CLINICS 2011;66(1):107-111 DOI:10.

1590/S1807-59322011000100019

CLINICAL SCIENCE
Echocardiographic evaluation during weaning from
mechanical ventilation
Luciele Medianeira Schifelbain,I Silvia Regina Rios Vieira,II Janete Salles Brauner,III Deise Mota Pacheco,IV
Alexandre Antonio NaujorksIV
I
Intensive Care Unit, Hospital de Caridade Dr. Astrogildo de Azevedo, Santa Maria, RS, Brazil. II Intensive Care Unit, Hospital de Clı́nicas de Porto Alegre
(HCPA), Porto Alegre, RS, Brazil. III Intensive Care Unit, HCPA, Porto Alegre, RS, Brazil; Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil.
IV
Department of Cardiology, Hospital de Caridade Dr. Astrogildo de Azevedo, Santa Maria, RS, Brazil.

INTRODUCTION: Echocardiographic, electrocardiographic and other cardiorespiratory variables can change during
weaning from mechanical ventilation.

OBJECTIVES: To analyze changes in cardiac function, using Doppler echocardiogram, in critical patients during
weaning from mechanical ventilation, using two different weaning methods: pressure support ventilation and T-
tube; and comparing patient subgroups: success vs. failure in weaning.

METHODS: Randomized crossover clinical trial including patients under mechanical ventilation for more than 48 h
and considered ready for weaning. Cardiorespiratory variables, oxygenation, electrocardiogram and Doppler
echocardiogram findings were analyzed at baseline and after 30 min in pressure support ventilation and T-tube.
Pressure support ventilation vs. T-tube and weaning success vs. failure were compared using ANOVA and Student’s
t-test. The level of significance was p,0.05.

RESULTS: Twenty-four adult patients were evaluated. Seven patients failed at the first weaning attempt. No
echocardiographic or electrocardiographic differences were observed between pressure support ventilation and T-
tube. Weaning failure patients presented increases in left atrium, intraventricular septum thickness, posterior wall
thickness and diameter of left ventricle and shorter isovolumetric relaxation time. Successfully weaned patients had
higher levels of oxygenation.

CONCLUSION: No differences were observed between Doppler echocardiographic variables and electrocardio-
graphic and other cardiorespiratory variables during pressure support ventilation and T-tube. However cardiac
structures were smaller, isovolumetric relaxation time was larger, and oxygenation level was greater in successfully
weaned patients.

KEYWORDS: Echocardiography; Doppler echocardiogram; Cardiorespiratory variables; Ventilator weaning;

Artificial ventilation.
Schifelbain LM, Vieira SRR, Brauner JS, Pacheco DM, Naujorks AA. Echocardiographic evaluation during weaning from mechanical ventilation. Clinics.
2011;66(1):107-111.
Received for publication on October 14, 2010; First review completed on October 14, 2010; Accepted for publication on October 19, 2010
E-mail: luciele@terra.com.br
Tel.: 55 55 3222-2448

INTRODUCTION (LV) afterload, O2 consumption and catecholamine secre-

tion.
Weaning from mechanical ventilation (MV) involves The return of spontaneous breathing can increase
changes in the interaction between patient and ventilator. myocardial O2 demand and the product of heart rate 6
During weaning, the support provided by the ventilator is arterial blood pressure by as much as 35%, which can lead
reduced, while the patient progressively takes over the to myocardial ischemia. However, this increase was not
work of breathing.1 Changes associated with transition from associated with weaning failure.2–4 A study of 15 patients
MV to spontaneous ventilation overload the cardiorespira- with chronic obstructive pulmonary disease who failed
tory system with increases in: venous return, left ventricle during weaning from MV demonstrated that, during the
first 10 min of spontaneous breathing, there was an increase
in cardiac index (CI), heart rate (HR), central venous
pressure (CVP) and arterial blood pressure (BP).5 An
Copyright ß 2011 CLINICS – This is an Open Access article distributed under increase in pulmonary capillary wedge pressure (PCWP)
the terms of the Creative Commons Attribution Non-Commercial License (http:// from 8 to 25 mmHg was associated with evidence of acute
creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-
commercial use, distribution, and reproduction in any medium, provided the respiratory failure due to increased preload.5 After 1 week
original work is properly cited. of treatment with diuretics, these patients were weaned

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Echocardiography and weaning from ventilation CLINICS 2011;66(1):107-111
Schifelbain LM et al.

