Comparisons of predictive performance of breathing pattern variability measured during T-piece, automatic tube compensation, and pressure support ventilation for weaning intensive care unit patients from mechanical ventilation*

Objective:To investigate the influence of different ventilatory supports on the predictive performance of breathing pattern variability for extubation outcomes in intensive care unit patients. Design and Setting:A prospective measurement of retrospectively analyzed breathing pattern variability in a medical center. Patients:Sixty-eight consecutive and ready-for-weaning patients were divided into success (n = 45) and failure (n = 23) groups based on their extubation outcomes. Measurements:Breath-to-breath analyses of peak inspiratory flow, total breath duration, tidal volume, and rapid shallow breathing index were performed for three 30-min periods while patients randomly received T-piece, 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure, and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure trials. Coefficient of variations and data dispersion (standard descriptor values SD1 and SD2 of the Poincaré plot) were analyzed to serve as breathing pattern variability indices. Main Results:Under all three trials, breathing pattern variability in extubation failure patients was smaller than in extubation success patients. Compared to the T-piece trial, 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure decreased the ability of certain breathing pattern variability indices to discriminate extubation success from extubation failure. The areas under the receiver operating characteristic curve of these breathing pattern variability indices were: T-piece (0.73–0.87) > 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure (0.60–0.79) > 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure (0.53–0.76). Analysis of the classification and regression tree indicated that during the T-piece trial, a SD1 of peak inspiratory flow >3.36 L/min defined a group including all extubation success patients. Conversely, the combination of a SD1 of peak inspiratory flow ≤3.36 L/min and a coefficient of variations of rapid shallow breathing index ≤0.23 defined a group of all extubation failure patients. The decision strategies using SD1 of peak inspiratory flow and coefficient of variations of rapid shallow breathing index measured during 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure trials achieved a less clear separation of extubation failure from extubation success. Conclusions:Since 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure reduce the predictive performance of breathing pattern variability, breathing pattern variability measurement during the T-piece trial is the best choice for predicting extubation outcome in intensive care unit patients patients.

[1]  Lu-qing Wei,et al.  A Decision-Tree Model for Predicting Extubation Outcome in Elderly Patients After a Successful Spontaneous Breathing Trial , 2010, Anesthesia and analgesia.

[2]  Vasilios Papaioannou,et al.  Biosignal analysis techniques for weaning outcome assessment. , 2010, Journal of critical care.

[3]  M. Bien,et al.  Rapid shallow breathing index and its predictive accuracy measured under five different ventilatory strategies in the same patient group. , 2010, The Chinese journal of physiology.

[4]  J. Bates,et al.  Variation in the rapid shallow breathing index associated with common measurement techniques and conditions. , 2009, Respiratory care.

[5]  Pablo Casaseca-de-la-Higuera,et al.  A Multichannel Model-Based Methodology for Extubation Readiness Decision of Patients on Weaning Trials , 2009, IEEE Transactions on Biomedical Engineering.

[6]  P. Singer,et al.  Prediction of extubation outcome: a randomised, controlled trial with automatic tube compensation vs. pressure support ventilation , 2009, Critical care.

[7]  E. Knobel,et al.  Automatic versus manual pressure support reduction in the weaning of post-operative patients: a randomised controlled trial , 2009, Critical care.

[8]  T. Similowski,et al.  Source of human ventilatory chaos: Lessons from switching controlled mechanical ventilation to inspiratory pressure support in critically ill patients , 2008, Respiratory Physiology & Neurobiology.

[9]  L. Goldman,et al.  Airway pressure alters wavelet fractal dynamics and short-range dependence of respiratory variability , 2008, Respiratory Physiology & Neurobiology.

[10]  Pierre Baconnier,et al.  Effects of hypercapnia and hypocapnia on ventilatory variability and the chaotic dynamics of ventilatory flow in humans. , 2007, American journal of physiology. Regulatory, integrative and comparative physiology.

[11]  N. MacIntyre.  Discontinuing mechanical ventilatory support. , 2006, Chest.

[12]  E. Naumova,et al.  A randomized, controlled trial of the role of weaning predictors in clinical decision making* , 2006, Critical care medicine.

[13]  Thomas Similowski,et al.  Reduced breathing variability as a predictor of unsuccessful patient separation from mechanical ventilation* , 2006, Critical care medicine.

[14]  Pablo Casaseca-de-la-Higuera,et al.  Weaning from mechanical ventilation: a retrospective analysis leading to a multimodal perspective , 2006, IEEE Transactions on Biomedical Engineering.

[15]  P. Singer,et al.  Extubation outcome following a spontaneous breathing trial with automatic tube compensation versus continuous positive airway pressure , 2006, Critical care medicine.

[16]  T. Similowski,et al.  La variabilité du comportement ventilatoire : perspectives pour le malade de réanimation , 2006 .

