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Katira BH, Engelberts D, Bouch S, Fliss J, Bastia L, Osada K, Connelly KA, Amato MBP, Ferguson ND, Kuebler WM, Kavanagh BP, Brochard LJ, Post M. Repeated endo-tracheal tube disconnection generates pulmonary edema in a model of volume overload: an experimental study. Crit Care 2022; 26:47. [PMID: 35180891 PMCID: PMC8857825 DOI: 10.1186/s13054-022-03924-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An abrupt lung deflation in rodents results in lung injury through vascular mechanisms. Ventilator disconnections during endo-tracheal suctioning in humans often cause cardio-respiratory instability. Whether repeated disconnections or lung deflations cause lung injury or oedema is not known and was tested here in a porcine large animal model. METHODS Yorkshire pigs (~ 12 weeks) were studied in three series. First, we compared PEEP abruptly deflated from 26 cmH2O or from PEEP 5 cmH2O to zero. Second, pigs were randomly crossed over to receive rapid versus gradual PEEP removal from 20 cmH2O. Third, pigs with relative volume overload, were ventilated with PEEP 15 cmH2O and randomized to repeated ETT disconnections (15 s every 15 min) or no disconnection for 3 h. Hemodynamics, pulmonary variables were monitored, and lung histology and bronchoalveolar lavage studied. RESULTS As compared to PEEP 5 cmH2O, abrupt deflation from PEEP 26 cmH2O increased PVR, lowered oxygenation, and increased lung wet-to-dry ratio. From PEEP 20 cmH2O, gradual versus abrupt deflation mitigated the changes in oxygenation and vascular resistance. From PEEP 15, repeated disconnections in presence of fluid loading led to reduced compliance, lower oxygenation, higher pulmonary artery pressure, higher lung wet-to-dry ratio, higher lung injury score and increased oedema on morphometry, compared to no disconnects. CONCLUSION Single abrupt deflation from high PEEP, and repeated short deflations from moderate PEEP cause pulmonary oedema, impaired oxygenation, and increased PVR, in this large animal model, thus replicating our previous finding from rodents. Rapid deflation may thus be a clinically relevant cause of impaired lung function, which may be attenuated by gradual pressure release.
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Affiliation(s)
- Bhushan H Katira
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
- The Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Paediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Doreen Engelberts
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
| | - Sheena Bouch
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
| | - Jordan Fliss
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Luca Bastia
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Kohei Osada
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
| | - Kim A Connelly
- Keenan Research Centre for Biomedical Sciences, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Niall D Ferguson
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health Systems, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Brian P Kavanagh
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
- The Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Departments of Critical Care Medicine and Anaesthesiology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Laurent J Brochard
- Keenan Research Centre for Biomedical Sciences, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Martin Post
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada.
- The Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
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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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Maybauer DM, Talke PO, Westphal M, Maybauer MO, Traber LD, Enkhbaatar P, Morita N, Traber DL. Positive End-expiratory Pressure Ventilation Increases Extravascular Lung Water Due to a Decrease in Lung Lymph Flow. Anaesth Intensive Care 2019; 34:329-33. [PMID: 16802485 DOI: 10.1177/0310057x0603400307] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Positive end-expiratory pressure (PEEP) is used to improve gas exchange, increase functional residual capacity, recruit air spaces, and decrease pulmonary shunt in patients suffering from respiratory failure. The effect of PEEP on extravascular lung water (EVLW), however, is still not fully understood. This study was designed as a prospective laboratory experiment to evaluate the effects of PEEP on EVLW and pulmonary lymph flow (QL) under physiologic conditions. Twelve adult sheep were operatively prepared to measure haemodynamics of the systemic and pulmonary circulation, and to assess EVLW. In addition, the lung lymphatic duct was cannulated and a tracheostomy performed. The animals were then mechanically ventilated in the awake-state without end-expiratory pressure (PEEP 0). After a two-hour baseline period, PEEP was increased to 10 cmH2O for the duration of two hours, and then reduced back to 0 cmH2O. Cardiopulmonary variables, QL, and arterial blood gases were recorded intermittently; EVLW was determined two hours after each change in PEEP. The increase in PEEP resulted in a decrease in QL (7±1 vs 5±1 ml/h) and an increase in EVLW (498±40 vs 630±58 ml; P<0.05 each) without affecting cardiac output. As PEEP was decreased back to baseline, QL increased significantly (5±1 vs 10±2 ml/h), whereas EVLW returned back to baseline. This study suggests that institution of PEEP produces a reversible increase in EVLW that is linked to a decrease in QL.
