Intensive Care Medicine

, Volume 36, Issue 7, pp 1171–1179 | Cite as

Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients

  • Belén Cabello
  • Arnaud W. Thille
  • Ferran Roche-Campo
  • Laurent Brochard
  • Francisco J. Gómez
  • Jordi ManceboEmail author



To compare cardiovascular and respiratory responses to different spontaneous breathing trials (SBT) in difficult-to-wean patients using T-piece and pressure support ventilation (PSV) with or without positive end-expiratory pressure (PEEP).


Prospective physiological study. Fourteen patients who were monitored with a Swan-Ganz catheter and had failed a previous T-piece trial were studied. Three SBTs were performed in random order in all patients: PSV with PEEP (PSV-PEEP), PSV without PEEP (PSV-ZEEP), and T-piece. PSV level was 7 cmH2O, and PEEP was 5 cmH2O. Inspiratory muscle effort was calculated, and hemodynamic parameters were measured using standard methods.

Results [median (and interquartile range)]

Most patients succeeded in the PSV-PEEP (11/14) and PSV-ZEEP (8/14) trials, but all failed the T-piece trial. Patient effort was significantly higher during T-piece than during PSV with or without PEEP [esophageal pressure-time product was 292 (238–512), 128 (58–299), and 148 (100–465) cmH2O·s/min, respectively, p < 0.05]. Left ventricular heart failure was observed in 11 of the 14 patients during the T-piece trial. Pulmonary artery occlusion pressure and respiratory rate were significantly higher during T-piece than with PSV-PEEP [21 (18–24) mmHg versus 17 (14–22) mmHg, p < 0.05 and 27 (21–35) breaths/min versus 19 (16–29) breaths/min, p < 0.05 respectively]. Tidal volume was significantly lower during the T-piece trial.


In this selected population of difficult-to-wean patients, PSV and PSV plus PEEP markedly modified the breathing pattern, inspiratory muscle effort, and cardiovascular response as compared to the T-piece. Caregivers should be aware of these differences in SBT as they may play an important role in weaning decision-making.


Weaning from mechanical ventilation Spontaneous breathing trial Pressure support ventilation Heart failure 



B.C. was supported by grants from the Instituto de Salud Carlos III (expedient CM04/00096, Ministerio de Sanidad) and the Instituto de Recerca Hospital de la Santa Creu i Sant Pau.

Supplementary material

134_2010_1870_MOESM1_ESM.doc (37 kb)
Supplementary material 1 (DOC 37 kb)