[17]  J. Guttmann,et al.  "Simplify your life" does not necessarily work when applying automatic tube compensation and proportional assist ventilation. , 2005, Critical care medicine.

[18]  I. Grossbach-Landis,et al.  Weaning from mechanical ventilation , 2005, ERS practical Handbook of Invasive Mechanical Ventilation.

[19]  I. Moppett,et al.  Breathing pattern and workload during automatic tube compensation, pressure support and T-piece trials in weaning patients. , 2005, European journal of anaesthesiology.

[20]  Huey-Wen Yien,et al.  Instability of spontaneous breathing patterns in patients with persistent vegetative state , 2005, Respiratory Physiology & Neurobiology.

[21]  Huey-Wen Yien,et al.  Breathing pattern variability: a weaning predictor in postoperative patients recovering from systemic inflammatory response syndrome , 2004, Intensive Care Medicine.

[22]  R Rossaint,et al.  Breathing pattern and workload during automatic tube compensation, pressure support and T-piece trials in weaning patients , 2003, European journal of anaesthesiology.

[23]  J. Guttmann,et al.  Extubation after breathing trials with automatic tube compensation, T‐tube, or pressure support ventilation , 2002, Acta anaesthesiologica Scandinavica.

[24]  Martin J Tobin,et al.  Dyspnea and decreased variability of breathing in patients with restrictive lung disease. , 2002, American journal of respiratory and critical care medicine.

[25]  G. Guyatt,et al.  Predicting success in weaning from mechanical ventilation. , 2001, Chest.

[26]  D Hess,et al.  Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. , 2001, Chest.

[27]  B. Lanini,et al.  Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autonomous breathing. , 2001, American journal of respiratory and critical care medicine.

[28]  G. Benchetrit.  Breathing pattern in humans: diversity and individuality. , 2000, Respiration physiology.

[29]  N. Calaf,et al.  Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. , 1998, American journal of respiratory and critical care medicine.

[30]  M. Engoren,et al.  Approximate entropy of respiratory rate and tidal volume during weaning from mechanical ventilation. , 1998, Critical care medicine.

[31]  M. Tobin,et al.  Effect of resistive loading on variational activity of breathing. , 1998, American journal of respiratory and critical care medicine.

[32]  E. Bruce,et al.  Chemoreflex and vagal afferent mechanisms enhance breath to breath variability of breathing. , 1997, Respiration physiology.

[33]  B. Krieger,et al.  Serial measurements of the rapid-shallow-breathing index as a predictor of weaning outcome in elderly medical patients. , 1997, Chest.

[34]  R. Branson,et al.  Use of the rapid/shallow breathing index as an indicator of patient work of breathing during pressure support ventilation. , 1997, Surgery.

[35]  J. Guttmann,et al.  Breathing pattern and additional work of breathing in spontaneously breathing patients with different ventilatory demands during inspiratory pressure support and automatic tube compensation , 1997, Intensive Care Medicine.

[36]  C. Manthous,et al.  The unassisted respiratory rate/tidal volume ratio accurately predicts weaning outcome in postoperative patients. , 1997, Critical care medicine.

[37]  R. Harper,et al.  Dynamics of Respiratory Patterning in Normal Infants and Infants Who Subsequently Died of the Sudden Infant Death Syndrome , 1996, Pediatric Research.

[38]  S. Venkataraman,et al.  Predictors of extubation success and failure in mechanically ventilated infants and children. , 1996, Critical care medicine.

[39]  C. Manthous,et al.  The unassisted respiratory rate-tidal volume ratio accurately predicts weaning outcome. , 1996, The American journal of medicine.

[40]  M. Tobin,et al.  A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. , 1992, The New England journal of medicine.

[41]  M. Tobin,et al.  Measurement of minute ventilation in ventilator‐dependent patients: Need for standardization , 1991, Critical care medicine.

[42]  A D Bersten,et al.  Additional work of breathing imposed by endotracheal tubes, breathing circuits, and intensive care ventilators. , 1989, Critical care medicine.

[43]  E. DeLong,et al.  Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. , 1988, Biometrics.

[44]  J. Marini,et al.  Estimation of inspiratory muscle strength in mechanically ventilated patients: The measurement of maximal inspiratory pressure , 1986 .

[45]  N. Anthonisen,et al.  Breathing patterns in patients with chronic obstructive pulmonary disease. , 1984, The American review of respiratory disease.

[46]  J. Bertrand,et al.  Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing , 2005, Intensive Care Medicine.

[47]  M. El-Khatib,et al.  Pattern of spontaneous breathing: potential marker for weaning outcome , 2001, Intensive Care Medicine.

[48]  Eugene N. Bruce,et al.  Mechanisms and analysis of ventilatory stability , 1995 .