Pulmonary edema

Brussels Exhibition & Convention Center
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