Extravascular Lung Water and Acute Respiratory Distress Syndrome

Abstract

We studied eleven consecutive patients to assess the influence of extravascular lung water on clinical outcome. All patients were mechanically ventilated using a standardized protocol. Inspired oxygen concentration was adjusted to an initial target P_aO₂ of greater than 8.0 kPa (60.8 mmHg). All patients received inhaled nitric oxide (NO) at a concentration of 20 ppm. Extravascular lung water index (EVLWI) was measured by a dual indicator technique (COLD Z-021 monitoring system, Pulsion, Munich, Germany). Patients were managed with fluids and inotropes according to a standard protocol.

Median age was 45 (range 27–60) years, mean APACHE II score on admission 31 (range 17–36), duration of mechanical ventilation 15 (range 6–28) days, mean admission Murray lung injury score 2.5 (range 2–3) and admission EVLWI 20.8 (range 8.7 to 54.7) ml.kg⁻¹.

The only variables independently predictive of P_aO₂/FiO₂ ratio were serum albumin (B = 1.7±1.61) and EVLWI (B = −2.1 ±0.47), r²=0.33, P<0.0001. In severe ARDS, (P_aO₂/FiO₂<l50 mmHg), mean EVLWI was 24.4 (22.4 to 26.4, 95% confidence intervals) ml.kg⁻¹ compared with 15.1 (12.2 to 18.0) ml.kg⁻¹ during moderate ARDS (P<0.001). Serum albumin likewise differed, 29.4 (27.6 to 31.2) vs 35.1 (31.8 to 38.4) g.1⁻¹, P<0.005. PAOP was higher during periods of poor oxygenation, 12.7 (11.9 to 13.5) vs 9.3 (7.9 to 10.7) mmHg, P<0.001. The four survivors had greater initial EVLWI than non-survivors, 31 (24.1 to 37.9) vs 20.7 (16.0 to 25.4) ml.kg⁻¹, P=0.034 and showed a greater reduction in lung water, 15.2 (9.3 to 21.1) vs 5.4 (2.1 to 8.7) ml.kg⁻¹, P=0.013.

Keywords

LUNG: acute distress syndrome extra-vascular lung water FLUID BALANCE: extravascular lung water

References

Ashbaugh

D.G.

, Bigelow

D.B.

, Petty

T.L.

, Levine

B.E.

Acute respiratory distress syndrome in adults. Lancet 1967; 2: 319–323.

Petty

T.L.

, Ashbaugh

D.G.

The adult respiratory distress syndrome: Clinical features, factors influencing prognosis and principles of management. Chest 1971; 60: 233–239.

Dreyfuss

, Saumon

Should the lung be rested or recruited? The Charybdis and Scylla of ventilator management. Am J Respir Crit Care Med 1994; 149: 1066–1068.

Bigatello

L.M.

, Zapol

W.M.

New approaches to acute lung injury. Br J Anaesth 1996; 77: 99–109.

Cuthbertson

B.R.

, Scott

, Webster

N.R.

Use of nitric oxide in British intensive therapy units. Br J Anaesth 1997; 78: 696–700.

Pfeiffer

U.J.

, Birk

, Aschenbrenner

, Petrowitz

, Blumel

Validity of the thermal dye technique for measurement of extravascular lung water. Eur J Surg Res 1980; 2: 106–108.

Keiffer

U.J.

, Birk

, Aschenbrenner

, Blumel

The system for quantification of thermal dye extravascular lung water. In: Computers in critical care and pulmonary medicine, Vol 2. Plenum, London: 123–126.

Effros

R.M.

Lung water measurements with the mean transit time approach. J Appl Physiol 1985; 59: 673–689.

Wickerts

, Jakobsson

, Frostell

, Hedenstierna

Measurement of extravascular lung water by the thermal dye dilution technique: mechanisms of cardiac output dependance. Intensive Care Med 1990; 16: 115–120

10.

Lichtwarck-Aschoff

, Zeravik

, Pfeiffer

U.J.

Intra-thoracic blood volume accurately reflects circulatory volume status in critically ill patients with mechanical ventilation. Intensive Care Med 1992; 18: 142–147.

11.

Knaus

W.A.

, Draper

E.A.

, Wagner

D.P.

, Zimmerman

J.E.

APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818–829.

12.

Wiener-Kronish

J.P.

, Gropper

M.A.

, Matthay

M.A.

The adult respiratory distress syndrome: definition and prognosis, pathogenesis and treatment. Br J Anaesth 1990; 114: 267–284.

13.

Katzenstein

, Asken

F.B.

Acute lung injury patterns: diffuse alveolar damage, acute interstitial pneumonia, bronchiolitis obliterans-organising pneumonia. In: Surgical Pathology of the Non-Neoplastic Lung Diseases. 2nd ed. Philadelphia: WB Saunders, 1990; 937.

14.

Grundmann

, Heistermann

Postoperative albumin infusion therapy based on colloid osmotic pressure. A prospectively randomised trial. Arch Surg 1985; 20: 911–915.

15.

Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Why albumin may not work. Roberts I and Cochrane Injuries Group Albumin Reviewers BMJ 1998; 317: 235–240.

16.

Buchon

, Hopewell

P.C.

, Murray

Interactions between permeability and hydrostatic pressure in perfused dogs’ lungs. J Appl Physiol 1981; 50: 905–911.

17.

Winn

, Stothert

, Nadir

, Hildebrandt

Lung fluid balance, vascular permeability, and gas exchange after acid aspiration in awake goats. J Appl Physiol 1984; 56: 979–985.

18.

Lichtwarck-Aschoff

, Beale

, Pfeiffer

U.J.

Central venous pressure, pulmonary artery occlusion pressure, intrathoracic blood volume, and right ventricular cnd-diastolic volume as indicators of cardiac preload. J Crit Care 1996; 11: 180–188.

19.

Noble

W.H.

, Kay

J.C.

Effects of emboli, positive pressure ventilation and airway water on lung water measurements. J App Physiol 1998; 156–164.

20.

Pfeiffer

U.J.

, Birk

, Kohler

, Sagerer

, Blumel

Extravvasaleslungen Wasser und plasmakoloidosmotischer Druck bei der pulmonalen Mikroembolie. Chirurgischcs Forum Fur Experimentelle Und Klinische Forschung 1981; 81: 28–32.

21.

Sivak

E.D.

, Tita

, Meden

, Ishigami

, Graves

, Kavlich

, Stowe

N.T.

, Magnuisson

M.O.

Effects of furosemide versus isolated ultrafiltration on extravascular lung water in oleic acid-induced pulmonary oedema. Critl Care Med 1986; 14: 48–51.

22.

Simmons

R.S.

, Berdine

D.G.

, Seidenfeld

J.J.

, Prihoda

, Harris

G.D.

, Smith

J.D.

, Gilbert

, Mota

, Johanson

J.R.

Fluid balance and the adult respiratory distress syndrome. Am Rev Respir Dis 1987; 35: 924–929.

23.

Bone

R.C.

Treatment of adult respiratory distress syndrome with diuretics, dialysis and positive end-expiratory pressure. Crit Care Med 1998; 6: 136–139.

24.

Mitchell

J.P.

, Schuller

, Calandrino

F.S.

, Schuster

D.P.

Improved outcome based on fluid management in critically ill patients

Extravascular Lung Water and Acute Respiratory Distress Syndrome—Oxygenation and Outcome

Abstract

Keywords

References