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Clinical question: Does fluid management guided by daily plasma natriuretic peptide-driven (BNP) levels in mechanically ventilated patients improve weaning outcomes compared with usual therapy dictated by clinical acumen?

Background: Ventilator weaning contributes at least 40% of the total duration of mechanical ventilation; strategies aimed at optimizing this process could provide substantial benefit. Previous studies have demonstrated that BNP levels prior to ventilator weaning independently predict weaning failure. No current objective practical guide to fluid management during ventilator weaning exists.

Study design: Randomized controlled trial.

Setting: Multiple international centers.

Synopsis: Three hundred four patients who met specific inclusion and exclusion criteria were randomized to either a BNP-driven or physician-guided strategy for fluid management during ventilator weaning. Patients with renal failure were excluded because of the influence of renal function on BNP levels.

All patients in both groups were ventilated with an automatic computer-driven weaning system to standardize the weaning process. In the BNP-driven group, diuretic use was higher, resulting in a more negative fluid balance and significantly shorter time to successful extubation (58.6 hours vs. 42.2 hours, P=0.03). The effect on weaning time was strongest in patients with left ventricular systolic dysfunction, whereas those with COPD seemed less likely to benefit. The two groups did not differ in baseline characteristics, length of stay, mortality, or development of adverse outcomes of renal failure, shock, or electrolyte disturbances.

Bottom line: Compared with physician-guided fluid management, a BNP-driven fluid management protocol decreased duration of ventilator weaning without significant differences in adverse events, mortality rate, or length of stay between the two groups.

Citation: Dessap AM, Roche-Campo F, Kouatchet A, et al. Natriuretic peptide-driven fluid management during ventilator weaning. Am J Respir Crit Care Med. 2012;186(12):1256-1263.

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