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Gavelli F, Shi R, Teboul JL, Azzolina D, Mercado P, Jozwiak M, Chew MS, Huber W, Kirov MY, Kuzkov VV, Lahmer T, Malbrain MLNG, Mallat J, Sakka SG, Tagami T, Pham T, Monnet X. Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis. Crit Care 2022; 26:202. [PMID: 35794612 PMCID: PMC9258010 DOI: 10.1186/s13054-022-04061-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background The prognostic value of extravascular lung water (EVLW) measured by transpulmonary thermodilution (TPTD) in critically ill patients is debated. We performed a systematic review and meta-analysis of studies assessing the effects of TPTD-estimated EVLW on mortality in critically ill patients.
Methods Cohort studies published in English from Embase, MEDLINE, and the Cochrane Database of Systematic Reviews from 1960 to 1 June 2021 were systematically searched. From eligible studies, the values of the odds ratio (OR) of EVLW as a risk factor for mortality, and the value of EVLW in survivors and non-survivors were extracted. Pooled OR were calculated from available studies. Mean differences and standard deviation of the EVLW between survivors and non-survivors were calculated. A random effects model was computed on the weighted mean differences across the two groups to estimate the pooled size effect. Subgroup analyses were performed to explore the possible sources of heterogeneity. Results Of the 18 studies included (1296 patients), OR could be extracted from 11 studies including 905 patients (464 survivors vs. 441 non-survivors), and 17 studies reported EVLW values of survivors and non-survivors, including 1246 patients (680 survivors vs. 566 non-survivors). The pooled OR of EVLW for mortality from eleven studies was 1.69 (95% confidence interval (CI) [1.22; 2.34], p < 0.0015). EVLW was significantly lower in survivors than non-survivors, with a mean difference of −4.97 mL/kg (95% CI [−6.54; −3.41], p < 0.001). The results regarding OR and mean differences were consistent in subgroup analyses. Conclusions The value of EVLW measured by TPTD is associated with mortality in critically ill patients and is significantly higher in non-survivors than in survivors. This finding may also be interpreted as an indirect confirmation of the reliability of TPTD for estimating EVLW at the bedside. Nevertheless, our results should be considered cautiously due to the high risk of bias of many studies included in the meta-analysis and the low rating of certainty of evidence. Trial registration the study protocol was prospectively registered on PROSPERO: CRD42019126985. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04061-6.
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Ingelse SA, IJland MM, van Loon LM, Bem RA, van Woensel JBM, Lemson J. Early restrictive fluid resuscitation has no clinical advantage in experimental severe pediatric acute respiratory distress syndrome. Am J Physiol Lung Cell Mol Physiol 2021; 320:L1126-L1136. [PMID: 33826416 DOI: 10.1152/ajplung.00613.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Intravenous fluids are widely used to treat circulatory deterioration in pediatric acute respiratory distress syndrome (PARDS). However, the accumulation of fluids in the first days of PARDS is associated with adverse outcome. As such, early fluid restriction may prove beneficial, yet the effects of such a fluid strategy on the cardiopulmonary physiology in PARDS are unclear. In this study, we compared the effect of a restrictive with a liberal fluid strategy on a hemodynamic response and the formation of pulmonary edema in an animal model of PARDS. Sixteen mechanically ventilated lambs (2-6 wk) received oleic acid infusion to induce PARDS and were randomized to a restrictive or liberal fluid strategy during a 6-h period of mechanical ventilation. Transpulmonary thermodilution determined extravascular lung water (EVLW) and cardiac output (CO). Postmortem lung wet-to-dry weight ratios were obtained by gravimetry. Restricting fluids significantly reduced fluid intake but increased the use of vasopressors among animals with PARDS. Arterial blood pressure was similar between groups, yet CO declined significantly in animals receiving restrictive fluids (P = 0.005). There was no difference in EVLW over time (P = 0.111) and lung wet-to-dry weight ratio [6.1, interquartile range (IQR) = 6.0-7.3 vs. 7.1, IQR = 6.6-9.4, restrictive vs. liberal, P = 0.725] between fluid strategies. Both fluid strategies stabilized blood pressure in this model, yet early fluid restriction abated CO. Early fluid restriction did not limit the formation of pulmonary edema; therefore, this study suggests that in the early phase of PARDS, a restrictive fluid strategy is not beneficial in terms of immediate cardiopulmonary effects.