successfully.5 There is evidence that 6–10% of patients The weaning protocol was interrupted if the patient
exhibit electrocardiographic findings of cardiac ischemia exhibited: oxygen arterial saturation (SaO2) ,88%, oxygen
while being weaned, mainly those with coronary artery arterial pressure (PaO2) ,60–55 mmHg; respiratory rate (f)
disease.5 .35–38 rpm or increased by 50%; HR .140 bpm or
Echocardiography is being used routinely in some increased by 20%; systolic blood pressure .180 mmHg or
intensive care units (ICUs). It permits direct observation of ,90 mmHg or increased/reduced by 20%; and agitation,
all cardiac structures and the patient’s hemodynamic status, diaphoresis or a reduced level of consciousness. This was
allowing immediate intervention related to volume replace- considered failure of the weaning trial.
ment and the use of inotropic agents.6,7 In patients on MV, Clinical status, respiratory mechanics and arterial blood
its use can explain some cardiac morphological and gas analyses, electrocardiograms (ECG) and echocardio-
functional analyses that may influence weaning from MV, grams were performed during the trial period (at baseline
particularly when weaning is difficult or there is refractory and at the 30th minute of each ventilation mode). If
hypoxemia that cannot be explained by lung disease alone.8 the patient showed signs of decompensation before the
Nevertheless, there are few descriptions in the literature of predetermined time, the assessment was performed
bedside studies of these cardiorespiratory changes during immediately and the patient placed back on MV with
weaning from MV using echocardiography.9,10 the same parameters used at the beginning of the weaning
The objective of this study was to analyze changes in protocol.
cardiac function using Doppler echocardiogram in critical Clinical assessment included data on identification, diag-
patients in a general ICU during weaning from MV using nosis, Acute Physiologic and Chronic Health Evaluation
pressure support ventilation (PSV) and T-tube, and to (APACHE) II score for the first 24 h after admission, level of
compare a subgroup of patients: success vs. failure during consciousness, preexisting heart disease, use of sedative
the weaning trial. drugs and opioids, type of mechanical ventilator used,
ventilation mode, MV parameters and arterial blood gas
analysis. Patients were also monitored non-invasively: BP,
MATERIALS AND METHODS HR, f and SaO2 using a multiparameter monitor (Philips;
This study included adult patients (18 years or more) USA). Ventilation mechanics were monitored using a
admitted to the adult general ICU of a hospital requiring VENTRAK 1500 (Novametrix Medical Systems, Walling-
invasive MV for at least 48 h and considered ready for ford, CT, USA) connected to a PC Pentium 100 using
weaning by the medical team. It was a randomized software provided by Novametrix for data storage and later
crossover clinical trial aiming to study changes in echocar- analysis. The following parameters were analyzed: f (rpm),
diographic cardiac function variables (both systolic and tidal volume (VT = mL), minute volume (Ve = L/min),
diastolic) and other cardiorespiratory and electrocardio- rapid–shallow breathing index (RSBI or f/VT) and airway
graphic variables related to weaning from MV during two occlusion pressure (P0.1).
methods of weaning (PSV and T-tube). The research Cardiac performance was assessed using 12-lead ECG
protocol was approved by the appropriate research ethics and echocardiogram using a Caris ultrasound machine
committee. (Esaote Spa, Genova, Italy) with pulse, continuous and
All patients were hemodynamically stable with normal color Doppler, and a 2.5–3.5 MHz transducer, coupled to a
central blood pressure values, conscious (Glasgow scale 17-inch Sony Cpd-e200 monitor. The following data were
$13), with adequate gaseous exchange (O2 saturation analyzed: Mode M; bidimensional mode; spectral and
$95%, fraction of inspired oxygen (FiO2) #40% and positive tissue Doppler and myocardial performance index (Tei
end-expiratory pressure (PEEP) = 5, with pulmonary radi- index). Ejection fraction was determined using the Teicholz
ological characteristics as in baseline conditions, no acidosis method as it offers greater accuracy than the Cubo method,
or alkalosis), normal electrolyte levels and the presence of has less interobserver variation and is less dependent on an
respiratory drive. Informed consent was signed by the optimal echocardiographic window to obtain measure-
patients and/or family members. Exclusion criteria ments than the Simpson method.11 Doppler echocardio-
included hemodynamic instability, severe intracranial dis- graphy was used to assess LV systolic and diastolic
ease and barotrauma. function and structural abnormalities. Echocardiogram
The sequence in which the methods were implemented was always performed by the same cardiologist. Echo-
was determined by randomly selecting sealed envelopes. cardiogram and ECG were done at baseline and in the 30th
This randomization was carried out by the duty physician minute of each method after resting for 30 min between
before the patient was enrolled in the protocol. Patients methods.
were submitted to a baseline assessment and then placed on
the first method of weaning for 30 min. After a rest period of Statistical analysis
30 min, patients were submitted to the other method for Measurements obtained during PSV and T-tube were
30 min. compared. Patients were classified into two groups based on
One weaning method was T-tube, in which patients made weaning success or failure.
the inspiratory and expiratory effort unaided, receiving Analyses were performed with the aid of Statistical
oxygen at 5 L/min. The other method was PSV in which Package for the Social Sciences (SPSS) 12.0, and results
patients breathing was aided by equipment with graduated were presented as mean¡standard deviation or median
inspiratory pressure at an inspiratory level of 10 cmH2O. (interquartile 25–75). Comparisons were made using
This PSV level is routinely used in the ICU during weaning Student’s t-test for paired and unpaired samples and
trials. The humidification system used was heat- and analysis of variance (ANOVA) for repeated measures. The
moisture-exchanging (HME) filters. level of significance was set at p,0.05.

