Summary of “Incidence and risk factors of weaning-induced pulmonary oedema: results from a multicentre, observational study”
Abstract
This multicenter observational study evaluated the incidence and risk factors of weaning-induced pulmonary oedema (WIPO) in critically ill patients during spontaneous breathing trials (SBTs). Conducted across 13 ICUs in France, Italy, and India, the study revealed that WIPO accounted for more than one-third of weaning failures. It emphasized the importance of identifying high-risk patients, particularly those with pre-existing cardiac disease and COPD.
Key Points:
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Study Design and Scope: The study included 500 adult ICU patients who underwent 634 spontaneous breathing trials (SBTs) between July 2019 and February 2021 across 13 centers. Patients were assessed retrospectively for WIPO.
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Weaning Outcome Classification: Among the SBTs, 66% (417 patients) succeeded, while 34% (217 patients) failed. Weaning was classified as short (83%), difficult (9%), or prolonged (8%) based on standardized weaning definitions.
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WIPO Incidence: WIPO occurred in 12% of all SBTs and accounted for 36% of the 217 weaning failures. It was significantly more frequent with T-piece trials compared to pressure support ventilation (PSV) with or without PEEP.
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Spontaneous Breathing Trial Techniques: WIPO occurred in 15% of T-piece SBTs, 8% of PSV-PEEP SBTs, and 9% of PSV-ZEEP SBTs. These findings suggest that SBT technique significantly influences the risk of WIPO.
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Expert-Based Diagnosis: WIPO was diagnosed retrospectively by five blinded experts based on clinical signs, hemodynamic data, and echocardiographic indicators, highlighting the need for standardized real-time assessment tools.
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Independent Risk Factors: Multilevel logistic regression identified COPD and prior cardiomyopathy as independent predictors of WIPO during weaning. These comorbidities may predispose patients to cardiac dysfunction upon transition to spontaneous breathing.
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Mechanism of WIPO: WIPO is driven by heart-lung interactions during the shift from positive to negative intrathoracic pressure, leading to increased cardiac preload and afterload and unmasking latent cardiac insufficiency.
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Clinical Implications: Recognizing WIPO as a significant cause of weaning failure underscores the importance of cardiac evaluation prior to weaning, particularly in patients with known heart disease or COPD.
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Trial Registration and Ethics: The study was retrospectively registered on ClinicalTrials.gov (NCT05318261) and received appropriate ethical approvals. Data collection was observational with no protocolized intervention.
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Call for Personalized Weaning Strategies: Authors advocate for personalized weaning protocols integrating cardiovascular risk stratification and echocardiographic monitoring to reduce WIPO-related failure.
Conclusion
WIPO is a frequent and underrecognized cause of weaning failure, affecting 1 in 3 patients who fail an SBT. COPD and prior cardiomyopathy significantly increase this risk. Tailoring weaning strategies with cardiovascular assessment and selecting appropriate SBT modes could improve outcomes in vulnerable ICU populations.
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