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Affiliation(s)
- Sarah A Ingelse
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marloes M IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lex M van Loon
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Cardiovascular and Respiratory Physiology Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Reinout A Bem
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Mayr U, Lukas M, Habenicht L, Wiessner J, Heilmaier M, Ulrich J, Rasch S, Schmid RM, Lahmer T, Huber W, Herner A. B-Lines Scores Derived From Lung Ultrasound Provide Accurate Prediction of Extravascular Lung Water Index: An Observational Study in Critically Ill Patients. J Intensive Care Med 2020; 37:21-31. [PMID: 33148110 PMCID: PMC8609506 DOI: 10.1177/0885066620967655] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Visualization of B-lines via lung ultrasound provides a non-invasive estimation of pulmonary hydration. Extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) assessed by transpulmonary thermodilution (TPTD) represent the most validated parameters of lung water and alveolocapillary permeability, but measurement is invasive and expensive. This study aimed to compare the correlations of B-lines scores from extensive 28-sector and simplified 4-sector chest scan with EVLWI and PVPI derived from TPTD in the setting of intensive care unit (primary endpoint). Methods: We performed scoring of 28-sector and 4-sector B-Lines in 50 critically ill patients. TPTD was carried out with the PiCCO-2-device (Pulsion Medical Systems SE, Maquet Getinge Group). Median time exposure for ultrasound procedure was 12 minutes for 28-sector and 4 minutes for 4-sector scan. Results: Primarily, we found close correlations of 28-sector as well as 4-sector B-Lines scores with EVLWI (R2 = 0.895 vs. R2 = 0.880) and PVPI (R2 = 0.760 vs. R2 = 0.742). Both B-lines scores showed high accuracy to identify patients with specific levels of EVLWI and PVPI. The extensive 28-sector B-lines score revealed a moderate advantage compared to simplified 4-sector scan in detecting a normal EVLWI ≤ 7 (28-sector scan: sensitivity = 81.8%, specificity = 94.9%, AUC = 0.939 versus 4-sector scan: sensitivity = 81.8%, specificity = 82.1%, AUC = 0.902). Both protocols were approximately equivalent in prediction of lung edema with EVLWI ≥ 10 (28-sector scan: sensitivity = 88.9%, specificity = 95.7%, AUC = 0.977 versus 4-sector scan: sensitivity = 81.5%, specificity = 91.3%, AUC = 0.958) or severe pulmonary edema with EVLWI ≥ 15 (28-sector scan: sensitivity = 91.7%, specificity = 97.4%, AUC = 0.995 versus 4-sector scan: sensitivity = 91.7%, specificity = 92.1%, AUC = 0.978). As secondary endpoints, our evaluations resulted in significant associations of 28-sector as well as simplified 4-sector B-Lines score with parameters of respiratory function. Conclusion: Both B-line protocols provide accurate non-invasive evaluation of lung water in critically ill patients. The 28-sector scan offers a marginal advantage in prediction of pulmonary edema, but needs substantially more time than 4-sector scan.
