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Brussels, March 27-30, 2007

Pulmonary edema – Get a clearer picture

Pulmonary edema – Clinical relevance and detection

Michael Quintel

Universitätsklinikum

Georg-August Universität Göttingen


Ware LB, Matthay MA.

Clinical practice. Acute pulmonary edema.

N Engl J Med 2005; 353:2788-96


Drainage from thorax

via hilus vessels

via pleural space

via abdominal space

Blomqvist H, Frostell C, Pieper R, Hedenstierna G.

Measurement of dynamic lung fluid balance in the mechanically

ventilated dog. Theory and results.

Acta Anaesthesiol Scand 1990; 34:370-376


Thoracic lymph flow (TLF) was found to be 6.1 +/- 1.4 ml/h before, and 29 +/- 4.6

ml/h after the induction of lung damage with oleic acid. TLF was depressed by

50% both before and after lung damage, when a positive end-expiratory pressure

(PEEP) of 10 cm H 2O was applied.

This suggests impeded drainage of the lung tissue.

Spontaneous breathing, compared to mechanical ventilation, significantly increased

TLF by approximately 70%.

Abdominal lymph flow increased from 61 +/- 5.3 ml/h to 111 +/- 12.6 ml/h,

when a PEEP of 10 cm H 2O was applied.

Frostell C, Blomqvist H, Hedenstierna G, Halbig I, Pieper R.

Thoracic and abdominal lymph drainage in relation to mechanical ventilation and PEEP.

Acta Anaesthesiol Scand 1987; 31:405-12


Ware LB, Matthay MA.

Alveolar fluid clearance is impaired in the majority of patients with acute lung injury and the

acute respiratory distress syndrome.

Am J Respir Crit Care Med 2001; 163:1376-1383


Ware LB, Matthay MA.

Alveolar fluid clearance is impaired in the majority of patients with acute lung injury and the

acute respiratory distress syndrome.

Am J Respir Crit Care Med 2001; 163:1376-1383


Principals of pulmonary edema formation

high pulmolvascular pressures

increased filtration pressure

high pressure edema

hydrostatic edema

inflammatory reaction

pathologic increase of endothelial permeability

low pressure edema

permeability edema


Matthay MA, Zimmerman GA.

Acute lung injury and the acute respiratory distress syndrome: four

decades of inquiry into pathogenesis and rational management.

Am J Respir Cell Mol Biol 2005; 33:319-27


"overhydrated patient"


patient after "aggressive" CVVH (-17 l)


Matthay MA, Zimmerman GA.

Acute lung injury and the acute respiratory distress syndrome: four

decades of inquiry into pathogenesis and rational management.

Am J Respir Cell Mol Biol 2005; 33:319-27


Guidot DM, Folkesson HG, Jain L, Sznajder JI, Pittet JF, Matthay MA.

Integrating acute lung injury and regulation of alveolar fluid clearance.

Am J Physiol Lung Cell Mol Physiol 2006; 291:L301-6


Ware LB, Kaner RJ, Crystal RG, Schane R, Trivedi NN, McAuley D, Matthay MA. Related Articles, Links

VEGF levels in the alveolar compartment do not distinguish between ARDS and hydrostatic pulmonary oedema.

Eur Respir J.2005; 26:101-5


Guidot DM, Folkesson HG, Jain L, Sznajder JI,

Pittet JF, Matthay MA.

Integrating acute lung injury and regulation of

alveolar fluid clearance

Am J Physiol Lung Cell Mol Physiol 2006;

291:301-306


RA

Pressures to estimate LV preload

and influences

PA

PAP

CVP PAOP

LVEDP

RV

CVP PAP PAOP LAP LVEDP LVEDV

Trikuspidalis vitium

RV diastolic disturbane

pulmonalvascular resistance

HR

alveolar pressure

pulmonal vasculary disease

Mitralis vitium

HR

PV

LAP

LA

LV

LV diastolic disturbance

Ao


Malbrain ML.

Is it wise not to think about intraabdominal hypertension in the ICU?

Curr Opin Crit Care 2004; 10:132-45


Luecke T, Roth H, Herrmann P, Joachim A, Weisser G, Pelosi P, Quintel M.

PEEP decreases atelectasis and extravascular lung water but not lung tissue volume in

surfactant-washout lung injury.

Intensive Care Med 2003; 29:2026–2033


PCWP, PAOP) does not allow to distinguish

between hydrostatic and permeability edema !

Ware LB, Matthay MA.

Clinical practice.

Acute pulmonary edema.

N Engl J Med 2005; 353:2788-96


Proportion Surviving

Connors AF et al.: JAMA 1996

SUPPORT: The effectiveness of right heart

catheterization in the initial care of critically

ill patients

1,0

0,9

0,8

0,7

0,6

p=0.02

0 5 10 15 20 25 30

Follow-up Time [d]

No RHC

RHC


SUPPORT: The effectiveness of right heart catheterization in

the initial care of critically ill patients

with PAC without PAK

• 30 d mortality 37,5% 32,8%

• 180 d mortality 54,0% 48,8%

• ICU stay 14,8 d 13,0 d

• costs [$] 49.300 35.700

• highest catheter-associated „risik" in postoperative less serious ill patients

Connors AF et al.: JAMA 1996


Pulmonary Artery Catheter in shock and ARDS

Richard C. et al (2003) JAMA 26:2713-2720


National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;

Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL.

Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.

N Engl J Med 2006; 354(21):2213-24


National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;

Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL.

Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.

N Engl J Med 2006; 354(21):2213-24


CVP

Bolus -

injektion

Transpulmonala Indikatordilutions-

Indikatordilutions

Technik

−ΔT in °C

0.3

0.2

0.1

0.0

mtt

CO/CI

0 10 20 30 40 50

arterieler Thermistorkatheter

GEDV (ITBV)

EVLW

dst

[s]


Extravascular lung water (EVLW)

EVLW corresponds to the water content of the whole lungs and is

calculated by subtraction of ITBV from ITTV

=

ITTV

ITBV

EVLW

RAEDV RVEDV LAEDV LVEDV

PTV

RAEDV RVEDV PBV LAEDV LVEDV

EVLW

EVLW


Normal values

parameter range units

HI 3.0 – 5.0 l/min/m 2

SVI 40 – 60 ml/m 2

SVRI 1200 – 1800 dyn*s*cm -5 *m

MAD 70 – 90 mmHg

GEF 25 – 35 %

CFI 4.5 – 6.5 1/min

HR 60 – 90 1/min

GEDVI 680 – 800 ml/m 2

ITBVI 850 – 1000 ml/m 2

SVV < 10 %

EVLWI 3.0 – 7.0 ml/kg


Sakka SG, Klein M, Reinhart K, Meier-Hellmann A.

Prognostic value of extravascular lung water in critically ill

patients.

Chest 2002; 122:2080-6


Sakka SG, Klein M, Reinhart K, Meier-Hellmann A.

Prognostic value of extravascular lung water in critically ill

patients.

Chest 2002; 122:2080-6


n=101

22 days

Clinical impact of EVLW

* *

9 days

Mitchell JP, Schuller D, Calandrino FS, Schuster DP:

Am Rev Resp Dis 145: 990-998, 1992

15 days

7 days

PAC group EVLW group PAC group EVLW group

ventilator days ICU days


National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;

Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL.

Comparison of two fluid-management strategies in acute lung injury.

N Engl J Med 2006; 354:2564-75


National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;

Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL.

Comparison of two fluid-management strategies in acute lung injury.

N Engl J Med 2006; 354:2564-75


National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;

Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL.

Comparison of two fluid-management strategies in acute lung injury.

N Engl J Med 2006; 354:2564-75


extravascular lung water/pulmonary blood volume = PVPI

extravascular lung water index over

global end-diastolic volume index = GEDVI

Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul JL.

Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of

hydrostatic pulmonary edema from ALI/ARDS.

Intensive Care Med 2007 Jan 13; [Epub ahead of print]


Am J Respir Crit Care Med 2006; 173:281–287

The exclusion criteria were as follows:

age younger than 18 yr

participation in other intervention trials

severe obstructive airway disease requiring nebulized or

intravenous ß 2-agonist treatment with ß-blockers within 48 h

neutrophil count of less than 0.3 x 109 There was no difference in 28-d

mortality in the salbutamol-treated

L,

group (58%) compared with

brainstem death

placebo (66%; p=0.4).

treatment withdrawal within 24 h

immunosuppression

(steroids > 20 mg/d, chemotherapy or other immunosuppressive agents within 2 wk)

lobectomy/pneumonectomy

burns over more than 40% of body surface area

assent declined from the next of skin


Am J Respir Crit Care Med 2006; 173:281–287


McAuley DF, Giles S, Fichter H, Perkins GD, Gao F.

What is the optimal duration of ventilation in the prone position in acute lung injury

and acute respiratory distress syndrome ?

Intensive Care Med 2002; 28:414–418

11


Luecke T, Roth H, Herrmann P, Joachim A, Weisser G, Pelosi P, Quintel M.

PEEP decreases atelectasis and extravascular lung water but not lung tissue volume in

surfactant-washout lung injury.

Intensive Care Med 2003; 29:2026–2033


Patroniti N, Bellani G, Maggioni E, Manfio A, Marcora B, Pesenti A.

Measurement of pulmonary edema in patients with acute respiratory distress syndrome.

Crit Care Med 2005; 33:2547-54


EVLWI has been proposed as an index to identify patients

with ARDS, threshold values of 7 to 10 mL/kg have been

suggested. We found EVLWI values similar to the ones

reported by other investigators in patients with ARDS.

Some of our patients although satisfying all the criteria for

ARDS, had EVLWI values only slightly increased above normal.

For such patients, the suggested EVLWI threshold of 10 mL/kg

for the diagnosis of ARDS appears too selective.

Patroniti N, Bellani G, Maggioni E, Manfio A, Marcora B, Pesenti A.

Measurement of pulmonary edema in patients with acute respiratory distress syndrome.

Crit Care Med 2005; 33:2547-54

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