Résumé
La survenue d’un œdème aigu pulmonaire est une cause fréquente d’échec du sevrage de la ventilation mécanique, en particulier chez les patients ayant une cardiopathie gauche sous-jacente et une bronchopneumopathie chronique obstructive associée. Trois phénomènes initiateurs à l’origine d’un cercle vicieux sont principalement responsables de l’apparition d’un œdème pulmonaire cardiogénique de sevrage: 1) la négativation de la pression intrathoracique responsable de l’augmentation du retour veineux systémique, du volume sanguin central et de la précharge ventriculaire gauche (VG) ainsi que de l’augmentation de la postcharge VG; 2) l’augmentation du travail respiratoire entraînant une augmentation de la consommation myocardique en oxygène, facteur favorisant la survenue d’une ischémie myocardique chez les patients prédisposés; 3) l’intense stimulation sympathique induite par le stress émotionnel, l’hypoxémie et l’éventuelle hypercapnie survenant lors du débranchement du respirateur. L’œdème pulmonaire de sevrage peut être diagnostiqué sur l’élévation de la pression artérielle pulmonaire d’occlusion lors d’un test de ventilation spontanée (VS). Des moyens moins invasifs que le cathétérisme artériel pulmonaire ont été récemment développés pour diagnostiquer un œdème pulmonaire de sevrage. Ainsi, les variations lors d’un test de VS, d’indices échocardiographiques de la fonction diastolique gauche, ou de la concentration de biomarqueurs tels que le B-type natriuretic peptide (BNP), ou mieux encore de la protidémie ont été démontrés avoir un intérêt diagnostique. Il est important d’identifier les patients présentant un œdème pulmonaire de sevrage car un traitement approprié par diurétiques et/ou vasodilatateurs (comme les dérivés nitrés), choisi en fonction du mécanisme supposé être prédominant, peut permettre le succès du sevrage.
Abstract
Acute pulmonary oedema is a frequent cause of failure of weaning from mechanical ventilation, especially in patients with underlying left-sided heart disease and associated chronic obstructive pulmonary disease. There are three main factors that can lead to the development of cardiogenic pulmonary oedema during weaning: (1) negative intrathoracic pressure, which leads to an increase in systemic venous return pressure, central blood volume and left ventricular preload, as well as increasing the left ventricular afterload; (2) increase in respiratory rate, leading to an increase in myocardial oxygen demand, which increases the risk of myocardial ischaemia in predisposed patients and (3) intense stimulation of the sympathetic nervous system caused by emotional stress, hypoxaemia, and in some cases, hypercapnia when patients are disconnected from a ventilator. An increase in pulmonary artery occlusion pressure measured during a spontaneous breathing trial using a pulmonary artery catheter can be used to help diagnose weaning-induced pulmonary oedema. Less invasive diagnostic methods have also recently been developed. Thus, during a spontaneous breathing trial, changes in echocardiographic indices of left ventricular function or in B-type natriuretic peptide (BNP) biomarker levels and in plasma protein concentration have been reported to have diagnostic value in weaning-induced pulmonary oedema. It is important to diagnose patients presenting with weaning-induced pulmonary oedema, as appropriate treatment with diuretics and/or vasodilators (e.g. nitrate derivatives), based on the predominant mechanism, can enable successful weaning.
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Cet article correspond à la conférence faite par l’auteur au congrès de la SRLF 2012 dans la session : Sevrage difficile.
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Hamzaoui, O., Monnet, X. & Teboul, J.L. Sevrage difficile d’origine cardiaque. Réanimation 21 (Suppl 2), 426–433 (2012). https://doi.org/10.1007/s13546-011-0342-z
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DOI: https://doi.org/10.1007/s13546-011-0342-z
Mots clés
- Œdème pulmonaire cardiogénique
- Sevrage de la ventilation
- Cathétérisme artériel pulmonaire
- Pression artérielle pulmonaire d’occlusion
- Échocardiographie
- B-type natriuretic peptide (BNP)
- Protidémie