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Affiliation(s)
- Ulrich Mayr
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Marina Lukas
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Livia Habenicht
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Johannes Wiessner
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Markus Heilmaier
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Jörg Ulrich
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Sebastian Rasch
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Roland M. Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Wolfgang Huber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
- Wolfgang Huber deceased
| | - Alexander Herner
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Transpulmonary thermodilution detects rapid and reversible increases in lung water induced by positive end-expiratory pressure in acute respiratory distress syndrome. Ann Intensive Care 2020; 10:28. [PMID: 32124129 PMCID: PMC7052093 DOI: 10.1186/s13613-020-0644-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 02/21/2020] [Indexed: 01/22/2023] Open
Abstract
PURPOSE It has been suggested that, by recruiting lung regions and enlarging the distribution volume of the cold indicator, increasing the positive end-expiratory pressure (PEEP) may lead to an artefactual overestimation of extravascular lung water (EVLW) by transpulmonary thermodilution (TPTD). METHODS In 60 ARDS patients, we measured EVLW (PiCCO2 device) at a PEEP level set to reach a plateau pressure of 30 cmH2O (HighPEEPstart) and 15 and 45 min after decreasing PEEP to 5 cmH2O (LowPEEP15' and LowPEEP45', respectively). Then, we increased PEEP back to the baseline level (HighPEEPend). Between HighPEEPstart and LowPEEP15', we estimated the degree of lung derecruitment either by measuring changes in the compliance of the respiratory system (Crs) in the whole population, or by measuring the lung derecruited volume in 30 patients. We defined patients with a large derecruitment from the other ones as patients in whom the Crs changes and the measured derecruited volume were larger than the median of these variables observed in the whole population. RESULTS Reducing PEEP from HighPEEPstart (14 ± 2 cmH2O) to LowPEEP15' significantly decreased EVLW from 20 ± 4 to 18 ± 4 mL/kg, central venous pressure (CVP) from 15 ± 4 to 12 ± 4 mmHg, the arterial oxygen tension over inspired oxygen fraction (PaO2/FiO2) ratio from 184 ± 76 to 150 ± 69 mmHg and lung volume by 144 [68-420] mL. The EVLW decrease was similar in "large derecruiters" and the other patients. When PEEP was re-increased to HighPEEPend, CVP, PaO2/FiO2 and EVLW significantly re-increased. At linear mixed effect model, EVLW changes were significantly determined only by changes in PEEP and CVP (p < 0.001 and p = 0.03, respectively, n = 60). When the same analysis was performed by estimating recruitment according to lung volume changes (n = 30), CVP remained significantly associated to the changes in EVLW (p < 0.001). CONCLUSIONS In ARDS patients, changing the PEEP level induced parallel, small and reversible changes in EVLW. These changes were not due to an artefact of the TPTD technique and were likely due to the PEEP-induced changes in CVP, which is the backward pressure of the lung lymphatic drainage. Trial registration ID RCB: 2015-A01654-45. Registered 23 October 2015.
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Zong HF, Guo G, Liu J, Bao LL, Yang CZ. Using lung ultrasound to quantitatively evaluate pulmonary water content. Pediatr Pulmonol 2020; 55:729-739. [PMID: 31917899 DOI: 10.1002/ppul.24635] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 12/27/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Increases in extravascular lung water (EVLW) can lead to respiratory failure. This study aimed to investigate whether the B-line score (BLS) was correlated with the EVLW content determined by the lung wet/dry ratio in a rabbit model. METHODS A total of 45 New Zealand rabbits were randomly assigned to nine groups. Among the animals, models of various lung water content levels were induced by the infusion of different volumes of warm sterile normal saline (NS) via the endotracheal tube. The arterial blood gas, spontaneous respiratory rate, and PaO2 /FiO2 ratio were detected before and after infusion. In addition, the B-lines were determined before and immediately after infusion in each group. Finally, both lungs were resected to determine the wet/dry ratio. In addition, all lung specimens were analyzed histologically, and EVLW was quantified using the BLS based on the number and confluence of B-lines in the intercostal space. RESULTS The BLS increased with increasing infusion volume. The BLS was statistically correlated with the wet/dry ratio (r2 = .946) and with the PaO2 /FiO2 ratio (r2 = .916). Furthermore, a repeatability study was performed for the lung ultrasound (LUS) technology (Bland-Altman plots), and the results suggest that LUS had favorable intraobserver and interobserver reproducibility. CONCLUSIONS This study is the first to suggest that the BLS can serve as a sensitive, quantitative, noninvasive, and real-time indicator of EVLW in a rabbit model of lung water accumulation. Notably, the BLS displayed an obvious correlation with the experimental gravimetry results and could also be used to predict the pulmonary oxygenation status.