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Schifelbain LM et al.

RESULTS Table 2 - Baseline Doppler echocardiographic assessment

During the period between December 2005 and August of the patient sample (mean¡SD).
2007, 24 patients were assessed. Thirteen (58%) patients Success (n = 17) Failure (n = 7) p*
were male, and the mean age was 53¡20 years. Mean
APACHE score was 18¡14. Median time on MV was 13 (8– LA (mm) 34.4¡5.1 41.9¡2.9 0.001
RV (mm) 18.3¡3.2 22.6¡6.3 0.135
21) days and length of stay in the ICU was 22 (13–35) days.
LVS (mm) 39.9¡4.4 33.4¡7.1 0.416
Eight patients (33%) had neurological diseases, and the LVD (mm) 50.5¡4.7 56.3¡5.3 0.016
remaining patients had been admitted for sepsis, general SEP (mm) 9.3¡1.5 11.3¡0.8 0.006
postoperative care, neoplasms and respiratory infections. PW (mm) 9.3¡1.6 11.3¡0.9 0.006
Ten patients (41.7%) had a history of hypertension and/or EF (%) 70.2¡5.9 69.6¡11.7 0.900
thoracic pain, with no history of myocardial infarction or E (m/s) 0.71¡0.14 0.82¡0.29 0.352
A (m/s) 0.76¡0.25 0.67¡0.3 0.444
previous left ventricular failure. Eleven patients were
E/A Ra 1.02¡0.39 1.53¡0.98 0.221
tracheostomized. Seven patients failed during the weaning IVRT (m/s) 112¡31.4 84.5¡20.8 0.046
trial. Two of them died and five were weaned later. Of the DT (m/s) 239¡72 187¡43 0.101
successfully weaned patients, only one was reintubated E9 (m/s) 0.09¡0.03 0.13¡0.04 0.053
after 5 days, and one died because of a lymphoma. The A9 (m/s) 0.14¡0.12 0.29¡0.36 0.329
individual characteristics of the patients assessed are E/E9 Ra 8.25¡2.95 7.24¡3.62 0.480
Tei index 0.60¡0.18 0.66¡0.46 0.614
described in Table 1.
At baseline, all patients were on MV settings, with PSV at A = peak velocity of A wave; A9 = A9 wave; DT = deceleration time; E = peak
15–20 cmH2O, PEEP at 5 cmH2O and a FiO2 of 0.4. With velocity of E wave; E9 = E9 wave; E/A Ra = E/A ratio; E/E9 Ra = E/E9 ratio;
respect to the variables analyzed at baseline and at the end EF = ejection fraction; IVRT = isovolumetric relaxation time; LA = left
atrium; LV = left ventricle; LVD = left ventricle diastolic diameter; LVS = left
of 30 min using Doppler echocardiogram, the size of the left
ventricle systolic diameter; Tei index = myocardial performance index;
atrium (LA), the interventricular septum, the posterior wall PW = posterior wall; RV = right ventricle; SEP = interventricular septum.
and LV diastolic diameter (LVD) were all significantly *
Unpaired t-test.
smaller among patients who were successfully weaned from
MV at the first attempt. Isovolumetric relaxation time Twelve-lead electrocardiograms did not detect any differ-
(IVRT) was significantly shorter among patients whose
ences between baseline assessment and weaning modes
weaning failed. The Tei index values were slightly higher
assessed. No changes in ST segment were detected during
among patients who failed, but without statistical signifi-
continuous cardiac monitoring.
cance (Table 2).
There were no statistical differences for cardiorespiratory
The mean Doppler echocardiography results during the
assessment during baseline and weaning trials. However,
two weaning modes (PSV, T-tube) were very similar, and no
patients whose weaning was successful showed higher
differences were observed when comparing the outcome
PaO2 and SaO2 (133¡30 vs. 103¡33, p = 0.04; and 98¡1.1
(success vs. failure in Table 3). Results observed during PSV
vs. 96¡1.9, p = 0.01). We also observed a tendency to a lower
and T-tube were similar to values observed at baseline.
f/VT (75¡39 vs. 91¡19, p = 0.13) and to a lower P0.1
(0.46¡0.17 vs. 0.62¡0.09, p = 0.4) during T-tube in this
Table 1 - Clinical characteristics of the patients assessed. group of patients.
Time on Hypertension/
Age Sex APACHE II MV thoracic pain Outcome DISCUSSION
57 W 22 7 Yes Success There were no differences between the Doppler echocar-
35 W 22 8 No Success diography variables during the two weaning methods. The
65 W 18 31 Yes Failure analysis of the Doppler echocardiograms demonstrated that
90 M 24 45 No Failure
the sizes of cardiac structures were significantly smaller in
27 W 11 66 No Success
45 M 6 4 No Success
patients who were successfully weaned from MV at the first
32 M 19 50 Yes Success attempt, whereas IVRT was significantly shorter among
64 M 17 12 No Success patients whose weaning failed. Considering cardiorespira-
51 M 23 28 Yes Failure tory variables, PaO2 and SaO2 were significantly higher
66 W 32 13 No Success among successfully weaned patients with no other sig-
74 W 17 11 Yes Success
nificant differences.
27 M 21 23 Yes Failure
68 W 24 8 No Success Several research teams have investigated prognostic
76 M 16 16 Yes Success indices for weaning success, including f/VT ratio12–14 and
51 M 6 7 Yes Success P0.1.15 The lower the f/VT, the greater the chance of
21 M 16 15 No Success successfully withdrawing MV.12,14,16 In our study, f/VT
22 M 19 21 No Success was higher and P0.1 was lower among patients who could
51 W 22 19 No Success
34 M 2 12 No Failure
not be weaned, although without statistical difference.
45 W 22 7 No Success However, in agreement with the literature, successfully
78 M 34 11 Yes Failure weaned patients showed better oxygenation levels.15
72 M 15 14 Yes Success Physiological changes associated with the transition from
63 W 12 7 No Success MV to spontaneous breathing involve an overload of the
68 M 23 13 No Failure
cardiorespiratory system: increased venous return (pre-
APACHE = Acute Physiologic and Chronic Health Evaluation; M = man; load), increased LV afterload, increase in O2 consumption
MV = mechanical ventilation; W = woman. from 15% to 25% and increased secretion of catecholamines.

