Recent advance of lung water measurement and clinical implications

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Alison Jacobs
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1 42 Recent advance of lung water measurement and clinical implications (EVLW) 1) EVLW 35 2) ICU ARDS 3,4) 1 2 5) Meier Zierler 6) 1 1 (mean transit time : MTt) (Q) (V ) MTt volume Q q q q = c(t)(qdt) = Q c(t)dt Q Q = q/ c(t)dt t Qc(t) h(t) = Qc(t)/q h(t) Q Qh(t)dt (t) dv dv = [t][qh(t)dt]

2 idqwl:indicator dilution quantity of extravascular water in the lung, Qwl:quantity of extravascular water in the lung, THO:tritiated water, Data were obtained from animal study. *: Data from experimental lung edema. h(t) V = dv dt = Q th(t)dt th(t)dt MTt(mean transit time) Q = MTt = = MTt = th(t)dt q Qc(t) ht = c(t)dt q th(t)dt = Q q tc(t)dt c(t)dt tc(t)dt 1) 2 (EVLW) 2) 1 T Na 7) RISA 51 Crred cell (ICG) Na + (conductivity) THO:tritiated water (D 2 O) (ICG) 8)

3 44 Na + 9,1) (ETV) (PETW) - 11) injection MTt DSt recirculation 1 Down slope time mean transit time 2 2 Down slope time volume(dst volume) MTt volume 1951 Newman 12) q V t c Q c = q/v Q dq/dt = Qq/V = Qc V dc/dt = Qc/V (Q/V )t c = ae 2 3 V 1 V 2 V 3 V 2 a t = ta( ta: appearance time) c = q/v (Q/V )(t ta) c = q/v e t ( 1) Q/V DSt Q V Q V = DStQ V = DStCO

211 45 small chamber large chamber injection 3 DSt volume 2 12) ( 3) 1) MTt volume DSt volume ( 4) MTt volume MTt CO ITBV ITTV EVLW Lung water computer DSt volume DSt CO DStCO PBV PTV 4 MTt volume

4 small chamber large chamber injection 3 DSt volume 2 12) ( 3) 1) MTt volume DSt volume ( 4) MTt volume MTt CO ITBV ITTV EVLW Lung water computer DSt volume DSt CO DStCO PBV PTV 4 MTt volume DSt volume * MTt EVLW EVLW = ITTV ITBV = CO(MTt th MTt dye ) * MTt DSt EVLW EVLW = PTV PBV PBV = ITBV GEDV ITBV = 1.25GEDV GEDV EVLW = PTV.25GEDV = CODSt th.25co (MTt th DSt th ) MTt volume Volume measured form mean transit time, DSt volume volume measured from down slope time, ITBV intrathoracic blood volume, PBV pulmonary blood volume, ITTV intrathoracic thermal volume, PTV pulmonary thermal volume, EVLW extravascular lung weight, GEDV global endodiastric volume. EVLW Elings DSt volume -

5 46 right heart mixing volume RHMV RHMV=PBV DSt volume PTV RHMV EVTW 13) RHMV=PBV Sakka 14) 1 MTt volume DSt volume ITTV PTV Global endodiastolic volume (GEDV) PBV = ITBV GEDV, EVLW = PTV (ITBV GEDV) 2 ITBV ITBV GEDV ITBV GEDV ITBV = 1.25GEDV 28.4 (ml) ITBV 1.25GEDV EWLV = PTV.25GEDV = CODSt th.25co(mtt th DSt th ) = CO(1.25DSt th.25mtt th ) CO transpulmonary thermodilution method (TPTD) 2) (TPTD) TPTD (PiCCO; Pulsion Medical Systems, Germany) (y) (x) y = 1.3 x , r = ) LPS 16) EVLW TPTD ITBV = 1.25 GEDV TPTD - gold standard TPTD 17) TPTD ITBV EVLW - 14) 3 (PAC) PAC ICU

6 PAC PAOP ARDS 18) 19) 198 (EVLW) 1987 Eisenberg 2) ICU EVLW 4 EVLW=7 ml/kg PAOP=18 mmhg EVLW EVLW PAOP X EVLW EVLW ARDS () Fluid resuscitation PAC Sakka 21) ICU 373 TPTD EVLW 24 EVLW EVLW ROC EVLW APACHEII SOFA SAPSII EVLW ARDS EVLW ARDS 22) Craig EVLW EVLWa EVLWp ALI/ARDS 23) 48 EVLW ICU primary outcome EVLWa EVLWp 6 EVLWp APACHEII ROC EVLWp 16 ml/kg ALI/ARDS EVLWa 7 ml/kg ALI/ARDS 24) EVLWp 7 ml/kg EVLWa 1 ml/kg

