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• W2154240045 abstract "EDITORIAL FOCUSMeasurement of extravascular lung water in patients with pulmonary edemaMichael A. MatthayMichael A. MatthayPublished Online:01 Jun 2008https://doi.org/10.1152/ajplung.90279.2008This is the final version - click for previous versionMoreSectionsPDF (42 KB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations ShareShare onFacebookTwitterLinkedInEmailWeChat measurement of extravascular lung water has been a topic of major interest for more than two decades (1, 5, 19). In the recent article by Effros et al. (2), they provide a review of current and past efforts to measure extravascular lung water with thermal and osmotic dilution methods. The authors discuss several of the limitations of these methods, including problems related to early recirculation of the thermal indicator, as well as potential problems related to heterogeneous perfusion of edematous lungs. Although the authors have provided a thoughtful critique of some of the limitations of the transpulmonary thermodilution technique for measuring extravascular lung water, there is some recent evidence that this methodology may provide valuable insights into lung fluid balance in patients with acute pulmonary edema and acute lung injury.In 2006, Perkins et al. (13) published the results of a randomized placebo-controlled clinical trial in which 40 patients with acute lung injury were treated with either intravenous salbutamol (a β2-agonist) or placebo. The primary objective of the trial was to determine if the β-agonist reduced extravascular lung water in these patients. β-agonist therapy has been proposed as a treatment that may accelerate the resolution of alveolar edema by upregulating salt and water transport mechanisms in the alveolar epithelium (3, 4). The results of this blinded trial showed that the patients who were treated with intravenous salbutamol had a 40% reduction in extravascular lung water compared with the controls. The reduction in extravascular lung water was matched by a reduction in the plateau airway pressure, a measure of quasistatic respiratory compliance that may reflect less pulmonary edema. In spite of the methodological concerns pointed out by Effros et al. (2), the results of this blinded trial seemed to indicate that the transpulmonary thermodilution technique (PiCCO; Pulsion Medical Systems, Munich, Germany) is able to detect a significant change in lung water with a treatment that might be expected to achieve this objective.In addition, the results of a recent clinical trial published in April 2008 also support the conclusion that this methodology for measuring extravascular lung water is able to detect clinically significant changes in lung water (8). In this trial, the patients had their extravascular lung water measured before surgical resection of a lung lobe for cancer, and then the extravascular lung water was measured again every 6 h postoperatively. The patients were randomized in an elegant crossover design to receive every 6 h either 5 mg of inhaled salbutamol (β2-agonist) or 0.5 mg of inhaled ipratroprium. When patients were treated with inhaled salbutamol, there was an 18% reduction in extravascular lung water (P = 0.019) and a corresponding improvement in oxygenation (P = 0.012). The results of this study provide further evidence that the measurement of extravascular lung water with this transpulmonary thermodilution technique is sensitive to detecting changes in the quantity of pulmonary edema in patients with pulmonary edema.It should also be noted that several investigators have tested the reliability of the extravascular lung water measurement compared with gravimetric measurements in animal models and in patients (6, 7, 9, 15–18). Most of these studies have found a good correlation with gravimetric measurements. Also, a recent study from Phillips et al. (14) reported that the combined measurement of extravascular lung water and pulmonary dead space in patients with acute lung injury has prognostic value for identifying patients at the highest risk of nonsurvival. In fact, extravascular lung water that was greater than 16 ml/kg/predicted body weight predicted death with 100% specificity and 86% sensitivity. The use of predicted body weight for indexing extravascular lung water measurements may increase the accuracy of this method because of the prevalence of obesity in European and U.S. populations (11, 12).In summary, the concerns expressed by Effros et al. (2) regarding the methodological issues with measurement of extravascular lung water are important to appreciate. However, the results of experimental studies, observational clinical studies, and two double-blind controlled trials indicate that significant changes in extravascular lung water can be detected in patients, and therefore measurements of lung water have research value (8, 13). The studies by the late Dr. Schuster and his colleagues (10) almost 20 years ago suggested the potential benefit of measuring extravascular lung water as a method for improving clinical outcomes. Thus, in my opinion, further studies are needed to assess extravascular lung water in patients at risk for developing pulmonary edema as well