SpO2 during SBT and showed that weaning failure occurred when SvO2 was 60%. Armaganidis and Dhainaut (29) monitored SvO2 in postoperative coronary artery bypass graft patients and demonstrated that SvO2 of 60% was the best weaning success predictor studied and depended on O2ER measurements. Different from these previous studies, our study group was comprised predominantly of critical ill nonsurgical MVdependent patients, and our results demonstrated that ScvO2 was an effective EF predictor in difcult-to-wean patients who underwent a successful Ttube trial.
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The choice of ScvO2 instead of SvO2 was due to limited use of a pulmonary artery catheter during weaning period, reecting our everyday clinical practice. Pulmonary artery catheterization is costly and has inherent risks. In comparison, ScvO2 is part of the standard care of critically ill patients and is easier and safer. Others investigators (1315) had demonstrated adequate correlation between ScvO2 and SvO2, except in critically ill patients. Rivers et al (12) and Vallet et al (15) previously showed that early goaldirected therapy based on ScvO2 reduces

mortality in patients with severe sepsis and septic shock. Measurement of ScvO2 is a potentially reliable and convenient tool, which could rapidly warn about acute change in the oxygen supply and demand of critically ill patients. Our data showed that, during MV (immediately before SBT), ScvO2 was not different between EF and ES patients, but that ScvO2 reduction during T-tube trial was able to predict EF in 86% of the cases. ScvO2 remained unchanged in the ES group. Overall mortality was 18%, with a mean APACHE II score of 17 corrob-

orating the ndings of Knaus et al (17). It is noteworthy that the APACHE II score was higher in the EF group (16 5 vs. 20 7, p .006) and could contribute to failure and elevated mortality in this group as well as presence of COPD (7% vs. 29%, p .02) and a large number of septic patients at the time of ICU admission (42%). Patients with COPD present reduced pulmonary function and develop dynamic hyperination during spontaneous ventilation, which increases the intrinsic positive end-expiratory pressure and makes weaning from MV difcult (1). Furthermore, the large presence of COPD patients in the EF group could contribute to prolong MV duration and ICU days in this group because noninvasive ventilation was only used after a successful SBT and extubation in this subgroup of patients. However, at multivariate analysis,

Table 4. Outcomes Extubation Success (n 42) ICU days MV days Mortality in ICU, % 12 10 77 1 (2) Extubation Failure (n 31) 24 14 95 12 (39)

p .0001 .02 .0001

Figure 2. Changes in blood gases, from mechanical ventilation (MV) to 30th min of spontaneous breathing trial (SBT), comparing extubation failure (dashed line) and extubation success (continuous line). *p .001 compared with MV measurement; #p .02 comparing extubation failure and extubation success; p .0001 comparing extubation failure and extubation success. SaO2, arterial oxygen saturation; ScvO2, central venous oxygen saturation; O2ER, oxygen extraction rate.

ICU, intensive care unit; MV, mechanical ventilation.

Figure 3. Receiver operating characteristic curve for central venous oxygen saturation (A) and simplied oxygen extraction ratio (B) variations (30th min of spontaneous breathing trial measuredmechanical ventilation measured). A 4.5% reduction of central venous oxygen saturation was associated with greater risk of reintubation (odds ratio 49.5, 95% condence interval 12.1201.5, p .0001). Receiver operating characteristic curve demonstrated 88% of sensitivity, 95% of specicity, positive predictive value of 0.93, and negative predictive value of 0.90 for extubation failure. In addition, a 8% increase of simplied oxygen extraction ratio demonstrated 95% of sensitivity, 63% of specicity, positive predictive value of 0.76 and negative predictive value of 0.91 to detect extubation failure (odds ratio 32, 95% condence interval 7163, p .0002). AUC, area under the curve.

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the ScvO2 reduction during SBT was independent from the other variables. This studys main limitation is the nonrandom design. In difcult-to-wean patients, the tolerance to SBT did not guarantee successful extubation. In these cases, reduction of ScvO2 was able to predict extubation outcome. Therefore, we believe that measurements of ScvO2 during T-tube trial could be considered as a new parameter for difcultto-wean patients.

8.

9.

10.

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