7 48 4 TPTD TPTD EVLW>15 ml/kg <1 ml/kg 21) EVLW EVLW ARDS 25) 22,26) TPTD 27) 28) ARDS 12 ml/kg 73 >1 ml/kg 25) ARDS 29) CT 3) AECC 31) ARDS TPTD PA 1. Sivak ED, Richmond BJ, O Donavan PB, Borkowski GP. Value of extravascular lung water measurement vs portable chest x-ray in the management of pulmonary edema. Crit Care Med Jul;11(7): Snashall PD, Keyes SJ, Morgan BM, McAnulty RJ, Mitchell-Heggs PF, McLvor JM, et al. The radiographic detection of acute pulmonary oedema. A comparison of radiographic appearances, densitometry and lung water in dogs. Br J Radiol Apr;54(64): Meade MO, Cook RJ, Guyatt GH, Groll R, Kachura JR, Bedard M, et al. Interobserver variation in interpreting chest radiographs for the diagnosis of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2 Jan;161(1): Rubenfeld GD, Caldwell E, Granton J, Hudson LD, Matthay MA. Interobserver variability in applying a radiographic definition for ARDS. Chest Nov;116(5): Fernandez-Mondejar E, Rivera-Fernandez R, Garcia-Delgado M, Touma A, Machado J, Chavero J. Small increases in extravascular lung water are accurately detected by transpulmonary thermodilution. J Trauma. 25 Dec;59(6):142-3; discussion Meier P, Zierler KL. On the theory of the indicator-dilution method for measurement of blood flow and volume. J Appl Physiol Jun;6(12): Pearce ML. Sodium recovery from normal and edematous lungs studied by indicator dilution curves. Circ Res Jun;24(6): Lewis FR, Jr., Elings VI. Microprocessor determination of lung water using thermalgreen dye double indicator dilution. Surg Forum. 1978;29: Ishibe Y, Umeda T, Izumi T, Nakamura M, Suekane K, Sato K, et al. [Measurement of lung water with a double indicator dilution method in dogs using heat and sodium ions]. Masui Mar;35(3): Arakawa M, Kambara K, Segawa T, Ando F, Kawada T, Ohno M. Usefulness of sodium chloride as a nondiffusible indicator in the measurement of extravascular lung thermal volume in dogs. Med Biol Eng Comput Jul;31 Suppl:S Yamamoto I, Sawada Y, Ueyama M, Hirokane T, Sato K, Ishibe Y, et al. [A clinical study of pulmonary edema on paraquat poisoning by double indicator dilution method using heat and sodium]. Kokyu To Junkan May;37(5): Newman EV, Merrell M, Genecin A, Monge C, Milnor WR, Mc KW. The dye dilution method for describing the central circulation. An analysis of factors shaping the time-concentration curves. Circulation Nov;4(5):

8 Elings VB, Lewis FR. A single indicator technique to estimate extravascular lung water. J Surg Res Nov;33(5): Sakka SG, Ruhl CC, Pfeiffer UJ, Beale R, McLuckie A, Reinhart K, et al. Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med. 2 Feb;26(2): Katzenelson R, Perel A, Berkenstadt H, Preisman S, Kogan S, Sternik L, et al. Accuracy of transpulmonary thermodilution versus gravimetric measurement of extravascular lung water. Crit Care Med. 24 Jul;32(7): Kirov MY, Kuzkov VV, Kuklin VN, Waerhaug K, Bjertnaes LJ. Extravascular lung water assessed by transpulmonary single thermodilution and postmortem gravimetry in sheep. Crit Care. 24 Dec;8(6):R Schuster DP, Calandrino FS. Single versus double indicator dilution measurements of extravascular lung water. Crit Care Med Jan;19(1): Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deboisblanc B, et al. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 26 May 25;354(21): Isakow W, Schuster DP. Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives to the pulmonary artery catheter. Am J Physiol Lung Cell Mol Physiol. 26 Dec;291(6):L Eisenberg PR, Hansbrough JR, Anderson D, Schuster DP. A prospective study of lung water measurements during patient management in an intensive care unit. Am Rev Respir Dis Sep;136(3): Sakka SG, Klein M, Reinhart K, Meier- Hellmann A. Prognostic value of extravascular lung water in critically ill patients. Chest. 22 Dec;122(6): Phillips CR, Chesnutt MS, Smith SM. Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted body weight improves correlation with severity of illness and survival. Crit Care Med. 28 Jan;36(1): Craig TR, Duffy MJ, Shyamsundar M, Mc- Dowell C, McLaughlin B, Elborn JS, et al. Extravascular lung water indexed to predicted body weight is a novel predictor of intensive care unit mortality in patients with acute lung injury. Crit Care Med. 21 Jan;38(1): Crapo RO, Morris AH, Gardner RM. Reference spirometric values using techniques and equipment that meet ATS recommendations. Am Rev Respir Dis Jun;123(6): Martin GS, Eaton S, Mealer M, Moss M. Extravascular lung water in patients with severe sepsis: a prospective cohort study. Crit Care. 25 Apr;9(2):R Berkowitz DM, Martin G. Extravascular lung water measurement in acute respiratory distress syndrome. Crit Care Med. 29 Jan;37(1): Neumann P. Extravascular lung water and intrathoracic blood volume: double versus single indicator dilution technique. Intensive Care Med Feb;25(2): Easley RB, Mulreany DG, Lancaster CT, Custer JW, Fernandez-Bustamante A, Colantuoni E, et al. Redistribution of pulmonary blood flow impacts thermodilutionbased extravascular lung water measurements in a model of acute lung injury. Anesthesiology. 29 Nov;111(5): 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. 25 Nov;33(11): Graham MR, Gulati H, Kha L, Girling LG, Goertzen A, Mutch WA. Resolution of pulmonary edema with variable mechanical ventilation in a porcine model of acute lung injury. Can J Anaesth. 211 Aug;58(8): Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American- European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med Mar;149(3 Pt 1): ( )

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Extravascular lung water and pulmonary arterial wedge pressure for fluid management in patients with acute respiratory distress syndrome

Hu et al. Multidisciplinary Respiratory Medicine 2014, 9:3 ORIGINAL RESEARCH ARTICLE Open Access Extravascular lung water and pulmonary arterial wedge pressure for fluid management in patients with acute