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Affiliation(s)
- Hai-Feng Zong
- Department of Paediatrics, The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Paediatrics, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthecare Hospital, Beijing, China
- Department of Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, China
| | - Guo Guo
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthecare Hospital, Beijing, China
- Department of Paediatrics, Medical School of Chinese PLA, Beijing, China
- Department of Neonatology, The Fifth Medical Center of The PLA General Hospital, Beijing, China
| | - Jing Liu
- Department of Paediatrics, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthecare Hospital, Beijing, China
| | - Lin-Lin Bao
- Department of Dermatology, Shenzhen People's Hospital, Shenzhen, China
| | - Chuan-Zhong Yang
- Department of Paediatrics, The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, China
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Patrucco F, Daverio M, Gavelli F, Castello L, Boldorini R, Rena O, Casadio C, Balbo P. Cryobiopsy in the diagnosis of lung tumors: a single center experience. MINERVA BIOTECNOL 2019. [DOI: 10.23736/s1120-4826.19.02561-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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7
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Montemezzo J, Patrucco F, Gavelli F, Ferrari L, Faolotto G, Crobu MG, Castello LM, Daverio M, Balbo PE, Ravanini P. Evaluation of a new diagnostic method for quantification of EBV and HHV-6 viral load in bronchoalveolar lavage. MINERVA BIOTECNOL 2019. [DOI: 10.23736/s1120-4826.19.02557-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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8
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Ferré A, Guillot M, Lichtenstein D, Mezière G, Richard C, Teboul JL, Monnet X. Lung ultrasound allows the diagnosis of weaning-induced pulmonary oedema. Intensive Care Med 2019; 45:601-608. [PMID: 30863935 DOI: 10.1007/s00134-019-05573-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/19/2019] [Indexed: 12/19/2022]
Abstract
RATIONALE Detecting weaning-induced pulmonary oedema (WIPO) is important because its treatment might prompt extubation. For this purpose, lung ultrasound might be an attractive tool, since it demonstrates pulmonary oedema through the appearance of B-lines. OBJECTIVES To test the ideal profile (increase in the number of B-lines) for diagnosing WIPO. METHODS Before and at the end of 62 spontaneous breathing trials (SBT) performed in 42 patients, we prospectively assessed lung ultrasound on four anterior chest wall points. B-lines were counted before and at the end of SBT. We looked for the threshold of B-line increase (Delta-B-lines) that provided the best diagnostic accuracy, compared to the reference diagnosis of WIPO established by experts blinded to lung ultrasound. RESULTS SBT failed in 33 cases. WIPO occurred in 17 cases and all failed. The best diagnostic accuracy was reached with a Delta-B-lines ≥ 6. Among WIPO, the number of B-lines increased by ≥ 6 in 15 cases (including 13 cases with an increase of ≥ 8 B-lines). Among the 16 cases with SBT failure but without WIPO, the Delta-B-lines was ≥ 6 in two cases. Among the 33 cases with SBT failure, this profile diagnosed WIPO with a sensitivity of 88% (64-98) and a specificity of 88% (62-98) [area under the receiver operating characteristic curve 0.91 (0.75-0.98)]. Among the 29 cases with SBT success, a Delta-B-lines ≥ 6 occurred in two cases. CONCLUSIONS This study suggests that a Delta-B-lines ≥ 6 on four anterior points allows the diagnosis of WIPO with the best accuracy. This should be confirmed in larger populations.
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Affiliation(s)
- Alexis Ferré
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Max Guillot
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Daniel Lichtenstein
- AP-HP, Service de réanimation médicale, Hôpital Ambroise-Paré, Boulogne, Paris, France
| | - Gilbert Mezière
- Service de réanimation polyvalente, Centre Hospitalier Gaston Ramon, Sens, France
| | - Christian Richard
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Inserm UMR_S 999, Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France. .,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.
