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2023, Number 7

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Med Crit 2023; 37 (7)

Ventilatory ratio as a predictor index of failure to withdrawal of invasive mechanical ventilation in the critically ill patient

Esquivel PA, Gaytán GCJ, Herrera PLJ, Mazo MB, Martínez DBA, Aguirre SJS

Language: Spanish
References: 23
Page: 525-533
PDF size: 327.43 Kb.


ABSTRACT

Introduction: weaning from invasive mechanical ventilation (IMV) is an essential element in the treatment of the critical patient. Despite this, the incidence of IMV weaning failure is not negligible, even with good predictors of success. The ventilatory ratio (VR) has been described as a bedside tool to evaluate the patient's ventilatory deterioration. Its value reflects the capacity of the lungs to eliminate carbon dioxide (CO2). In several studies, a high VR has been described as an independent predictor of mortality in patients with acute respiratory distress syndrome (ARDS); however, there are no studies that support its use as a tool to determine the probability of IMV weaning failure. Objective: to evaluate the use of VR to predict IMV weaning failure in critically ill patients.Material and methods: retrospective cohort, in patients in the intensive care unit (ICU) of the ABC Medical Center from January 2021 to August 2023. Patients with IMV in a ventilatory weaning protocol were evaluated. The VR was calculated with the formula VR = measured VE × measured PaCO2 / predicted VE x ideal PaCO2. A ROC curve and area under the curve analysis were performed to determine the best predictive performance of VR for IMV weaning failure. The cut-off points of 1, 1.2, 1.4, 1.6 were established and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each one. Likewise, the regression coefficient was estimated for each cut-off point through logistic regression models. For all determinations, the 95% confidence interval was estimated and a p value < 0.05 was considered statistically significant. Results: the cut-off point with the best performance to predict extubation failure was a VR > 1.4 with sensitivity 82.6%, specificity 56.4%, PPV 52.8% and NPV 84.6%. Likewise, the VR was positively involved in the mortality of patients in the ICU. In this regard, the best cut-off point was VR > 1.6 with sensitivity 72.7%, specificity 76.5%, PPV 40.0% and NPV 92.9%. Conclusions: VR > 1.4 is a new tool to predict failure to withdraw from IMV.


REFERENCES

  1. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J [Internet]. 2007;29(5):1033-1056. Available in: https://erj.ersjournals.com/content/erj/29/5/1033.full.pdf

  2. Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med [Internet]. 1996;335(25):1864-189. Available in: http://dx.doi.org/10.1056/nejm199612193352502

  3. Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA [Internet]. 2002;287(3):345-355. Available in: https://jamanetwork.com/journals/jama/fullarticle/194560

  4. Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med [Internet]. 2000;161(5):1530-1536. Available in: http://dx.doi.org/10.1164/ajrccm.161.5.9905102

  5. Esteban A, Frutos F, Tobin MJ, Alía I, Solsona JF, Valverdu V, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med [Internet]. 1995;332(6):345-350. Available in: http://dx.doi.org/10.1056/nejm199502093320601

  6. Vallverdú I, Calaf N, Subirana M, Net A, Benito S, Mancebo J. Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med [Internet]. 1998;158(6):1855-1862. Available in: http://dx.doi.org/10.1164/ajrccm.158.6.9712135

  7. Thille AW, Cortés-Puch I, Esteban A. Weaning from the ventilator and extubation in ICU. Curr Opin Crit Care [Internet]. 2013;19(1):57-64. Available in: https://journals.lww.com/co-criticalcare/fulltext/2013/02000/weaning_from_the_ventilator_and_extubation_in_icu.10.aspx

  8. McConville JF, Kress JP. Weaning patients from the ventilator. N Engl J Med [Internet]. 2012;367(23):2233-2239. Available in: http://dx.doi.org/10.1056/nejmra1203367

  9. Nuckton TJ, Alonso JA, Kallet RH, Daniel BM, Pittet JF, Eisner MD, et al. Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med [Internet]. 2002;346(17):1281-1286. Available in: http://dx.doi.org/10.1056/nejmoa012835

