Inflammatory or cardiogenic lung edema? It does matter!

Transcription

1 Inflammatory or cardiogenic lung edema? It does matter! Dr Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital FRANCE

2 Conflict of interest

3 Inflammatory or cardiogenic lung edema? It does matter! Dr Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital FRANCE

4 Inflammatory and cardiogenic lung edema are not the same! barrière alvéolocapillaire intacte P hydrostat Cardiogenic PE Inflammatory PE Inflammatory and cardiogenic lung edema both correspond to the accumulation of extravascular lung water But the mechanisms are very different

5 Inflammatory and cardiogenic lung edema are not the same! barrière alvéolocapillaire intacte barrière alvéolocapillaire lésée P hydrostat Cardiogenic PE Inflammatory PE intact lung permeability the key criterion Lung permeability is the key criterion altered for distinguishing inflammatory and cardiogenic lung permeability lung edema

6 Inflammatory and cardiogenic lung edema? A clinical dilemma ICU 4 days ventilation for pneumonia renal failure LVEF = 40 % worsening of gas exchange worsening of lung infiltrates C-reactive protein = 150 mg/l fluid balance = ml Inflammatory OR cardiogenic lung edema?

7 Inflammatory and cardiogenic PE? diagnosis at the bedside How to differenciate inflammatory and cardiogenic lung edema PAOP This definition should be reconsidered for 3 reasons 1 2 3

8 PAOP is not the best for diagnosing ARDS 1 The PAOP measurement is subject to many pitfalls including PEEP

9 PAOP is not the best for diagnosing ARDS 2 Starling equation Q f = K the ( Δcapillary (P P capillary hydrostatic pressure P int) - σ x Δ P oncotic ) PAOP

10 PAOP is not the best for diagnosing ARDS 2 The PAOP is not the capillary pressure

11 PAOP is not the best for diagnosing ARDS 3 «If LV filling pressure is not elevated, should ARDS be ruled out?»

12 PAOP is not the best for diagnosing ARDS 3

13 PAOP is not the best for diagnosing ARDS 3 barrière alvéolocapillaire intacte barrière alvéolocapillaire lésée P hydrostat P hydrostat Cardiogenic PE Inflammatory PE The PAOP canalsobeelevatedin inflammatorype!

14 Inflammatory and cardiogenic PE? diagnosis at the bedside How to differenciate inflammatory and cardiogenic lung edema? PAOP which alternative?

15 Inflammatory and cardiogenic PE? diagnosis at the bedside How to differenciate inflammatory and cardiogenic lung edema? PAOP? which B-type alternative natriuretic peptide a more modern alternative?

16 Inflammatory and cardiogenic PE? B-type natriuretic peptide

17 Inflammatory and cardiogenic PE? B-type natriuretic peptide derivation cohort : 84 pts validation cohort : 120 pts ALI/ARDS established by experts All patients Creat clearance > 60 ml/min

18 Inflammatory and cardiogenic PE? B-type natriuretic peptide 90 pts ALI/ARDS established by experts a large grey zone! The «grey zone» is obviously too large

19 Inflammatory and cardiogenic PE? How to differenciate inflammatory and cardiogenic lung edema? PAOP B-type natriuretic peptide Transpulmonary thermodilution a more direct estimation of lung permeability

20 Inflammatory and cardiogenic lung edema are not the same! barrière alvéolocapillaire intacte barrière alvéolocapillaire lésée P hydrostat Cardiogenic PE Inflammatory PE the key criterion Lung permeability is the key criterion for distinguishing inflammatory and cardiogenic lung edema

21 Inflammatory and cardiogenic PE? How to differenciate inflammatory and cardiogenic lung edema? PAOP B-type natriuretic peptide Transpulmonary thermodilution a more direct estimation of lung permeability How does it work?

