The value of lung water measurement in assessing the origin of lung edema

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1 The value of lung water measurement in assessing the origin of lung edema Prof. Xavier MONNET Medical Intensive Care Unit Paris Sud University Hospitals

2 Link of interest Pulsion Medical Systems

3 Inflammatory and hydrostatic pulmonary edema are not the same! Hydrostatic PE Inflammatory PE P hydrostat Inflammatory and hydrostatic lung edema have different mechanisms Is it clinically important in the ICU?

4 Is it clinically important in the ICU? ICU for 4 days ventilation for pneumonia + worsening of lung infiltrates and gas exchange renal failure LVEF = 40 % C reactive protein = 150 mg/l + fluid bl balance = ml

5 The 6 take home messages 1 Differenciating hydrostatic pulmonary edema and ARDS is of clinical importance 2 3 How to distinguish between inflammatory and hydrostatic lung edema? 4 5 6

6 How to differenciate inflammatory and hydrostatic lung edema? Pulmonary artery catheter

7 PAOP to differenciate ARDS and hydrostatic lung edema? Pulmonary artery occlusion pressure Pulmonary capillary pressure

8 PAOP to differenciate ARDS and hydrostatic lung edema? Cardiogenic PE Inflammatory PE PAOP normal/low PAOP

9 PAOP to differenciate ARDS and hydrostatic lung edema? Pulmonary artery catheter PAOP is not the pulmonary capillary pressure

10 PAOP to differenciate ARDS and hydrostatic lung edema? PAOP 10 mmhg Pcap 12 to 20 mmhg depending on the value of cardiac output and pulmonary venous resistance

11 PAOP to differenciate ARDS and hydrostatic lung edema? Pulmonary artery catheter PAOP is not the pulmonary capillary pressure Manypitfalls in PAOP measurement/interpretation

12 PAOP to differenciate ARDS and hydrostatic lung edema? PAOP measurement must take into account Mechanical ventilation PAP therespiratory variations of intrathoracic pressure PAOP PAP Spontaneous breathing PAOP

13 PAOP to differenciate ARDS and hydrostatic lung edema? PAP PAOP measurement must take into account therespiratory variations of intrathoracic pressure Spontaneous breathing the transmission of PEEP and PEEPi 15 mmhg PAOP 13 mmhg 0 3 sec 3 mmhg

14 PAOP to differenciate ARDS and hydrostatic lung edema? 2013?

15 PAOP for differenciating ARDS and hydrostatic lung edema? Pulmonary artery catheter PAOP is not the pulmonary capillary pressure Manypitfalls in PAOP measurement/interpretation Hydrostatic edema can be associated with ARDS

16 PAOP to differenciate ARDS and hydrostatic lung edema? Hydrostatic PE Inflammatory PE PAOP PAOP PAOP can also be elevated in case of inflammatory lung edema!

17 PAOP to differenciate ARDS and hydrostatic lung edema?

18 The 6 take home messages 1 Differenciating hydrostatic pulmonary edema and ARDS is of clinical importance 2 PAOP is not the ideal criterion to differenciate hydrostatic pulmonary edema and ARDS in the context of ICU

19 How to differenciate inflammatory and hydrostatic lung edema? Pulmonary artery catheter PAOP is not the pulmonary B type natriuretic peptide capillary pressure Manypitfalls in PAOP measurement/interpretation Hydrostatic edema can be associated with ARDS

20 BNP to differenciate ARDS and hydrostatic lung edema?

21 BNP to differenciate ARDS and hydrostatic lung edema? 54 ICU patients BNP within 48 hrs ALI/ARDS established by experts Very large overlap

22 BNP to differenciate ARDS and hydrostatic lung edema? 90 pts ALI/ARDS established by experts A large grey zone! 49% of the population

23 How to differenciate inflammatory and hydrostatic lung edema? Pulmonary artery catheter B type natriuretic peptide Numerous confounding factors in the ICU

24 The 6 take home messages 1 Differenciating hydrostatic pulmonary edema and ARDS is of clinical importance 2 PAOP is not the ideal criterion to differenciate hydrostatic pulmonary edema and ARDS in the context of ICU 3 Due to confounding factors, B type natriuretic peptide cannot be used for this purpose 4 Any alternative? 5 6

25 How to differenciate inflammatory and hydrostatic lung edema? Pulmonary artery catheter B type natriuretic peptide Numerous confounding factors Transpulmonary thermodilution in the ICU

26 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? Hydrostatic PE Inflammatory PE Normal permeability permeability

27 The 6 take home messages 2 qquestions 1 Differenciating hydrostatic pulmonary edema and ARDS is of clinical importance p 2 PAOP is not the ideal criterion to differenciate hydrostatic pulmonary edema and ARDS in the context of ICU 3 Due to confounding factors, B type natriuretic peptide cannot be used for this purpose 4 An increased lung permability is the pathophysiological hallmark of ARDS 5 6 Æ 2 questions

28 2 questions How to measure lung permeability? How to use lung permeability?

