[Clinical value of extravascular lung water and preload parameters in weaning of mechanical ventilation in patients with septic shock].

Objective: To investigate the values of extravascular lung water and preload parameters of weaning from mechanical ventilation on patients with septic shock.
Methods: A prospective study was conducted. A total of 52 septic shock patients with mechanical ventilation were enrolled from January 2010 to July 2012. All patients were treated and monitored by pulse induced continuous cardiac output (PiCCO) till they reached weaning criteria, and then spontaneous breathing trial (SBT), weaning, and extubation were performed in turn. The enrolled patients were divided into two groups including successful weaning group (n=38) and weaning failure group (n=14) according to clinical manifestations during 48 hours after weaning. Extravascular lung water index (EVLWI), preload parameters such as global end diastolic volume index (GEDVI) and intra-thoracic blood volume index (ITBVI), pulmonary vascular permeability index (PVPI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were compared at the time before weaning, 0.5 hour after weaning, 0.5 hour after extubation, and time of weaning failure or 48 hours after weaning. The patients in weaning failure group were sub-divided into high PVPI group (PVPI≥1.5 ml/m(2)) and low PVPI group (PVPI<1.5 ml/m(2)), the NT-proBNP and pulmonary blood volume (PBV) were compared between two groups.
Results: Before weaning, there was no statistical difference in NT-proBNP, volume parameters and EVLWI between two groups. EVLWI, GEDVI, ITBVI, PVPI and log NT-proBNP were gradually increased after weaning and extubation in two groups. The EVLWI, PVPI and log NT-proBNP were significantly higher at end point of observation in weaning failure group compared with those in successful weaning group (EVLWI: 12.81±2.13 ml/kg vs. 8.48±1.53 ml/kg, PVPI: 2.79±1.29 ml/m(2) vs. 2.19±0.94 ml/m(2), log NT-proBNP: 3.72±0.35 vs. 3.44±0.28, P<0.05 or P<0.01). GEDVI, ITBVI at 0.5 hour after weaning and end point of observation in weaning failure group were significantly higher than those in successful weaning group (0.5 hour after extubation: GEDVI 986.29±166.44 ml/m(2) vs. 856.47±149.15 ml/m(2), ITBVI: 1171.07±167.03 ml/m(2) vs. 1045.79±146.09 ml/m(2); end point of observation: GEDVI 957.00±67.25 ml/m(2) vs. 816.86±27.58 ml/m(2), ITBVI: 1184.29±209.68 ml/m(2) vs. 993.79±168.90 ml/m(2), P<0.05 or P<0.01). Sub-analysis showed that in weaning failure group, higher log NT-proBNP and PBV were found in patients with low PVPI compared with those with high PVPI (log NT-proBNP: 4.02±0.11 vs. 3.71±0.23, PBV: 507.19±25.72 ml vs. 347.85±47.52 ml, P<0.05 and P<0.01).
Conclusions: Increased EVLW is the reason of pulmonary edema caused by weaning in septic shock patients, to which both hydrostatic and pulmonary permeability may contribute, and the latter could be more important. Monitoring preload parameters could help distinguish the mechanism of pulmonary edema after weaning, which may be useful in treatment.