  1. 1.
    Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, Johnson MM, Browder RW, Bowton DL, Haponik EF (1996) Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 335:1864–1869CrossRefPubMedGoogle Scholar
  2. 2.
    Tobin MJ, Jubran A (2006) Variable performance of weaning-predictor tests: role of Bayes’ theorem and spectrum and test-referral bias. Intensive Care Med 32:2002–2012CrossRefPubMedGoogle Scholar
  3. 3.
    Buda AJ, Pinsky MR, Ingels NB Jr, Daughters GT 2nd, Stinson EB, Alderman EL (1979) Effect of intrathoracic pressure on left ventricular performance. N Engl J Med 301:453–459PubMedCrossRefGoogle Scholar
  4. 4.
    Lemaire F, Teboul JL, Cinotti L, Giotto G, Abrouk F, Steg G, Macquin-Mavier I, Zapol WM (1988) Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 69:171–179CrossRefPubMedGoogle Scholar
  5. 5.
    Lamia B, Maizel J, Ochagavia A, Chemla D, Osman D, Richard C, Teboul JL (2009) Echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation. Crit Care Med 37:1696–1701CrossRefPubMedGoogle Scholar
  6. 6.
    Brochard L, Rauss A, Benito S, Conti G, Mancebo J, Rekik N, Gasparetto A, Lemaire F (1994) Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 150:896–903PubMedGoogle Scholar
  7. 7.
    Esteban A, Frutos F, Tobin MJ, Alia I, Solsona JF, Valverdu I, Fernandez R, de la Cal MA, Benito S, Tomas R et al (1995) A comparison of four methods of weaning patients from mechanical ventilation Spanish Lung Failure Collaborative Group. N Engl J Med 332:345–350CrossRefPubMedGoogle Scholar
  8. 8.
    Esteban A, Alia I, Gordo F, Fernandez R, Solsona JF, Vallverdu I, Macias S, Allegue JM, Blanco J, Carriedo D, Leon M, de la Cal MA, Taboada F, Gonzalez de Velasco J, Palazon E, Carrizosa F, Tomas R, Suarez J, Goldwasser RS (1997) Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 156:459–465PubMedGoogle Scholar
  9. 9.
    Ezingeard E, Diconne E, Guyomarc’h S, Venet C, Page D, Gery P, Vermesch R, Bertrand M, Pingat J, Tardy B, Bertrand JC, Zeni F (2006) Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing. Intensive Care Med 32:165–169CrossRefPubMedGoogle Scholar
  10. 10.
    Sassoon CS, Light RW, Lodia R, Sieck GC, Mahutte CK (1991) Pressure-time product during continuous positive airway pressure, pressure support ventilation, and T-piece during weaning from mechanical ventilation. Am Rev Respir Dis 143:469–475PubMedGoogle Scholar
  11. 11.
    Koh Y, Hong SB, Lim CM, Lee SD, Kim WS, Kim DS, Kim WD (2000) Effect of an additional 1-hour T-piece trial on weaning outcome at minimal pressure support. J Crit Care 15:41–45CrossRefPubMedGoogle Scholar
  12. 12.
    Kuhlen R, Max M, Dembinski R, Terbeck S, Jurgens E, Rossaint R (2003) Breathing pattern and workload during automatic tube compensation, pressure support and T-piece trials in weaning patients. Eur J Anaesthesiol 20:10–16CrossRefPubMedGoogle Scholar
  13. 13.
    Cabello B, Mancebo J (2006) Cardiovascular and Respiratory Alterations during Different Spontanous Breathing Trials The role of congestive heart failure. Am J Respir Crit Care Med 3:A40Google Scholar
  14. 14.
    Girault C, Breton L, Richard JC, Tamion F, Vandelet P, Aboab J, Leroy J, Bonmarchand G (2003) Mechanical effects of airway humidification devices in difficult to wean patients. Crit Care Med 31:1306–1311CrossRefPubMedGoogle Scholar
  15. 15.
    Vallverdu I, Calaf N, Subirana M, Net A, Benito S, Mancebo J (1998) 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 158:1855–1862PubMedGoogle Scholar
  16. 16.
    Fishman A (1985) Pulmonary Circulation Handbook of physiology. The respiratory system Vol I. Circulation and nonrespiratory functions. American Physiological Society, Bethesda, pp 93–166Google Scholar
  17. 17.
    Baydur A, Behrakis PK, Zin WA, Jaeger MJ, Milic-Emili J (1982) A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis 126:788–791PubMedGoogle Scholar
  18. 18.
    Cabello B, Mancebo J (2006) Work of breathing. Intensive Care Med 32:1311–1314CrossRefPubMedGoogle Scholar
  19. 19.
    Mancebo J, Albaladejo P, Touchard D, Bak E, Subirana M, Lemaire F, Harf A, Brochard L (2000) Airway occlusion pressure to titrate positive end-expiratory pressure in patients with dynamic hyperinflation. Anesthesiology 93:81–90CrossRefPubMedGoogle Scholar
  20. 20.
    Fleury B, Murciano D, Talamo C, Aubier M, Pariente R, Milic Emili J (1985) Work of breathing in patients with chronic obstructive pulmonary disease in acute respiratory failure. Am Rev Respir Dis 131:822–827PubMedGoogle Scholar
  21. 21.
    Brochard L, Harf A, Lorino H, Lemaire F (1989) Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis 139:513–521PubMedGoogle Scholar
  22. 22.
    El-Khatib MF, Zeineldine SM, Jamaleddine GW (2008) Effect of pressure support ventilation and positive end expiratory pressure on the rapid shallow breathing index in intensive care unit patients. Intensive Care Med 34:505–510CrossRefPubMedGoogle Scholar
  23. 23.
    Brochard L, Pluskwa F, Lemaire F (1987) Improved efficacy of spontaneous breathing with inspiratory pressure support. Am Rev Respir Dis 136:411–415PubMedGoogle Scholar
