Monitoring lung edema

Transcription

1 Monitoring lung 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 Acute onset PaO2/FiO2<300, <200 Bilateral infiltrates PAOP 18 mmhg Radiographic score r = 0.1 p > Agreement inter-observer is no better than chance in half the x-rays Rubenfeld GD, Chest 1999;116:1347 Meade MO, AJRCCM 2000; 161: D ELWI Böck J, J Surg Res 1990;48:254

3 ALI/ARDS Bernard GR et al (1994). Report of the American-European consensus conference on ARDS: Intensive Care Med 20: Pulmonary edema and inflammation Acute onset PaO2/FiO2<300, <200 Bilateral infiltrates PAOP 18 mmhg PAOP is elevated in 30% of ALI/ARDS patients Ferguson ND et al. Intensive Care Med 2002;28: 1073 Wiedemann HP et al. NEJM 2006;354: 2564 PAOP is influenced by many factors Monet X, Teboul JL. Curr Op Crit Care 2006; 12: 235 PAOP may not reflect microvascular hydrostatic pressure Nunes S et al. Intens Care Med 2003;29: 2174

4 Retrospective analysis 382 Autopsies of critical care patients False positive > 33% False negative > 11%

5 An Early PEEP/FiO 2 Trial Separates Patients with established ARDS From Those with ALI and ARF Villar J, Pérez L, López J, Belda J, Kacmarek R, Aguilar G...and the HELP network Am J Respir Crit Care Med 2007 Design: Multicentric, prospective, randomized, intervention Methods: 170 patients AECC criteria for ALI / ARDS BGA day 0 and 24 h after standard settings Settings: VT: 7 ml/kg and FR for PCO2:35-50 mmhg + PEEP and FIO2 sequentially adjusted: PEEP 5 cmh2o and FlO2 0.5 PEEP 5 cmh2o and FIO2 1.0 PEEP 10 cmh2o and FIO2 0.5 PEEP 10 cmh2o and FIO2 1.0

6 Results: BGA at 0 and 24 h. 0 h ARDS ALI ARF h

7 Results: BGA at 0 and 24 h. 0 h 24 h ARDS ALI ARF

8 Mortality at 28 days FIGURA 2. Mortalidad en T24 por grupos bajo las cuatro modalidades ventilatorias 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 50% FiO2=0.5; FiO2=0.5; PEEP= 5 p= % PEEP=10 p= % 35% 30% 25% 20% 15% 10% 5% 0% ARDS ALI ARF ARDS ALI ARF N=140 N=22 N=8 N=99 N=55 N=16 50% FiO2=1; FiO2=1; p= % PEEP=5 PEEP=10 40% 35% 30% 25% 20% 15% 10% 5% 0% ARDS ALI ARF ARDS ALI ARF N=126 N=19 N=25 N=75 N=59 N=36 p=0.810

9 Schuster DP. Intensive Care Med 2007;33:400 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.

10 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

11 Dye-dilution curve: (Indocyanin green) Intra Thoracic Blood Volume Intrathoracic Blood Volume ITBV = CO * MTt ICG MTt MTt: Mean transit time half of the indicator passed the point of detection ITTV = CO * MTt cold Intrathoracic Thermal Volume MTt Thermo-dilution curve: (8ºC) Intra Thoracic Thermal Volume

12 Measurement of EVLW ITTV cold ITBV dye = EVLW Do we need to perform the double indicator technique?

13 Single vs double dye-thermal dilution n = 209 pts r = 0.96 Bias = -0.2 ml/kg SD = 1.4 ml/kg EVLW measurement by the single TPTD correlates very well with the double indicator technique Is EVLW-TPTD accurate? Reflects EVLW?

14 15 mongrel dogs (20-30 Kg) 5 controls 5 H. permeability 5 Hydrostatic EVLW PiCCO TPTD Gravimetry Normal values: 4-7 ml/kg Kirov M et al. Crit Care 2004;8:R lung injured sheep: r = 0.85, p < ELWI by PiCCO y = 1.03x r = 0,97 p < 0, ELWI by gravimetry

15 Crit Care Med 2007;35: sheep 35 Kg 4 h Pneumonectomy 19 Right-sided 7 Left-sided 4 Sham thoracotomy EVLW TPTD = 0,97 EVLW G + 0,51 r = 0,94 p<0,0001

16 14 ARDS patients Lung weight: CTscan vs ELW (Pulmonary Thermal Volume) Csr: 34 ±12 ELWI: 12 ± 3 In patients with ARDS, EVLW measured by TPTD method were tightly correlated with lung weight measured by CT How much edema can be detected?