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Schifelbain LM et al.

Table 3 - Mean Doppler echocardiogram results for analyzed weaning patients and observed that echocardio-
minute 30 using PSV and T-Tube: weaning success vs. gram can detect T-tube-induced changes in the central
failure (mean¡SD). hemodynamic status, helping to identify patients at high
risk of cardiac-related weaning failure. Cabello et al.,18
PSV T-tube p* monitoring weaning patients with a Swan–Ganz catheter,
also observed differences in cardiovascular responses
LA (mm)
Success 33¡3.8 34¡6 comparing T-tube with PSV. It is important to consider
Failure 35¡3.2 35¡2.6 0.68 that, in these studies, there was a large number of patients
RV (mm) with cardiac diseases and/or signs of cardiac failure. In our
Success 18¡3.8 18¡4.1 sample, patients were under MV for a long period of time,
Failure 20¡5.7 22¡2.7 0.12
but there was no evidence of preexisting defined heart
LVS (mm)
Success 31¡4.4 31¡4.1
disease or LV failure.
Failure 32¡6.1 31¡8.7 0.32 The baseline LA diameter, intraventricular septum thick-
LVD (mm) ness, posterior wall thickness and LV diastolic diameter
Success 51¡3.9 51¡5.2 were significantly larger among patients whose weaning
Failure 54¡6.2 54¡7.7 0.77 failed. It has been demonstrated that increased LA size
SEP
Success 9¡1.9 9¡1.8
could cause an increased filling pressure due to reduced LV
Failure 11¡0.8 11¡0.8 0.81 compliance or diastolic dysfunction. There is evidence in the
PW literature suggesting that this increase in the size of the LA
Success 9¡1.6 9¡2.3 measured by echocardiography could be predictive of
Failure 11¡0.9 11¡0.8 0.83 cardiovascular outcomes even in individuals without atrial
EF (%)
pathologies or valve disease.19,20
Success 70¡8.4 69¡6.1
Failure 71¡10 73¡10 0.23 We also observed in our study that the value of IVRT was
E (m/s) significantly lower among failing weaning patients. Also,
Success 0.70¡0.23 0.80¡0.17 the pressure gradient represented by the deceleration time,
Failure 0.82¡0.22 0.81¡0.24 0.16 which normally changes in line with IVRT, was lower,
A (m/s) although not statistically significant among patients
Success 0.77¡0.23 0.76¡0.26
Failure 0.71¡0.23 0.69¡0.22 0.34
who failed. The deceleration time is characteristically pro-
E/A Ra longed when relaxation is abnormal and becomes shorter
Success 1.12¡0.47 1.15¡0.46 when relaxation is rapid or high ventricular filling pressures
Failure 1.31¡0.65 1.38¡0.84 0.84 occur.21 The IVRT can be influenced by factors including
IVRT (m/s) ischemia, hypoxemia and right ventricle overload (which
Success 107¡24 97¡17
prolong the time) and blood volume status (indirect
Failure 84¡24 88¡19 0.21
DT (m/s) variation). Its absolute value is inversely related to
Success 233¡64 215¡61 PCWP,22 i.e. the lower the value of IVRT, the higher the
Failure 192¡36 198¡35 0.48 PCWP.23 Our patients did not exhibit hypervolemia,
E9 (m/s) which could have influenced the behavior of echocardio-
Success 0.105¡0.03 0.102¡0.03 graphic measurements. The preload, assessed in terms
Failure 0.108¡0.03 0.096¡0.03 0.23
A9 (m/s)
of the E/E9 ratio measured by tissue Doppler, demon-
