Extravascular lung water reflects pulmonary edema F Javier Belda MD, PhD Dept. Anesthesiology and Critical Care
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1 28 th ISICEM Brussels, 19 March 2008 Monitoring in respiratory failure Extravascular lung water reflects pulmonary edema F Javier Belda MD, PhD Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia (Spain)
2 ALI/ARDS Bernard GR et al (1994). Report of the American-European consensus conference on ARDS: Intensive Care Med 20: Pulmonary edema and inflammation Rapid onset PaO2/FiO /FiO2<300, <200 Bilateral infiltrates Compliance reduction PAOP 18 mmhg PAOP is elevated in 30% of ALI/ARDS patients Wiedemann HP et al. NEJM 2006; 354:2564 PAOP is influenced by many factors Monet X, Teboul JL. Curr Op Crit Care 2006; 12: PAOP may not reflect microvascular hydrostatic pressure Nunes S et al. Intens Care Med 2003;29: 2174
3 High intrathoracic pressure...during more than 80 years
4 Schuster DP. Intens Care Med 2007 Edema ARDS: Advanced ARDS Diffuse damage to the alveolo capillary barrier. Proteinaceous alveolar edema and hypoxemia. Criteria for ARDS: (1) An appropriate clinical setting (2) Bilateral radiographic infiltrates consistent with alveolar edema (3) Significantly increased pulmonary vascular permeability.
5 Edema of ALI/ARDS is not well detected by: Chest radiograph / Blood gas analysis Radiographic score r = 0.1 p > ELWI (ml/kg) Δ ELWI PaO 2 /FiO 2 Boeck J, J Surg Res 1990; Halperin et al, 1985, Chest 88: 649
6 Edema can be detected: Measuring EVLW by transpulmonary thermo-dye dilution Lungs Pulmonary Circulation CV catheter bolus injection cold indocyanine green Right Heart EVLW Left Heart arterial thermodilution catheter Arterial measurement of dye- and thermo-dilution curves
7 Dye-dilution curve: (Indocyanin green) Intra Thoracic Blood Volume Intrathoracic Blood Volume ITBV = CO * MTt MTt ICG MTt MTt: Mean transit time half of the indicator passed the point of detection ITTV = CO * MTt MTt cold Intrathoracic Thermal Volume MTt Thermo-dilution curve: (8ºC) Intra Thoracic Thermal Volume
8 Measurement of EVLW ITTV cold ITBV dye = EVLW Do we need to perform the double indicator technique? I hate indocyanin green... I always end up with my fingers turning green
9 n = 209 pts r = 0.96 Bias = -0.2 ml/kg SD = 1.4 ml/kg OK, the single transpulmonary thermodilution correlates very well with the double indicator technique. But, EVLW-TPTD is accurate? Reflects EVLW?
10 15 mongrel dogs (20-30 Kg) 5 controls 5 H. permeability 5 Hydrostatic EVLW Gravimetry
11 Crit Care 2004;8:R sheep Lung Injury: (7) E. coli lipopo.15 ng/kg/min iv 6 h (7) Oleic acid 0.06 ml/kg iv 30 min 4 Sham operation. y = 1.3 x r = 0.85, P < Mean difference: 4.9 ±2.5 ml/kg
12 Crit Care Med 2007;35: sheep 35 Kg 4 h 18 Pneumonectomy 7 Right-sided 7 Left-sided 4 Sham thoracotomy 12 Right pneumonectomy
13 Crit Care Med 2007;35: sheep 35 Kg 4 h 18 Pneumonectomy 7 Right-sided 7 Left-sided 4 Sham thoracotomy 12 Right pneumonectomy 6 Injurious (VT:12, ZEEP) 6 Protective (VT:6, PEEP 2)
14 14 ARDS patients Lung weight: CTscan vs ELW Csr: 34 ±12 ELWI: 12 ± 3 ELW (Pulmonary Thermal Volume)
15 14 ARDS patients Lung weight: CTscan vs ELW Csr: 34 ±12 ELWI: 12 ± 3 ELW (Pulmonary Thermal Volume) In patients with ARDS, EVLW measured by TDD method were tightly correlated with lung weight measured by CT-scan EVLW measurements showed good reproducibility. OK, EVLW-TPTD measures EVLW (edema). But... How much edema could be detected?
16 6 pigs (28-35 Kg) 50 ml saline intratracheal: : Normal-After lavage EVLW measurements 76.5% 85%
17 6 pigs (28-35 Kg) 50 ml saline intratracheal: : Normal-After lavage EVLW measurements OK, I m convinced!! 76.5% 85%
18 After a similar talk in Vanarasi (India)
19 Critical Care Medicine 2006; 34: consecutive severe sepsis patients with ALI/ARDS
20 (a) p< 0,05 intergroup EVLW Prognostic value
21 Crit Care Med 2008;36:69 19 patients sepsis-inducedinduced ARDS MV: ARDSnet protocol 100% specificity 86% Sensitivity Measurements (3 days) LIS, SOFA, P/F, VD/VT EVLWp SakkaSG et al. Chest 2002;122:2080 Kirov MY et al. Anesteziol Reanimatol 2003;4:41 Martin GS et al. Crit Care 2005;9:R74
22 Conclusions: : EVLW Bedside accurate/simple estimation of lung edema ALI/ARDS: Marker of disease, severity and progression Is it possible to discriminate high permeability edema from cardiogenic hydrostatic edema?
23 Thank you very much for your attention. Hasta la próxima Paul MacCartney. Arrival to Gijon (Spain). 24 May 2004
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