17 6 pigs (28-35 Kg) 50 ml saline intratracheal: Normal-After lavage EVLW measurements 76.5% 85%

18 Crit Care Med 2007;35: sheep 35 Kg 4 h Pneumonectomy 19 Right-sided 7 Left-sided 4 Sham thoracotomy EVLW measurement EVLW detected the reduction of lung parenchyma Licker M et al, Chest 2008;13: patients: Lung resection + salbutamol

19 Critical Care Medicine 2008; 6: Factors to consider incorporating: Candidate genes associated with ARDS (75 79) Markers of endothelial activation like Von Willebrand F (102) Markers of epithelial injury like the alveolar Type 1 cell-specific biomarker HTI56 (146) The serum Clara cell protein concentrations (147) Indices of pulmonary permeability (131) Markers of collagen synthesis like procollagen peptide (103)

20 PVPI = Pulmonary Vascular Permeability Index Difference between the PVPI with hydrostatic and high-permeability lung edema: EVLW EVLW PVPI = PBV PBV hydrostatic PBV EVLW EVLW PBV permeability PBV EVLW EVLW PBV PVPI normal (1-3) PVPI raised (>3)

21 49 MV critically-ill patients Severe pulmonary edema: -PaO2/FiO2 < 300 -Bilateral infiltrates chest Rx -EVLW 12 ml/kg Retrospective analysis at the time of diagnosis Hydrostatic/High permeability Intensive Care Medicine 2007 History, Rx CI, EVLW EF (echo) B-type NP Pulmonary Vascular Permeability Index, PVPI = EVLW / ITBV

22 Intensive Care Medicine 2007

23 PVPI 3 High permeability edema Sensitivity: 85% Specificity: 100% Intensive Care Medicine 2007

24 Van der Heijden M, Groeneveld AB. Extravascular lung water to blood volume ratios as measures of pulmonary capillary permeability in nonseptic critically ill patients. J Crit Care Mar;25: MV nonseptic critical patients with or at risk for ALI/ARDS before-after fluid loading ( CVP) PLI pulmonary leak index (67gallium-29 labeled transferrin) PVPI using EVLW/ITBV and PBV Baseline After fluid load CVP, mm Hg 5 ± 3 (0-11) 7 ± 3 (2-14)** PLI, Gallium 39 ± 45 (6-171) 40 ± 25 (8-141) EVLW, ml/kg 6.0 ± 2.7 ( ) 5.6 ± 2.4 ( ) EVLW/ITBV, ml/ml 0.25 ± 0.11 ( ) 0.22 ± 0.10 ( )* EVLW/PBV, ml/ml 1.4 ± 1.0 ( ) 1.2 ± 0.8 ( )* PaO2/FiO2, mm Hg 349 ± 139 (78-515) 360 ± 136 (90-524) Crs, ml/cmh2o 59 ± 20 (28-108) 53 ± 18 (21-93)

25 Vanarasi (India)

26 29 patients with criteria of severe sepsis <72 h Heart failure Lung injury in sepsis EVLW infraestimation: Poor accesibility of thermal indicator Groeneveld AB, Crit Care Med 2004;32:899 Roch A, Crit Care Med 2004;32:811

27 29 patients with criteria of severe sepsis <72 h Heart failure Lung injury in sepsis EVLW infraestimation: Poor accesibility of thermal indicator Groeneveld AB, Crit Care Med 2004;32:899 Roch A, Crit Care Med 2004;32:811 Mechanical vascular obstruction: intravascular microthrombi positive end-expiratory pressure Functional vascular obstruction: Redistribution of blood flow away from injured areas (focal or regional pulmonary injury). Michard F, Phillips C. Crit Care Med 2009;37: 2118

28 18 ARDS patients. CMV: VT: 6 ml/kg RM: CPAP seg +Descending PEEP trial Optimal PEEP: PEEP where PaO2 dropped by >10% + 2 cmh2o

29 EVLW and Recruitment maneuvers Aguilar G, Belda J, Ferrando C. Yearbook of Intensive Care, Springer-Verlag 2009; early ALI/ARDS patients OLA ELWI by TP-TD before and after Single Recruitment maneuver Age: 63±20 Weight: 65±12 VT: 490±100 PEEP: 13±3 6 breaths with PEEP 20 cmh2o and Ppl:40 cmh2o 3,18±1,60 3,18±1,75

30 EVLWI EVLW and Recruitment maneuvers Aguilar G, Belda J, Ferrando C. Yearbook of Intensive Care, Springer-Verlag 2009;