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Affiliation(s)
- D M Maybauer
- Department of Anaesthesiology, Investigational Intensive Care Unit, The University of Texas Medical Branch, and Shriners Burns Hospital for Children at Galveston, USA
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Bhattacharjee A, Pradhan D, Bhattacharyya P, Dey S, Chhunthang D, Handique A, Barman A, Yunus M. How Useful is Extravascular Lung Water Measurement in Managing Lung Injury in Intensive Care Unit? Indian J Crit Care Med 2017; 21:494-499. [PMID: 28904478 PMCID: PMC5588483 DOI: 10.4103/ijccm.ijccm_40_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Context: The primary goal of septic shock management is optimization of organ perfusion, often at the risk of overloading the interstitium and causing pulmonary edema. The conventionally used end points of resuscitation do not generally include volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). Aims: This study aimed to assess the prognostic value of EVLWI and PVPI by calculating their correlation with the severity of lung injury. Settings and Design: This prospective observational study included twenty mechanically ventilated critically ill patients with Acute Physiology and Chronic Health Evaluation score (APACHE II) >20. Subjects and Methods: EVLWI and PVPI were measured using transpulmonary thermodilution, and simultaneously, PaO2:FiO2 ratio, alveolar-arterial gradient of oxygen (AaDO2), and chest radiograph scores from two radiologists were obtained. Statistical Analysis: The correlation of EVLWI and PVPI with chest radiograph scores, PaO2:FiO2 ratio, and AaDO2 were calculated. The inter-observer agreement between the two radiologists was tested using kappa test. Results: EVLWI and PVPI correlated modestly with PaO2:FiO2 (r = −0.32, P = 0.0004; r = −0.39, P = 0.0001). There was a better correlation of EVLWI and PVPI with PaO2:FiO2 ratio (r = −0.71, P < 0.0001; r = −0.58, P = 0.0001) in the acute respiratory distress syndrome (ARDS) subgroup. The EVLWI values correlated significantly with corresponding chest radiograph scores (r = 0.71, P < 0.0001 for observer 1 and r = 0.68, P < 0.0001 for observer 2). Conclusions: EVLWI and PVPI may have a prognostic significance in the assessment of lung injury in septic shock patients with ARDS. Further research is required to reveal the usefulness of EVLWI as an end point of fluid resuscitation in the management of septic shock with ARDS.
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Affiliation(s)
- Anirban Bhattacharjee
- Department of Anaesthesiology and Critical Care, NEIGRIHMS, Shillong, Meghalaya, India
| | - Debasis Pradhan
- Department of Anaesthesiology and Critical Care, NEIGRIHMS, Shillong, Meghalaya, India
| | | | - Samarjit Dey
- Department of Anaesthesiology and Critical Care, NEIGRIHMS, Shillong, Meghalaya, India
| | - Daniala Chhunthang
- Department of Radiology and Imaging, NEIGRIHMS, Shillong, Meghalaya, India
| | - Akash Handique
- Department of Radiology and Imaging, NEIGRIHMS, Shillong, Meghalaya, India
| | - Angkita Barman
- Department of Anaesthesiology and Critical Care, NEIGRIHMS, Shillong, Meghalaya, India
| | - Mohd Yunus
- Department of Anaesthesiology and Critical Care, NEIGRIHMS, Shillong, Meghalaya, India
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Huber W, Mair S, Götz SQ, Tschirdewahn J, Frank J, Höllthaler J, Phillip V, Schmid RM, Saugel B. A systematic database-derived approach to improve indexation of transpulmonary thermodilution-derived global end-diastolic volume. J Clin Monit Comput 2016; 31:143-151. [PMID: 26831297 DOI: 10.1007/s10877-016-9833-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 01/20/2016] [Indexed: 12/28/2022]
Abstract
Global end-diastolic volume (GEDV) has been indexed to body surface area (BSA). However, data validating this indexation of GEDV are scarce. Furthermore, it has been suggested to index GEDV to "predicted BSA" based on predicted body weight. Therefore, we aimed to identify biometric parameters independently associated with GEDV. We analyzed a database including 3812 TPTD measurements in 234 patients treated in the ICU of a German university hospital. GEDVI indexed to actual BSA was significantly lower than GEDVI indexed to predicted BSA (748 ± 179 vs. 804 ± 190 mL/m2; p < 0.001). GEDV was independently associated with older age, male sex, height, and actual body weight. In a regression model for the estimation of GEDV, age and height were the most important parameters: Each year in age and each cm in height increased GEDV by 9 and 15 mL, respectively. In addition to height and weight also age and sex should be considered for indexation of GEDV.