29 How to differenciate inflammatory and hydrostatic lung edema? Pulmonary artery catheter B type natriuretic peptide Transpulmonary thermodilution Allows a direct estimation of pulmonary vascular permeability

30 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema?

31 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? Cold bolus Pulmonary vascular PVPI permeability index = lung water pulmonary blood volume Doesit really reflect lung permeability? PiCCO

32 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? 15 dogs Oleic acid iv. or left balloon inflation Transpulmory thermodilution ti PVPI In the clinical setting?

33 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? 48 patients established diagnosis of pulmonary edema bilateral lung infiltrates PaO 2 /FiO 2 < 300 mmhg lung water > 12 ml/kg differential diagnosis by experts past history examination CXR cardiac echo BNP ALI / ARDS vs. hydrostatic PE

34 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? 6 PVPI 48 patients with pulmonary edema inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device 4 * 2 PVPI is higher in inflammatory than in cardiogenic PE 0 ALI/ARDS Hydrostatic pulmonary edema

35 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? 48 patients with pulmonary edema PVPI inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device Cut off : Se = 85 % 2 * Sp = 100 % 1 0 ALI/ARDS Hydrostatic pulmonary edema

36 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? 100 PVPI 48 patients with pulmonary edema inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device ty sensitivi BNP p < specificity

37 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? 266 patients with pulmonary edema inflammatory vs. hydrostatic discriminated by experts PVPI by the PiCCO device

38 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? 200 pts with ARDS EVLW measured by PiCCO device Day 28 mortality (%) Odds Ratio ( CI 95%) p value PVPI max (1 unit 100= 1 point) 1.27 ( ) 0.03 p < Maximum blood 80 lactate (1 unit = 1 mmol/l) /) 1.27 ( ) Minimum PaO 60 2 /FiO 2 (1 unit = 1 mmhg) 69% 0.98 ( ) Mean PEEP (1 unit = 1 cmh 2 O) ( ) SAPS II (1 unit = 1 point) 37% 1.03 ( ) Mean cumulative fluid balance (1 unit = 1 ml) ( ) PVPI max > 3.8 PVPI max 3.8 The pulmonary vascular permeability measured by transpulmonary thermodilution has a real physiological significance

39 Transpulmonary thermodilution to differenciate ARDS and hydrostatic lung edema? 69 critically ill patients CVVH Blood pump flow at 0, 250 or 350 ml/min 7 6 ns CVVHF 350 ml/min The measurement of pulmonary permeability is not influenced by hemofiltration TD 1 TD 2

40 The 6 take home messages 1 Differenciating hydrostatic pulmonary edema and ARDS is of clinical importance p 2 PAOP is not the ideal criterion to differenciate hydrostatic pulmonary edema and ARDS in the context of ICU 3 Due to confounding factors, B type natriuretic peptide cannot be used for this purpose 4 An increased lung permability is the pathophysiological hallmark of ARDS 5 Transpulmonary thermodilution allows a reliable estimation of pulmonary vascular permeability 6

41 2 questions How to measure lung permeability? How to use lung permeability?

42 The risk of volume expansion 1,000 pts with ALI/ARDS Comparison of conservative vs. liberal fluid strategies We should avoid fluid overload in ARDS patients

43 The risk of volume expansion Cohort study 3,147 pts with sepsis We should avoid fluid overload in septic shock patients

44 How to avoid fluid overload? Lung water lung permeability lung permeability lung permeability lung permeability Lung water Pcap Pcap Volume expansion

45 How to avoid fluid overload? Pulmonary artery catheter B type natriuretic peptide Transpulmonary thermodilution

46 When to stop volume expansion? Lung water Physiologically, PAOP imperfectly reflects the risk of volume lung expansion permeability lung permeability lung permeability lung permeability Lung water Pcap PAOP Volume expansion Pcap

47 When to stop volume expansion? ARDS AP = 90 / 40 mmhg Cardiac index = 20L/min/m PaO 2 /FiO 2 = 180 mmhg 2 2 PLR test : positive PVPI = 4 PVPI = 7 volume expansion volume expansion? vasopressor?

48 The 6 take home messages 1 Differenciating hydrostatic pulmonary edema and ARDS is of clinical importance p 2 PAOP is not the ideal criterion to differenciate hydrostatic pulmonary edema and ARDS in the context of ICU 3 Due to confounding factors, B type natriuretic peptide cannot be used for this purpose 4 An increased lung permability is the pathophysiological hallmark of ARDS 5 Transpulmonary thermodilution allows a reliable estimation of pulmonary vascular permeability 6 The pulmonary vascular permeability index should help to guide fluid therapy in critically ill patients

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