31 P/ F ratio ELW I pre EVLW and Recruitment maneuvers Aguilar G, Belda J, Ferrando C. Yearbook of Intensive Care, Springer-Verlag 2009; P/ F variation y = 0,9 9 x R = 0, PFpre P/ F post Lineal (PFpre) 1 5 EWLI pre ( Lineal (EW ELW I post EVLWI post

32 Krebs J, Pelosi P, Tsagogiorgas C, Alb M, Luecke T. 20 patients ALI/ARDS: 10 normal IAP +10 IAH After RM: decremental PEEP IAH Normal IAP

33 Critical Care Medicine 2008;36: patients within 72 hrs of meeting AECC-ARDS 14 severe sepsis patients without ARDS.

34 Crit Care Med 2009;37: Critical Care 2009, 13:R30

35 29 patients with criteria of severe sepsis <72 h TP-TD PiCCO: ITBV, EVLW PPI = EVLW/ITBV ARDS (AECC criteria) vs non-ards EVLW: Nonsurvivors 14 ml/kg (7.4 20) Survivors 8.0 ml/kg ( ) (P < 0.001) Death was associated with greater EVLW over time (P < 0.001).

36 Critical Care Medicine 2006; 34: consecutive severe sepsis patients with ALI/ARDS (PVPI) (a) p< 0,05 intergroup

37 Crit Care Med 2008;36: patients sepsis-induced ARDS MV: ARDSnet protocol Measurements (3 days) LIS, SOFA, P/F, VD/VT EVLW (Predicted b weight) s Non survivors Survivors EVLWp>16 ml/kg 100% Specificity 86% Sensitivity Sakka SG et al. Chest 2002;122:2080 Kirov MY et al. Anesteziol Reanimatol 2003;4:41 Martin GS et al. Crit Care 2005;9:R74

38 44 ALI/ARDS patients (65% sepsis) 24 pulmonary 20 extrapulmonary Crit Care Med. 2010;38: Optimal cut-off value EVLWp>16 ml/kg 78% Specificity 75% Sensitivity

39 Conclusions: EVLW Is affected by high proportion of atelectasis OLA: Not affected by Recruitment Maneuver itself Related to Cdyn (edema) Marker of severity of ARDS Bedside accurate/simple estimation of lung edema Useful as early diagnostic tool High permeability (ARDS) vs hydrostatic Prognostic value EVLW: Marker of disease, severity and progression

40 Thank you very much For your attention Ringo Starr drummer Me 1971

41 Thank you very much for your attention

42 Definition Intensive Care Medicine 2007 Definition of shock: Life threatening clinical situation resulting from hemodynamic instability leading to a maldistribution of blood flow: poor tissue perfusion and oxygenation microcirculatory inadequacy to sustain tissue oxygen needs leading to tissue hypoxia Manifested by markers of hypoperfusion (lactate, SvO2) with or without hypotension.

43 Hypovolemic-hypodynamic early phase Circulatory insufficiency: Hipovolemia Miocardial depression Vasoregulatory alteration Hypoperfusion Tisular ischemia Macrocirculation O2 Supply O2 Demand Flow maldistribution Tissue hypoxia Microcirculation

44 Consensus Conference at the caribean sea

45 Ideal macrocirculation monitoring Monitoring tool: Diagnostic Therapeutic guide Low perfusion: Increase in oxygen delivery = oxygen demands DaO2 = CO x CaO2 = CO x [(Hb x 1,39 x SataO2)

46 Ideal macrocirculation monitoring Monitoring tool: Diagnostic Therapeutic guide Results Low perfusion: Increase in oxygen delivery = oxygen demands DaO2 = CO x CaO2 = CO x [(Hb x 1,39 x SataO2) Cardiac output Preload Afterload Contractility Hemoglobin Effect on Tissue hypoxia Lactate SvO2

47 However, what we do is... Diagnosis by the effects Clinical signs: Hypotension (SBP<90, MAP<65 or BPdrop >40 mmhg) or Hypoperfusion: altered mental status, delayed capilary refill, decreased urine output and cooled skin or extremities Confirmation: Base deficit, lactate (SvO2) Therapy guide: Central venous line + arterial line Give fluids ml Monitoring the results: Blood pressure and CVP Effects: Base deficit, lactate (SvO2) Is this right or wrong?