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Trebbia G, Sage E, Le Guen M, Roux A, Soummer A, Puyo P, Parquin F, Stern M, Pham T, Sakka SG, Cerf C. Assessment of lung edema during ex-vivo lung perfusion by single transpulmonary thermodilution: A preliminary study in humans. J Heart Lung Transplant 2018; 38:83-91. [PMID: 30391201 DOI: 10.1016/j.healun.2018.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 08/21/2018] [Accepted: 09/25/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Single transpulmonary thermodilution (SD) with extravascular lung water index (EVLWI) could become a new tool to better assess lung graft edema during ex-vivo lung perfusion (EVLP). In this study we compare EVLWI with conventional methods to better select lungs during EVLP and to predict post-transplant primary graft dysfunction (PGD). METHODS We measured EVLWI, arterial oxygen/fraction of inspired oxygen (P/F) ratio, and static lung compliance (SLC) during EVLP in an observational study. At the end of EVLP, grafts were accepted or rejected according to a standardized protocol blinded to EVLWI results. We compared the respective ability of EVLWI, P/F, and SLC to predict PGD. Mann-Whitney U-test, Fisher's exact test, and receiver-operating characteristic (ROC) curve data were used for analysis. p < 0.05 was considered statistically significant. RESULTS Thirty-five lungs were evaluated by SD during EVLP. Three lungs were rejected for pulmonary edema. Thirty-two patients were transplanted, 8 patients developed Grade 2 or 3 PGD, and 24 patients developed Grade 0 or 1 PGD. In contrast to P/F ratio, SLC, and pulmonary artery pressure, EVLWI differed between these 2 populations (p < 0.001). The area under the ROC for EVLWI assessing Grade 2 or 3 PGD at the end of EVLP was 0.93. Donor lungs with EVLWI >7.5 ml/kg were more likely associated with a higher incidence of Grade 2 or 3 PGD at Day 3. CONCLUSIONS Increased EVLWI during EVLP was associated with PGD in recipients.
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Affiliation(s)
| | | | | | - Antoine Roux
- Department of Pulmonary Medicine, Foch Hospital, Suresnes, France
| | | | | | | | - Marc Stern
- Department of Pulmonary Medicine, Foch Hospital, Suresnes, France
| | - Tai Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; Sorbonne Universités, Université Pierre et Marie Curie, Paris, France
| | - Samir G Sakka
- Sorbonne Universités, Université Pierre et Marie Curie, Paris, France
| | - Charles Cerf
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Center Cologne‒Merheim, University of Witten/Herdecke, Cologne, Germany
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Quantitative computed tomography in comparison with transpulmonary thermodilution for the estimation of pulmonary fluid status: a clinical study in critically ill patients. J Clin Monit Comput 2018; 33:5-12. [PMID: 29680878 DOI: 10.1007/s10877-018-0144-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/16/2018] [Indexed: 01/09/2023]
Abstract
Extravascular lung water (index) (EVLW(I)) can be estimated using transpulmonary thermodilution (TPTD). Computed tomography (CT) with quantitative analysis of lung tissue density has been proposed to quantify pulmonary edema. We compared variables of pulmonary fluid status assessed using quantitative CT and TPTD in critically ill patients. In 21 intensive care unit patients, we performed TPTD measurements directly before and after chest CT. Based on the density data of segmented CT images we calculated the tissue volume (TV), tissue volume index (TVI), and the mean weighted index of voxel aqueous density (VMWaq). CT-derived TV, TVI, and VMWaq did not predict TPTD-derived EVLWI values ≥ 14 mL/kg. There was a significant moderate positive correlation between VMWaq and mean EVLWI (EVLWI before and after CT) (r = 0.45, p = 0.042) and EVLWI after CT (r = 0.49, p = 0.025) but not EVLWI before CT (r = 0.38, p = 0.086). There was no significant correlation between TV and EVLW before CT, EVLW after CT, or mean EVLW. There was no significant correlation between TVI and EVLWI before CT, EVLWI after CT, or mean EVLWI. CT-derived variables did not predict elevated TPTD-derived EVLWI values. In unselected critically ill patients, variables of pulmonary fluid status assessed using quantitative CT cannot be used to predict EVLWI.