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Affiliation(s)
- Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Sebastian Mair
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Simon Q Götz
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Julia Tschirdewahn
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Johanna Frank
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Josef Höllthaler
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Veit Phillip
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Roland M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Bernd Saugel
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany. .,Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Influences of pleural effusion on respiratory mechanics, gas exchange, hemodynamics, and recruitment effects in acute respiratory distress syndrome. J Surg Res 2014; 186:346-53. [DOI: 10.1016/j.jss.2013.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 09/03/2013] [Accepted: 09/05/2013] [Indexed: 11/22/2022]
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HARTMANN EK, BOEHME S, DUENGES B, BENTLEY A, KLEIN KU, KWIECIEN R, SHI C, SZCZYRBA M, DAVID M, MARKSTALLER K. An inhaled tumor necrosis factor-alpha-derived TIP peptide improves the pulmonary function in experimental lung injury. Acta Anaesthesiol Scand 2013; 57:334-41. [PMID: 23216436 DOI: 10.1111/aas.12034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2012] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The lectin-like domain of TNF-α enhances the fluid clearance across the alveolar barrier. For experimental purposes, the lectin-like domain can be mimicked by a synthetic peptide representing the TIP-motif of TNF-α. The present study aims to assess the acute effect of TIP on the pulmonary function in a porcine model of acute respiratory distress syndrome (ARDS). METHODS Lung injury was induced in 16 pigs (25-27 kg) by bronchoalveolar lavage followed by injurious ventilation. Following randomisation, either nebulised TIP (1 mg/kg; AP301, APEPTICO, Vienna, Austria) or water for injection (control group) was administered. During 5 h of monitoring, the extravascular lung water index (EVLWI), the quotient of partial pressure of oxygen and inspired oxygen concentration (PaO(2) /FiO(2) ) and the pulmonary shunt fraction were repetitively assessed. The data were evaluated by an analysis of variance including Bonferroni-Holm correction. RESULTS Comparable baseline conditions in both groups were achieved. Ventilatory parameters were standardised in both groups. In the TIP group, a significant reduction of the EVLWI and a simultaneous increase in the PaO(2) /FiO(2) ratio was shown (each P < 0.0001). No changes in the control group were observed (EVLWI: P = 0.43, PaO(2) /FiO(2) : P = 0.60). The intergroup comparison demonstrates a significant advantage of TIP inhalation over placebo (EVLWI: P < 0.0001, PaO(2) /FiO(2) : P = 0.004, shunt fraction: P = 0.0005). CONCLUSIONS The inhalation of TIP induces an amelioration of clinical surrogate parameters of the lung function in a porcine lung injury model. By mimicking the lectin-like domain, the synthetic TIP peptide AP301 is an innovative approach as supportive therapy in ARDS.