48 2001 EGDT Algorithm Rivers E et al. NEJM 2001;345: Restore volume: Fluids ml/kg Protocol: 1. Fluid infusion to CVP Vasoactive drugs to MAP>65 <90

49 MAP mmhg Monitoring the Vital Parameters 150 The Mean Arterial Pressure does not correlate with Oxygen Delivery! n= 1232 DO2 ml. min -1.m -2 Reinhart K in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring Springer Verlag Berlin - Heidelberg - NewYork 1990, pp

50 Role of the filling pressures CVP / PCWP Correlation between Central Venous Pressure CVP and Stroke Volume Kumar et al., Crit Care Med 2004;32:

51 Role of the filling pressures CVP / PCWP Correlation between Pulmonary Capillary Wedge Pressure PCWP and Stroke Volume Kumar et al., Crit Care Med 2004;32:

52 CVP and PCWP Lichtwarck-Aschoff et al, Intensive Care Med 18: , 1992

53 96 consecutive septic patients PAC Fluid challenge: 500 ml starch in 20 min Responders (43%): Increase in CO 15% CVP<8; PAOP<12 mmhg Sensitivity 60% Specificity 55% PPV: 50% NPV: 60%. The combination of CVP and PAOP (instead of either pressure alone) did not improve the degree of prediction of volume responsiveness.

54 Hemodynamic response to fluid loading Patients Definition of Responders N Challenge Responders Preisman S (2005) Cardiac surgery > 15% SV ml colloids 32/70 VLS (46%) Hofer CK (2005) Cardiac surgery > 25% SVI ml/kg (IBW) 6% HES 21 (60% ) Swensen CH (2006) Abdominal surgery Increase in CO ml/kg of Ringer 4 (40%) Tavernier B (1998) Michard F (2000) Sepsis w. circulatory failure Sepsis w. circulatory failure > 15% SVI ml HES 21/35 VLS (60%) > 15% CI ml HES 16 (40%) Michard F (2003) Septic shock > 15% SVI ml HES 32/66 VLS (48%) Feissel M (2005) Septic shock > 15% CI 20 8 ml/kg HES 13/22 VLS (59%) Monnet X (2005) Critically ill w. circulatory failure > 15% increase in ABF (Doppler) ml NS 20 (53%) Vallee F (2005) Critically ill w. circulatory failure Heenan S (2006) Critically ill w. circulatory failure > 10% increase in SVI 51 4 ml/kg colloid X 2 > 15% in CO 21 1 L Ringer or 500 ml HES 20 (39%) 9 (43%) Lafanechère A (2006) Critically ill w. circulatory failure > 15% increase in ABF (Doppler) 22 PLR and 500 ml NS 10 (45%) Osman D (2007) Sepsis > 15% in CO ml HES 65/150 VLS (43%)

55 300 / 631 = 47.5% responders More than 50% of critically ill patients in which fluid administration was clinically indicated were loaded with fluids unnecessarily! Pulmonary edema may occur as a complication of fluid resuscitation. Practice parameters for hemodynamic support of sepsis in adult patients in sepsis Task Force of the ACCCM and the SCCM, CCM 2004

56 Problems with the CVP target Comparison of Two Fluid-Management Strategies in Acute Lung Injury The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network* NEJM 2006; 354 (15 June): patients with 24 h. ALI/ARDS 503 Conservative strategy 497 Liberal strategy Based on BP, CVP/PAOP, diuresis Cumulative fluid balance (7 days): Conservative: ml Liberal: ml

57 PPV: Pulse Pressure variation with IPPV dp max dp min Exp Insp Predict the response to fluids volume challenge Dynamic parameters

58 SVV: Stroke volume variation with IPPV SV max SV min SV mean SVV = Fluid status and fluid resposiveness: After aortic surgery With sepsis-induced hypotension. Cardiac surgery Mechanically ventilated patients after cardiac surgery Patients undergoing brain surgery Reduced cardiac function During open chest conditions SV max SV min SV mean

59 SVV-PPV - Coriat P et al (1994) Anesth Analg 78:46 - Tavernier B et al (1998) Anesthesiology 89: Michard F et al (2000) AJRCCM 62:134 - Berkenstadt et al (2000), Eur J Anaesthesiol 17: 49 - Reuter et al (2000) Eur J Anaesthesiol 17: Berkenstadt H et al (2001) Anesth Analg 92:984 - Reuter DA et al (2002) Br J Anaesth 88:124 - Reuter DA et al (2003) Crit Care Med 31: Reuter DA et al (2005) Br J Anaesth 94:318 - Preisman S et al (2005) Br J Anaesth 95:746 Fluid status and fluid responsiveness: After aortic surgery With sepsis-induced hypotension. Cardiac surgery Mechanically ventilated patients after cardiac surgery Patients undergoing brain surgery Reduced cardiac function During open chest conditions Predictive value PPV: 95% NPV: 93% Limitations: - Mechanical ventilation - Effect of ventilatory parameters (VT) - Sinus rithm

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