as in patients with established pulmonary edema from hydrostatic causes or from an increase in permeability (acute lung injury). Reliance on the chest radiograph or arterial oxygenation is not adequate for assessing the quantity of pulmonary edema. The transpulmonary thermodilution technique should be used to advance research into the mechanisms and potential therapeutic strategies in patients who are at risk for developing pulmonary edema from acute lung injury as well as in patients with established acute lung injury.REFERENCES1 Chinard FP, Enns T. Transcapillary pulmonary exchange of water in the dog. Am J Physiol 178: 197–202, 1954.Abstract | ISI | Google Scholar2 Effros RM, Pornsuriyasak P, Porszasz J, Casaburi R. Indicator dilution measurements of extravascular lung water: basic assumptions and observations. Am J Physiol Lung Cell Mol Physiol (March 21, 2008). doi: 10.1152/ajplung.00533.2007.Link | ISI | Google Scholar3 Folkesson HG, Matthay MA. Alveolar epithelial ion and fluid transport: recent progress. Am J Respir Cell Mol Biol 35: 10–19, 2006.Crossref | PubMed | ISI | Google Scholar4 Guidot DM, Folkesson HG, Jain L, Sznajder JI, Pittet JF, Matthay MA. Integrating acute lung injury and regulation of alveolar fluid clearance. Am J Physiol Lung Cell Mol Physiol 291: L301–L306, 2006.Link | ISI | Google Scholar5 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 291: L1118–L1131, 2006.Link | ISI | Google Scholar6 Katzenelson R, Perel A, Berkenstadt H, Preisman S, Kogan S, Sternik L, Segal E. Accuracy of transpulmonary thermodilution versus gravimetric measurement of extravascular lung water. Crit Care Med 32: 1550–1554, 2004.Crossref | PubMed | ISI | Google Scholar7 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 8: R451–R458, 2004.Crossref | PubMed | ISI | Google Scholar8 Licker M, Tschopp JM, Robert J, Frey JG, Diaper J, Ellenberger C. Aerosolized salbutamol accelerates the resolution of pulmonary edema after lung resection. Chest 133: 845–852, 2008.Crossref | PubMed | ISI | Google Scholar9 Mihm FG, Feeley TW, Rosenthal MH, Lewis F. Measurement of extravascular lung water in dogs using the thermal-green dye indicator dilution method. Anesthesiology 57: 116–122, 1982.Crossref | PubMed | ISI | Google Scholar10 Mitchell JP, Schuller D, Calandrino FS, Schuster DP. Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization. Am Rev Respir Dis 145: 990–998, 1992.Crossref | PubMed | ISI | Google Scholar11 Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 295: 1549–1555, 2006.Crossref | PubMed | ISI | Google Scholar12 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 33: 2547–2554, 2005.Crossref | PubMed | ISI | Google Scholar13 Perkins GD, McAuley DF, Thickett DR, Gao F. The beta-agonist lung injury trial (BALTI): a randomized placebo-controlled clinical trial. Am J Respir Crit Care Med 173: 281–287, 2006.Crossref | PubMed | ISI | Google Scholar14 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 36: 69–73, 2008.Crossref | PubMed | ISI | Google Scholar15 Roch A, Michelet P, Lambert D, Delliaux S, Saby C, Perrin G, Ghez O, Bregeon F, Thomas P, Carpentier JP, Papazian L, Auffray JP. Accuracy of the double indicator method for measurement of extravascular lung water depends on the type of acute lung injury. Crit Care Med 32: 811–817, 2004.Crossref | PubMed | ISI | Google Scholar16 Rossi P, Wanecek M, Rudehill A, Konrad D, Weitzberg E, Oldner A. Comparison of a single indicator and gravimetric technique for estimation of extravascular lung water in endotoxemic pigs. Crit Care Med 34: 1437–1443, 2006.Crossref | PubMed | ISI | Google Scholar17 Sakka SG, Ruhl CC, Pfeiffer UJ, Beale R, McLuckie A, Reinhart K, Meier-Hellmann A. Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med 26: 180–187, 2000.Crossref | PubMed | ISI | Google Scholar18 Schuster DP, Calandrino FS. Single versus double indicator dilution measurements of extravascular lung water. Crit Care Med 19: 84–88, 1991.Crossref | PubMed | ISI | Google Scholar19 Staub NC, Hyde RW, Crandall E. NHLBI workshop summary. Workshop on techniques to evaluate lung alveolar-microvascular injury. Am Rev Respir Dis 141: 1071–1077, 1990.Crossref | PubMed | ISI | Google ScholarAUTHOR NOTESAddress for reprint requests and other correspondence: M. A. Matthay, Univ. of California, San Francisco Cardiovascular Research Institute, 505 Parnassus Ave., M-917, San Francisco, CA 94143-0624 (e-mail: [email protected]) Download PDF Back to Top Next FiguresReferencesRelatedInformationCited ByPulmonary EdemaPulmonary Edema and Acute Lung InjuryExtravascular lung water indexed to predicted body weight is a novel predictor of intensive care unit mortality in patients with acute lung injury*Critical Care Medicine, Vol. 38, No. 1Redistribution of Pulmonary Blood Flow Impacts Thermodilution-based Extravascular Lung Water Measurements in a Model of Acute Lung InjuryAnesthesiology, Vol. 111, No. 5 More from this issue > Volume 294Issue 6June 2008Pages L1021-L1022 Copyright & PermissionsCopyright © 2008 the American Physiological Societyhttps://doi.org/10.1152/ajplung.90279.2008PubMed18441090History Published online 1 June 2008 Published in print 1 June 2008 Metrics" @default.
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