Success 0.121¡0.03 0.140¡0.8 strated variation within normal limits (below 15),24 without
Failure 0.123¡0.04 0.106¡0.03 0.11 any significant difference between the two groups of
E/E9 Ra patients.
Success 7.92¡4.33 8.54¡3.39 Our research did not demonstrate electrocardiographic
Failure 7.83¡2.37 8.62¡1.84 0.86
Tei index
abnormalities at all assessment situations, suggesting less or
Success 0.61¡0.19 0.53¡0.13 no heart disease among these patients who were admitted
Failure 0.58¡0.20 0.48¡0.12 0.94 predominantly as a result of neurological and infectious
diseases, with only prior history of hypertension recorded.
A = peak velocity of A wave; A9 = A9 wave; DT = deceleration time; E = peak
velocity of E wave; E9 = E9 wave; E/A Ra = E/A ratio; E/E9 Ra = E/E9 ratio; Research evaluation of weaning from MV has demonstrated
EF = ejection fraction; IVRT = isovolumetric relaxation time; LA = left cardiac ischemia mainly in patients with known coronary
atrium; LVD = left ventricle diastolic diameter; LVS = left ventricle systolic artery disease, and sometimes also in normal patients.4,25–29
diameter; Tei index = myocardial performance index; PSV = pressure
In an earlier study carried out by our team, ST segment
support ventilation; PW = posterior wall; SEP = interventricular septum.
*
ANOVA. abnormalities suggestive of myocardial ischemia were also
observed on ECG during both methods of weaning, but in
In patients with preexisting heart disease (coronary artery this previous study, a greater number of severe cardiac
disease and LV insufficiency), these physiological changes patients was included.30
associated with spontaneous breathing can trigger LV As limitations of this study, we have to consider that the
failure, which in turn may lead to respiratory failure and number of patients evaluated was small. In addition, no
unsuccessful weaning.2,3,17 In our study, there were no severe ischemic heart or heart failure patients were
differences in cardiorespiratory variables analyzed by included, which may explain the absence of ischemia and
echocardiography between the two weaning methods, cardiac dysfunction during weaning. Another limitation is
suggesting equivalency between both methods of weaning that, although no patient had clinical signs of cardiac failure,
in the population studied. Our results are in disagreement fluid balance or the use of diuretic drugs before the weaning
with recent data published in the literature.10,18 Caille et al.10 trial were not recorded.

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CLINICS 2011;66(1):107-111 Echocardiography and weaning from ventilation
Schifelbain LM et al.

13. Yang KL, Tobin MJ. A prospective study of indexes predicting the
CONCLUSION outcome of trials of weaning from mechanical ventilation. N Engl J Med.
1991;324:1445-50, doi: 10.1056/NEJM199105233242101.
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echocardiographic evaluation or in electrocardiographic American College of Chest Physicians; American Association for
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support: a collective task force facilitated by the American College of
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