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11
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Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28625165 PMCID: PMC5474867 DOI: 10.1186/s13054-017-1739-5] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background For complex patients in the intensive care unit or in the operating room, many questions regarding their haemodynamic management cannot be answered with simple clinical examination. In particular, arterial pressure allows only a rough estimation of cardiac output. Transpulmonary thermodilution is a technique that provides a full haemodynamic assessment through cardiac output and other indices. Main body Through the analysis of the thermodilution curve recorded at the tip of an arterial catheter after the injection of a cold bolus in the venous circulation, transpulmonary thermodilution intermittently measures cardiac output. This measure allows the calibration of pulse contour analysis. This provides continuous and real time monitoring of cardiac output, which is not possible with the pulmonary artery catheter. Transpulmonary thermodilution provides several variables beyond cardiac output. It estimates the end-diastolic volume of the four cardiac cavities, which is a marker of cardiac preload. It provides an estimation of the systolic function of the combined ventricles. It is more direct than the pulmonary artery catheter, but does not allow the distinct estimation of right and left cardiac function. It is easier and faster to perform than echocardiography, but does not provide a full evaluation of the cardiac structure and function. Transpulmonary thermodilution has the unique advantage of being able to estimate at the bedside extravascular lung water, which quantifies the volume of pulmonary oedema, and pulmonary vascular permeability, which quantifies the degree of a pulmonary capillary leak. Both indices are helpful for guiding fluid strategy, especially in case of acute respiratory distress syndrome. Conclusions Transpulmonary thermodilution provides a full cardiovascular evaluation that allows one to answer many questions regarding haemodynamic management. It belongs to the category of “advanced” devices that are indicated for the most critically ill and/or complex patients.
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Affiliation(s)
- Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France. .,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France. .,Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France
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Increased Extravascular Lung Water and Plasma Biomarkers of Acute Lung Injury Precede Oxygenation Impairment in Primary Graft Dysfunction After Lung Transplantation. Transplantation 2017; 101:112-121. [PMID: 27495752 DOI: 10.1097/tp.0000000000001434] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND After lung transplantation (LT), early prediction of grade 3 pulmonary graft dysfunction (PGD) remains a research gap for clinicians. We hypothesized that it could be improved using extravascular lung water (EVLWi) and plasma biomarkers of acute lung injury. METHODS After institutional review board approval and informed consent, consecutive LT recipients were included. Transpulmonary thermodilution-based EVLWi, plasma concentrations of epithelial (soluble receptor for advanced glycation endproducts [sRAGE]) and endothelial biomarkers (soluble intercellular adhesion molecule-1 and endocan [full-length and cleaved p14 fragment]) were obtained before and after LT (0 [H0], 6, 12, 24, 48 and 72 hours after pulmonary artery unclamping). Grade 3 PGD was defined according to the International Society for Lung and Heart Transplantation definition, combining arterial oxygen partial pressure (PaO2)/inspired fraction of oxygen (FiO2) ratio and chest X-rays. Association of clinical risk factors, EVLWi and biomarkers with grade 3 PGD was analyzed under the Bayesian paradigm, using logistic model and areas under the receiver operating characteristic curves (AUCs). RESULTS In 47 LT recipients, 10 developed grade 3 PGD, which was obvious at H6 in 8 cases. Clinical risk factors, soluble intercellular adhesion molecule-1 and endocan (both forms) were not associated with grade 3 PGD. Significant predictors of grade 3 PGD included (1) EVLWi (optimal cutoff, 13.7 mL/kg; AUC, 0.74; 95% confidence interval [CI], 0.48-0.99), (2) PaO2/FiO2 ratio (optimal cutoff, 236; AUC, 0.68; 95% CI, 0.52-0.84), and (3) sRAGE (optimal cutoff, 11 760 pg/mL; AUC, 0.66; 95% CI, 0.41-0.91) measured at H0. CONCLUSIONS Immediate postreperfusion increases in EVLWi and sRAGE along with impaired PaO2/FiO2 ratios were early predictors of grade 3 PGD at or beyond 6 hours and may trigger early therapeutic interventions.