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Affiliation(s)
- E. K. HARTMANN
- Department of Anaesthesiology; Medical Center of the Johannes Gutenberg-University; Mainz; Germany
| | | | - B. DUENGES
- Department of Anaesthesiology; Medical Center of the Johannes Gutenberg-University; Mainz; Germany
| | - A. BENTLEY
- Department of Anaesthesiology; Medical Center of the Johannes Gutenberg-University; Mainz; Germany
| | | | | | | | - M. SZCZYRBA
- Department of Anaesthesiology; Medical Center of the Johannes Gutenberg-University; Mainz; Germany
| | - M. DAVID
- Department of Anaesthesiology; Medical Center of the Johannes Gutenberg-University; Mainz; Germany
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Bognar Z, Foldi V, Rezman B, Bogar L, Csontos C. Extravascular lung water index as a sign of developing sepsis in burns. Burns 2010; 36:1263-70. [DOI: 10.1016/j.burns.2010.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 02/16/2010] [Accepted: 04/05/2010] [Indexed: 11/26/2022]
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The relationship between extravascular lung water and oxygenation in three patients with influenza A (H1N1)-induced respiratory failure. Wien Klin Wochenschr 2010; 122:637-40. [PMID: 20949325 PMCID: PMC7102316 DOI: 10.1007/s00508-010-1475-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 10/02/2010] [Indexed: 11/10/2022]
Abstract
This case series reports the correlation between extravascular lung water (EVLW) and the partial arterial oxygen pressure/fractional inspiratory oxygen (PaO2/FiO2) ratio in three patients with severe influenza A (H1N1)-induced respiratory failure. All patients suffered from grave hypoxia (PaO2, 26–42 mmHg) and were mechanically ventilated using biphasic airway pressure (PEEP, 12–15 mmHg; FiO2, 0.8–1) in combination with prone positioning at 12 hourly intervals. All patients were monitored using the PICCO® system for 8–11 days. During mechanical ventilation, a total of 62 simultaneous determinations of the PaO2/FiO2 ratio and EVLW were performed. A significant correlation between EVLW and the PaO2/FiO2 ratio (Spearman-rho correlation coefficient, –0.852; p < 0.001) was observed. In all patients, a decrease in EVLW was accompanied by an improvement in oxygenation. Serum lactate dehydrogenase levels were elevated in all patients and significantly correlated with EVLW during the intensive care unit stay (Spearman-rho correlation coefficient, 0.786; p < 0.001). In conclusion, EVLW seems increased in patients with severe H1N1-induced respiratory failure and appears to be closely correlated with impairments of oxygenatory function.
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Tagami T, Kushimoto S, Yamamoto Y, Atsumi T, Tosa R, Matsuda K, Oyama R, Kawaguchi T, Masuno T, Hirama H, Yokota H. Validation of extravascular lung water measurement by single transpulmonary thermodilution: human autopsy study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R162. [PMID: 20819213 PMCID: PMC3219254 DOI: 10.1186/cc9250] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 06/10/2010] [Accepted: 09/06/2010] [Indexed: 02/06/2023]
Abstract
Introduction Gravimetric validation of single-indicator extravascular lung water (EVLW) and normal EVLW values has not been well studied in humans thus far. The aims of this study were (1) to validate the accuracy of EVLW measurement by single transpulmonary thermodilution with postmortem lung weight measurement in humans and (2) to define the statistically normal EVLW values. Methods We evaluated the correlation between pre-mortem EVLW value by single transpulmonary thermodilution and post-mortem lung weight from 30 consecutive autopsies completed within 48 hours following the final thermodilution measurement. A linear regression equation for the correlation was calculated. In order to clarify the normal lung weight value by statistical analysis, we conducted a literature search and obtained the normal reference ranges for post-mortem lung weight. These values were substituted into the equation for the correlation between EVLW and lung weight to estimate the normal EVLW values. Results EVLW determined using transpulmonary single thermodilution correlated closely with post-mortem lung weight (r = 0.904, P < 0.001). A linear regression equation was calculated: EVLW (mL) = 0.56 × lung weight (g) - 58.0. The normal EVLW values indexed by predicted body weight were approximately 7.4 ± 3.3 mL/kg (7.5 ± 3.3 mL/kg for males and 7.3 ± 3.3 mL/kg for females). Conclusions A definite correlation exists between EVLW measured by the single-indicator transpulmonary thermodilution technique and post-mortem lung weight in humans. The normal EVLW value is approximately 7.4 ± 3.3 mL/kg. Trial registration UMIN000002780.
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Affiliation(s)
- Takashi Tagami
- Department of Emergency and Critical Care Medicine, Aidu Chuo Hospital, 1-1 Tsuruga, Aiduwakamatsu, Fukushima, 965-8611, Japan.