22 Inflammatory and cardiogenic PE? Transpulmonary thermodilution Cold bolus Blood temperature (Bd) ln Bt 1 inj inj 1 MTt Td t Total intrathoracic volume Total pulmonary volume 2 Global end-diastolic volume Extravascular lung water 4 Intrathoracic blood volume ITBV = 1.25 x GEDV Pulmonary blood volume

23 Inflammatory and cardiogenic PE? Transpulmonary thermodilution Cold bolus Blood temperature (Bd) ln Bt 1 inj inj 1 MTt Td t Total intrathoracic volume Total pulmonary volume pulmonary vascular 2 permeability index PVPI = extravascular lung water Global end-diastolic volume pulmonary intravascular blood volume Extravascular lung water 4 Intrathoracic blood volume ITBV = 1.25 x GEDV Pulmonary blood volume

24 Inflammatory and cardiogenic PE? Transpulmonary thermodilution Is it validated?

25 Inflammatory and cardiogenic PE? Transpulmonary thermodilution PVPI 15 dogs Oleic acid iv. or left balloon inflation Transpulmory thermodilution in the clinical setting?

26 Inflammatory and cardiogenic PE? Transpulmonary thermodilution 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

27 Inflammatory and cardiogenic PE? Transpulmonary thermodilution 6 4 PVPI * PVPI is higher in inflammatory than in cardiogenic PE 2 0 ALI/ARDS Hydrostatic pulmonary edema

28 Inflammatory and cardiogenic PE? Transpulmonary thermodilution ALI/ARDS PVPI * Hydrostatic pulmonary edema Cut-off : 3 Se = 85 % Sp = 100 %

29 Inflammatory and cardiogenic PE? Transpulmonary thermodilution sensitivity PVPI 20 n = specificity

30 Inflammatory and cardiogenic PE? Transpulmonary thermodilution 100 PVPI sensitivity BNP specificity PVPI is better than BNP n = 31 p < 0.05

31 Inflammatory and cardiogenic PE? Transpulmonary thermodilution How to differenciate inflammatory and cardiogenic lung edema? PAOP B-type natriuretic peptide transpulmonary thermodilution

32 Inflammatory and cardiogenic PE? Transpulmonary thermodilution False ALI/ARDS negative PVPI * Hydrostatic pulmonary edema some false negative cases

33 Inflammatory and cardiogenic PE? Transpulmonary thermodilution underestimation of EVLW in pulmonary vascular permeability index = extravascular lung lung water water pulmonary blood volume non homogeneous ARDS PVPI underestimation of PVPI

34 Inflammatory and cardiogenic PE? Transpulmonary thermodilution ALI/ARDS PVPI * Hydrostatic pulmonary edema Trust the high values!

35 Inflammatory or cardiogenic lung edema? It does matter! Dr Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital FRANCE

36 Inflammatory and cardiogenic PE? It does matter Why should we assess the lung permeability? For diagnosing the mechanism of lung edema directing fluid strategy in ARDS patients

37 It does matter for fluid strategy What is the problem of fluid therapy in ARDS? worsening of pulmonary edema improvement of cardiac output the benefit of fluid might be counterbalanced by worsening of lung edema

38 Does it matter? Limit fluid administration in ARDS!

39 Does it matter?

40 Does it matter? EVLW is a prognostic factor in ARDS

41 It does matter for fluid strategy How to tip the scale in the good direction? Administer fluid only if it actually Assess increase fluidcardiac responsiveness output!! improvement of cardiac output worsening of Assess the pulmonary risk of fluid edema infusion in terms of lung water!?

42 How to assess the risk of fluid infusion? lung permeability EVLW very high permeability high permeability on low permeability EVLW Pcap Pcap For assessing the risk of volume expansion

43 It does matter for fluid strategy ARDS AP = 90 / 40 mmhg Cardiac index = 2,0 L/min/m 2 PaO 2 /FiO 2 = 180 mmhg PLR test : positive PVPI = 4 PVPI = 6

44 Inflammatory and cardiogenic PE? Transpulmonary thermodilution ALI/ARDS PVPI * Hydrostatic pulmonary edema Trust the high values!

45 It does matter for fluid strategy ARDS AP = 90 / 40 mmhg Cardiac index = 2,0 L/min/m 2 ARDS AP = 90 / 40 mmhg Cardiac index = 2,0 L/min/m 2 PaO 2 /FiO 2 = 180 mmhg PaO 2 /FiO 2 = 180 mmhg PLR test : positive PLR test : positive PVPI = 4 PVPI = 6 volume expansion volume expansion? vasopressor?

46 Estimating the lung permeability? For distinguishing inflammatory and cardiogenic lung edema applicable at the bedside easy and accurate It does matter for directing fluid strategy in ARDS patients