  10. Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E, Marino A, et al. Lung inhomogeneity in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med [Internet]. 2014;189(2):149-158. Available in: http://dx.doi.org/10.1164/rccm.201308-1567oc

  11. J Raurich JM, Vilar M, Colomar A, Ibáñez J, Ayestarán I, Pérez-Bárcena J, et al. Prognostic value of the pulmonary dead-space fraction during the early and intermediate phases of acute respiratory distress syndrome. Respir Care [Internet]. 2010;55(3):282-287. Available in: http://rc.rcjournal.com/content/55/3/282.abstract

  12. George Aguilar F, González Carmona BG, Bernal Ríos N, Torres Aguilar O, Monares Zepeda E, Aguirre Sánchez J, et al. Factores pronósticos en pacientes con insuficiencia respiratoria aguda con base en potencial de reclutamiento alveolar. Rev Asoc Mex Med Crit y Ter Int [Internet]. 2015;29(1):22-26. Disponible en: https://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0187-84332015000100004

  13. Sinha P, Fauvel NJ, Singh S, Soni N. Ventilatory ratio: a simple bedside measure of ventilation. Br J Anaesth [Internet]. 2009;102(5):692-697. Available in: http://dx.doi.org/10.1093/bja/aep054

  14. Sinha P, Calfee CS, Beitler JR, Soni N, Ho K, Matthay MA, et al. Physiologic analysis and clinical performance of the ventilatory ratio in acute respiratory distress syndrome. Am J Respir Crit Care Med [Internet]. 2019;199(3):333-341. Available in: http://dx.doi.org/10.1164/rccm.201804-0692oc

  15. Sinha P, Singh S, Hardman JG, Bersten AD, Soni N. Evaluation of the physiological properties of ventilatory ratio in a computational cardiopulmonary model and its clinical application in an acute respiratory distress syndrome population. Br J Anaesth [Internet]. 2014;112(1):96-101. Available in: http://dx.doi.org/10.1093/bja/aet283

  16. Sinha P, Sanders RD, Soni N, Vukoja MK, Gajic O. Acute respiratory distress syndrome: The prognostic value of ventilatory ratio—A simple bedside tool to monitor ventilatory efficiency. Am J Respir Crit Care Med [Internet]. 2013;187(10):1150-1153. Available in: http://dx.doi.org/10.1164/rccm.201211-2037le

  17. Nunn JF. Ventilation nomograms during anaesthesia. Anaesthesia [Internet]. 1960;15:65. Available in: http://dx.doi.org/10.1111/j.1365-2044.1960.tb13898.x

  18. Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med [Internet]. 2000;342(18):1301-1308. Available in: http://dx.doi.org/10.1056/nejm200005043421801

  19. Sinha P, Fauvel NJ, Singh P, Soni N. Analysis of ventilatory ratio as a novel method to monitor ventilatory adequacy at the bedside. Crit Care [Internet]. 2013;17(1):R34. Available in: http://dx.doi.org/10.1186/cc1254

  20. Kallet RH, Alonso JA, Pittet JF, Matthay MA. Prognostic value of the pulmonary dead-space fraction during the first 6 days of acute respiratory distress syndrome. Respir Care [Internet]. 2004;49(9):1008-1014. Available in: http://rc.rcjournal.com/content/49/9/1008.abstract

  21. Siddiki H, Kojicic M, Li G, Yilmaz M, Thompson TB, Hubmayr RD, et al. Bedside quantification of dead-space fraction using routine clinical data in patients with acute lung injury: secondary analysis of two prospective trials. Crit Care [Internet]. 2010;14(4):R141. Available in: http://dx.doi.org/10.1186/cc9206

  22. Ferguson ND, Kacmarek RM, Chiche JD, Singh JM, Hallett DC, Mehta S, et al. Screening of ARDS patients using standardized ventilator settings: influence on enrollment in a clinical trial. Intensive Care Med [Internet]. 2004;30(6):1111-1116. Available in: http://dx.doi.org/10.1007/s00134-004-2163-2

  23. Witts LJ. Clinical trials. Br Med J. 1963;1(5336):1015.




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