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Lemson J, van Die LE, Hemelaar AEA, van der Hoeven JG. Extravascular lung water index measurement in critically ill children does not correlate with a chest x-ray score of pulmonary edema. Crit Care 2010; 14:R105. [PMID: 20529308 PMCID: PMC2911751 DOI: 10.1186/cc9054] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 03/18/2010] [Accepted: 06/08/2010] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Extravascular lung water index (EVLWI) can be measured at the bedside using the transpulmonary thermodilution technique (TPTD). The goal of this study was to compare EVLWI values with a chest x-ray score of pulmonary edema and markers of oxygenation in critically ill children. METHODS This was a prospective observational study in a pediatric intensive care unit of a university hospital. We included 27 critically ill children with an indication for advanced invasive hemodynamic monitoring. No specific interventions for the purpose of the study were carried out. Measurements included EVLWI and other relevant hemodynamic variables. Blood gas analysis, ventilator parameters, chest x-ray and TPTD measurements were obtained within a three-hour time frame. Two radiologists assessed the chest x-ray and determined a score for pulmonary edema. RESULTS A total of 103 measurements from 24 patients were eligible for final analysis. Mean age was two years (range: two months to eight years). Median cardiac index was 4.00 (range: 1.65 to 10.85) l/min/m2. Median EVLWI was 16 (range: 6 to 31) ml/kg. The weighted kappa between the chest x-ray scores of the two radiologists was 0.53. There was no significant correlation between EVLWI or chest x-ray score and the number of ventilator days, severity of illness or markers of oxygenation. There was no correlation between EVLWI and the chest x-ray score. EVLWI was significantly correlated with age and length (r2 of 0.47 and 0.67 respectively). CONCLUSIONS The extravascular lung water index in critically ill children does not correlate with a chest x-ray score of pulmonary edema, nor with markers of oxygenation.
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Affiliation(s)
- Joris Lemson
- Department of Intensive Care Medicine, Radboud University Nijmegen Medical Centre, Nijmegen. PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Lya E van Die
- Department of radiology, Radboud University Nijmegen Medical Centre, Nijmegen. PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Anique EA Hemelaar
- Department of Intensive Care Medicine, Radboud University Nijmegen Medical Centre, Nijmegen. PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Nijmegen Medical Centre, Nijmegen. PO box 9101, 6500 HB Nijmegen, The Netherlands
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Belda FJ, Aguilar G, Ferrando C. Variation in Extravascular Lung Water in ALI/ARDS Patients using Open Lung Strategy. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Effros RM, Pornsuriyasak P, Porszasz J, Casaburi R. Indicator dilution measurements of extravascular lung water: basic assumptions and observations. Am J Physiol Lung Cell Mol Physiol 2008; 294:L1023-31. [DOI: 10.1152/ajplung.00533.2007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Since they were introduced more than five decades ago, a variety of single-pass indicator, thermal, and osmotic dilution approaches have been developed for detecting and measuring excess fluid in the lungs. This brief review discusses why studies of the extravascular lung water (EVLW) continue to intrigue physiologists and clinicians and the likelihood that they will become sufficiently reliable for more widespread use. Emphasis is placed on the basic assumptions that underlie these measurements and limitations imposed by the nature of the data that are collected. A distinction is made between approaches that are based on compartmental models of solute and water exchange and those that represent extensions of more conventional washout procedures, which have been utilized extensively for measurements of gas volumes in the lungs. Although the compartmental approach has been used to simplify indicator dilution studies by eliminating the need for a vascular indicator, it is based on assumptions that may not be realistic. Early recirculation inevitably limits the period in which observations can be made and impairs detection of those portions of the lungs with decreased perfusion. These general principles are also used to develop a new method of analyzing osmotic transient studies. A short account is given of EVLW observations that have been made in animals and humans. Both the sensitivity and specificity of EVLW measurements in humans are uncertain, and the normal clinical range of EVLW remains in doubt.
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Khan S, Trof RJ, Groeneveld ABJ. Transpulmonary dilution-derived extravascular lung water as a measure of lung edema. Curr Opin Crit Care 2007; 13:303-7. [PMID: 17468563 DOI: 10.1097/mcc.0b013e32811d6ccd] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW This review highlights current insights concerning the (measurement of) extravascular lung water as an index of pulmonary edema, by transpulmonary dilution techniques. The focus is on the applicability of the technique at the bedside in monitoring critically ill patients. RECENT FINDINGS Several (animal) studies have been performed to validate the technique by postmortem gravimetry in different conditions. Moreover, recent clinical data emphasize the utility of the thermodilution-derived extravascular lung water, its contribution to the clinical manifestations of acute lung injury/acute respiratory distress syndrome, its response to treatment aimed at edema prevention or resolution, and as a prognostic parameter. SUMMARY The thermodilution-derived extravascular lung water is a useful adjunct to assess lung vascular injury, cardiogenic edema and overhydration and to guide treatment in critically ill patients. The effects on morbidity and mortality of this approach need to be studied further.