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Evaluation of Reperfusion Pulmonary Edema by Extravascular Lung Water Measurements After Pulmonary Endarterectomy. Crit Care Med 2017; 45:e409-e417. [DOI: 10.1097/ccm.0000000000002259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Wenjie W, Houqing L, Gengyun S. Detection methods of extravascular lung water and application in critical illness: a narrative review. TOXIN REV 2016. [DOI: 10.1080/15569543.2016.1217543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Jozwiak M, Teboul JL, Monnet X. Extravascular lung water in critical care: recent advances and clinical applications. Ann Intensive Care 2015; 5:38. [PMID: 26546321 PMCID: PMC4636545 DOI: 10.1186/s13613-015-0081-9] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 10/27/2015] [Indexed: 12/16/2022] Open
Abstract
Extravascular lung water (EVLW) is the amount of fluid that is accumulated in the interstitial and alveolar spaces. In lung oedema, EVLW increases either because of increased lung permeability or because of increased hydrostatic pressure in the pulmonary capillaries, or both. Increased EVLW is always potentially life-threatening, mainly because it impairs gas exchange and reduces lung compliance. The only technique that provides an easy measurement of EVLW at the bedside is transpulmonary thermodilution. The validation of EVLW measurements by thermodilution was based on studies showing reasonable correlations with gravimetry or thermo-dye dilution in experimental and clinical studies. EVLW should be indexed to predicted body weight. This indexation reduces the proportion of ARDS patients for whom EVLW is in the normal range. Compared to non-indexed EVLW, indexed EVLW (EVLWI) is better correlated with the lung injury score and the oxygenation and it is a better predictor of mortality of patients with acute lung injury or acute respiratory distress syndrome (ARDS). Transpulmonary thermodilution also provides the pulmonary vascular permeability index (PVPI), which is an indirect reflection of the integrity of the alveolocapillary barrier. As clinical applications, EVLWI and PVPI may be useful to guide fluid management of patients at risk of fluid overload, as during septic shock and ARDS. High EVLWI and PVPI values predict mortality in several categories of critically ill patients, especially during ARDS. Thus, fluid administration should be limited when EVLWI is already high. Whatever the value of EVLWI, PVPI may indicate that fluid administration is particularly at risk of aggravating lung oedema. In the acute phase of haemodynamic resuscitation during septic shock and ARDS, high EVLWI and PVPI values may warn of the risk of fluid overload and prevent excessive volume expansion. At the post-resuscitation phase, they may prompt initiation of fluid removal thereby achieving a negative fluid balance.
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Affiliation(s)
- Mathieu Jozwiak
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| | - Jean-Louis Teboul
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| | - Xavier Monnet
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
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Monnet X, Teboul JL. Devant un état de choc : pourquoi je fais un monitoring cardiovasculaire. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1041-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Enghard P, Rademacher S, Nee J, Hasper D, Engert U, Jörres A, Kruse JM. Simplified lung ultrasound protocol shows excellent prediction of extravascular lung water in ventilated intensive care patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:36. [PMID: 25656060 PMCID: PMC4335373 DOI: 10.1186/s13054-015-0756-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/19/2015] [Indexed: 12/04/2022]
Abstract
Introduction Ultrasound of the lung and quantification of B lines was recently introduced as a novel tool to detect overhydration. In the present study, we aimed to evaluate a four-region protocol of lung ultrasound to determine the pulmonary fluid status in ventilated patients in the intensive care unit. Methods Fifty patients underwent both lung ultrasound and transpulmonary thermodilution measurement with the PiCCO system. An ultrasound score based on number of single and confluent B lines per intercostal space was used to quantify pulmonary overhydration. To check for reproducibility, two different intensivists who were blinded as to the ultrasound pictures reassessed and classified them using the same scoring system. The results were compared with those obtained using other methods of evaluating hydration status, including extravascular lung water index (EVLWI) and intrathoracic blood volume index calculated with data from transpulmonary thermodilution measurements. Moreover, chest radiographs were assessed regarding signs of pulmonary overhydration and categorized based on a numeric rating scale. Results Lung water assessment by ultrasound using a simplified protocol showed excellent correlation with EVLWI over a broad range of lung hydration grades and ventilator settings. Correlation of chest radiography and EVLWI was less accurate. No correlation whatsoever was found with central venous pressure measurement. Conclusion Lung ultrasound is a useful, non-invasive tool in predicting hydration status in mechanically ventilated patients. The four-region protocol that we used is time-saving, correlates well with transpulmonary thermodilution measurements and performs markedly better than chest radiography.
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Affiliation(s)
- Philipp Enghard
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Sibylle Rademacher
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Jens Nee
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Dietrich Hasper
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Ulrike Engert
- Abteilung für Radiologie, Charité Universitätsmedizin Berlin, Augstenburger Platz 1, 13353, Berlin, Germany.
| | - Achim Jörres
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Jan M Kruse
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Dres M, Teboul JL, Monnet X. Weaning the cardiac patient from mechanical ventilation. Curr Opin Crit Care 2014; 20:493-8. [DOI: 10.1097/mcc.0000000000000131] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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