  24. 24.
    Epstein SK, Ciubotaru RL (1996) Influence of gender and endotracheal tube size on preextubation breathing pattern. Am J Respir Crit Care Med 154:1647–1652PubMedGoogle Scholar
  25. 25.
    Smith TC, Marini JJ (1988) Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol 65:1488–1499PubMedGoogle Scholar
  26. 26.
    Richard C, Teboul JL, Archambaud F, Hebert JL, Michaut P, Auzepy P (1994) Left ventricular function during weaning of patients with chronic obstructive pulmonary disease. Intensive Care Med 20:181–186CrossRefPubMedGoogle Scholar
  27. 27.
    Lenique F, Habis M, Lofaso F, Dubois-Rande JL, Harf A, Brochard L (1997) Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure. Am J Respir Crit Care Med 155:500–505PubMedGoogle Scholar
  28. 28.
    Pierard LA, Lancellotti P (2004) The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 351:1627–1634CrossRefPubMedGoogle Scholar
  29. 29.
    Jubran A, Tobin MJ (1997) Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med 155:906–915PubMedGoogle Scholar
  30. 30.
    Jubran A, Mathru M, Dries D, Tobin MJ (1998) Continuous recordings of mixed venous oxygen saturation during weaning from mechanical ventilation and the ramifications thereof. Am J Respir Crit Care Med 158:1763–1769PubMedGoogle Scholar
  31. 31.
    Zile MR, Gaasch WH, Carroll JD, Feldman MD, Aurigemma GP, Schaer GL, Ghali JK, Liebson PR (2001) Heart failure with a normal ejection fraction: is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure? Circulation 104:779–782CrossRefPubMedGoogle Scholar
  32. 32.
    Zile MR, Baicu CF, Gaasch WH (2004) Diastolic heart failure-abnormalities in active relaxation and passive stiffness of the left ventricle. N Engl J Med 350:1953–1959CrossRefPubMedGoogle Scholar
  33. 33.
    Gandhi SK, Powers JC, Nomeir AM, Fowle K, Kitzman DW, Rankin KM, Little WC (2001) The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med 344:17–22CrossRefPubMedGoogle Scholar
  34. 34.
    Richard C, Teboul JL (2005) Weaning failure from cardiovascular origin. Intensive Care Med 31:1605–1607CrossRefPubMedGoogle Scholar
  35. 35.
    Zakynthinos S, Routsi C, Vassilakopoulos T, Kaltsas P, Zakynthinos E, Kazi D, Roussos C (2005) Differential cardiovascular responses during weaning failure: effects on tissue oxygenation and lactate. Intensive Care Med 31:1634–1642CrossRefPubMedGoogle Scholar
  36. 36.
    Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R (1994) The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824Google Scholar
  37. 37.
    Pinsky MR (2003) Clinical significance of pulmonary artery occlusion pressure. Intensive Care Med 29:175–178PubMedGoogle Scholar
  38. 38.
    Hoyt JD, Leatherman JW (1997) Interpretation of the pulmonary artery occlusion pressure in mechanically ventilated patients with large respiratory excursions in intrathoracic pressure. Intensive Care Med 23:1125–1131CrossRefPubMedGoogle Scholar
  39. 39.
    Feihl F, Broccard AF (2009) Interactions between respiration and systemic hemodynamics, part I: basic concepts. Intensive Care Med 35:45–54CrossRefPubMedGoogle Scholar
  40. 40.
    Feihl F, Broccard AF (2009) Interactions between respiration and systemic hemodynamics, part II: practical implications in critical care. Intensive Care Med 35:198–205CrossRefPubMedGoogle Scholar
  41. 41.
    Frutos-Vivar F, Ferguson ND, Esteban A, Epstein SK, Arabi Y, Apezteguía C, González M, Hill NS, Nava S, D’Empaire G, Anzueto A (2006) Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 130:1664–1671CrossRefPubMedGoogle Scholar
  42. 42.
    Upadya A, Tilluckdharry L, Muralidharan V, Amoateng-Adjepong Y, Manthous CA (2005) Fluid balance and weaning outcomes. Intensive Care Med 31:1643–1647CrossRefPubMedGoogle Scholar
  43. 43.
    Straus C, Louis B, Isabey D, Lemaire F, Harf A, Brochard L (1998) Contribution of the endotracheal tube and the upper airway to breathing workload. Am J Respir Crit Care Med 157:23–30PubMedGoogle Scholar
  44. 44.
    Epstein SK, Ciubotaru RL, Wong JB (1997) Effect of failed extubation on the outcome of mechanical ventilation. Chest 112:186–192CrossRefPubMedGoogle Scholar
  45. 45.
    Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame F, Navalesi P (2005) Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 33:2465–2470CrossRefPubMedGoogle Scholar
  46. 46.
    Ferrer M, Sellares J, Valencia M, Carrillo A, Gonzalez G, Badia JR, Nicolas JM, Torres A (2009) Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet 374:1082–1088CrossRefPubMedGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2010

Authors and Affiliations

  • Belén Cabello
    • 1
  • Arnaud W. Thille
    • 2
  • Ferran Roche-Campo
    • 1
  • Laurent Brochard
    • 2
  • Francisco J. Gómez
    • 3
  • Jordi Mancebo
    • 1
    Email author
  1. 1.Servei de Medicina IntensivaHospital Santa Creu i Sant PauBarcelonaSpain
  2. 2.Medical Intensive Care Unit, AP-HP, Centre Hospitalier Albert Chenevier-Henri MondorUniversity of Paris 12CréteilFrance
  3. 3.Departamento de MedicinaUniversidad de GranadaGranadaSpain

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