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Affiliation(s)
- Saheed Khan
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
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Abstract
OBJECTIVES To review the advantages and limitations of dilution methods to assess extravascular lung water (EVLW) at the bedside and to discuss the clinical value of EVLW measurements. DATA SOURCE Experimental and clinical studies were searched in PUBMED by using "extravascular lung water" and "dilution method" as keywords and further selected as studies investigating either the reliability or the clinical usefulness of dilution methods to assess EVLW. Related articles and the reference lists of selected studies were scanned for additional relevant references. CONCLUSIONS Both the double-indicator (thermo-dye) dilution and the single-indicator (cold saline) dilution methods showed close agreement with gravimetric measurement of EVLW (the reference ex vivo method) and have the advantage of being available at the bedside. Most limitations of dilution methods have been described in experimental conditions and lead to an underestimation of EVLW. These limitations include large pulmonary vascular obstruction, focal lung injury, and lung resection. Dilution methods provide an easy and clinically acceptable estimation of EVLW in most critically ill patients, including those with acute respiratory distress syndrome (ARDS). Assessing EVLW may be useful to predict outcome, to diagnose pulmonary edema, to better characterize patients with ARDS, to guide fluid therapy, and to assess the value of new treatments or ventilatory strategies in patients with pulmonary edema.
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Affiliation(s)
- Frédéric Michard
- Department of Anesthesia and Critical Care, Béclère Hospital-University Paris XI, France.
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Toth I, Leiner T, Mikor A, Szakmany T, Bogar L, Molnar Z. Hemodynamic and respiratory changes during lung recruitment and descending optimal positive end-expiratory pressure titration in patients with acute respiratory distress syndrome*. Crit Care Med 2007; 35:787-93. [PMID: 17255855 DOI: 10.1097/01.ccm.0000257330.54882.be] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate respiratory and hemodynamic changes during lung recruitment and descending optimal positive end-expiratory pressure (PEEP) titration. DESIGN Prospective auto-control clinical trial. SETTING Adult general intensive care unit in a university hospital. PATIENTS Eighteen patients with acute respiratory distress syndrome. INTERVENTIONS Following baseline measurements (T0), PEEP was set at 26 cm H2O and lung recruitment was performed (40/40-maneuver). Then tidal volume was set at 4 mL/kg (T26R) and PEEP was lowered by 2 cm H2O in every 4 mins. Optimal PEEP was defined at 2 cm H2O above the PEEP where Pao2 dropped by > 10%. After setting the optimal PEEP, the 40/40-maneuver was repeated and tidal volume set at 6 mL/kg (T(end)). MEASUREMENTS AND MAIN RESULTS Arterial blood gas analysis was done every 4 mins and hemodynamic measurements every 8 mins until T(end), then in 30 (T30) and 60 (T60) mins. The Pao2 increased from T0 to T(end) (203 +/- 108 vs. 322 +/- 101 mm Hg, p < .001), but the extravascular lung water (EVLW) did not change significantly. Cardiac index (CI) and the intrathoracic blood volume (ITBV) decreased from T0 to T26R (CI, 3.90 +/- 1.04 vs. 3.62 +/- 0.91 L/min/m2, p < .05; ITBVI, 832 +/- 205 vs. 795 +/- 188 m/m2, p < .05). There was a positive correlation between CI and ITBVI (r = .699, p < .01), a negative correlation between CI and central venous pressure (r = -.294, p < .01), and no correlation between CI and mean arterial pressure (MAP). CONCLUSIONS Following lung recruitment and descending optimal PEEP titration, the Pao2 improves significantly, without any change in the EVLW up to 1 hr. This suggests a decrease in atelectasis as a result of recruitment rather than a reduction of EVLW. There is a significant change in CI during the maneuver, but neither central venous pressure, heart rate, nor MAP can reflect these changes.
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Affiliation(s)
- Ildiko Toth
- Department of Anaesthesia and Intensive Therapy, University of Pécs, Hungary
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Sato Y, Motoyama S, Maruyama K, Okuyama M, Hayashi K, Nakae H, Tajimi K, Ogawa J. Extravascular Lung Water Measured Using Single Transpulmonary Thermodilution Reflects Perioperative Pulmonary Edema Induced by Esophagectomy. Eur Surg Res 2006; 39:7-13. [PMID: 17106200 DOI: 10.1159/000096926] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 09/06/2006] [Indexed: 11/19/2022]
Abstract
Pulmonary edema is the most frequent postoperative complication following esophagectomy for thoracic esophageal cancer. We enrolled 23 patients who underwent esophagectomy with extended lymph node dissection for thoracic esophageal cancer in a prospective observational clinical trial. We used the PiCCO device to measure extravascular lung water with the aim of determining whether it correlates with the respiratory index and whether it is predictive of pulmonary complications. Based on constant criteria, the tracheal tubes of 11 patients were removed on the morning of postoperative day 1 (extubation group), while 12 patients remained intubated (intubation group). These two groups significantly differed in that all patients in the extubation group recovered without any pulmonary complications, whereas 4 patients (33%) in the intubation group developed pulmonary complications. The extravascular lung water measured using PiCCO correlated significantly with the respiratory index. In the intubation group, both extravascular lung water and respiratory index were elevated 12 h after surgery and were even higher 24 h after surgery. The extravascular lung water measured using PiCCO reflects the level of postoperative pulmonary edema and predicts the pulmonary complications induced by esophagectomy with extended lymph node dissection.
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Affiliation(s)
- Y Sato
- Department of Surgery, Akita University School of Medicine, Akita, Japan
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Kuzkov VV, Kirov MY, Sovershaev MA, Kuklin VN, Suborov EV, Waerhaug K, Bjertnaes LJ. Extravascular lung water determined with single transpulmonary thermodilution correlates with the severity of sepsis-induced acute lung injury. Crit Care Med 2006; 34:1647-53. [PMID: 16625129 DOI: 10.1097/01.ccm.0000218817.24208.2e] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To find out if the extravascular lung water index (EVLWI) and the derived permeability indexes determined by the single transpulmonary thermodilution technique are associated with markers of acute lung injury in human septic shock. DESIGN Prospective, observational study. SETTING Mixed intensive care unit of a 900-bed university hospital. PATIENTS Thirty-eight consecutive adult patients with septic shock and acute lung injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The variables were assessed over a 72-hr period and included hemodynamics, EVLWI, and pulmonary vascular permeability indexes determined with the single indicator transpulmonary thermodilution technique, lung compliance, oxygenation ratio (Pao2/Fio2), lung injury score, cell counts, and the plasma concentration of endothelin-1. At day 1, EVLWI was elevated (>or=7 mL/kg) in 28 (74%) patients and correlated with lung compliance (r=-.48, p=.002), Pao2/Fio2 (r=-.50, p=.001), lung injury score (r=.46, p=.004), roentgenogram quadrants (r=.39, p=.02), and platelet count (r=-.43, p=.007). At day 3, EVLWI correlated with compliance (r=-.51, p=.002), Pao2/Fio2 (r=-.49, p = .006), and lung injury score (r=.53, p=.003). At day 3, EVLWI and pulmonary vascular permeability indexes were higher in nonsurvivors (p<.05). The plasma concentration of endothelin-1 (mean+/-sd) was significantly higher in patients with elevated EVLWI (>or=7 mL/kg) (3.85+/-1.40 vs. 2.07+/-0.38 pg/mL, respectively). Twenty-two (59%) patients died before day 28. CONCLUSIONS In human septic shock, EVLWI demonstrated moderate correlation with markers of acute lung injury, such as lung compliance, oxygenation ratio, roentgenogram quadrants, and lung injury score. In nonsurvivors, EVLWI and permeability indexes were significantly increased at day 3. Thus, EVLWI might be of value as an indicator of prognosis and severity of sepsis-induced acute lung injury.
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Affiliation(s)
- Vsevolod V Kuzkov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russian Federation
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