Extravascular Lung Water Research Articles

Assessment of extravascular lung water by measuring the number of pulmonary ultrasound B-lines before and after CBP in patients with MODS.

To determine whether the change in the number of pulmonary ultrasound B-line can accurately assess the extravascular lung water (EVLW) before and after continuous bedside blood purification (CBP) in patients with multiple organ dysfunction syndrome (MODS).Seventy-six patients with MODS who underwent CBP were examined within 24 hours before and after CBP using pulmonary ultrasound to detect the number of ultrasound B-line or using pulse indicator continuous cardiac output method to examine extravascular lung water, blood oxygenation index, and B-type natriuretic peptide (BNP) content. The correlation of the change in the number of B lines before and after CBP treatment with the negative balance of 24 hours liquid, the change of oxygenation index, and BNP content were analyzed.In the 76 patients, CBP treatment significantly decreased EVLW, the number of B-line, and BNP (P < .05 for all), while it significantly increased the oxygenation index (P < .05). Correlation analysis showed that the decrease in B-line number after CBP treatment was positively correlated with the 24 hours negative lung fluid balance, decrease of EVLW, oxygenation index improvement, and decreased BNP content. The change in the numbers of pulmonary ultrasound B-line can accurately assess the change of EVLW before and after CBP treatment and reflect the efficiency of ventilation in the lungs and the risk of heart failure.Thus, it can replace pulse indicator continuous cardiac output as an indicator for evaluating EVLW in patients with MODS treated with CBP.

Hemodynamic Characteristics of Mechanically Ventilated COVID-19 Patients: A Cohort Analysis

Background Solid data on cardiovascular derangements in critically ill COVID-19 patients remain scarce. The aim of this study is to describe hemodynamic characteristics in a cohort of COVID-19-related critically ill patients. Methods A retrospective observational cohort study in twenty-eight consecutive mechanically ventilated COVID-19 patients. Pulse contour analysis-derived data were obtained from all patients, using the PiCCO® system. Results The mean arterial pressure increased from 77 ± 10 mmHg on day 1 to 84 ± 9 mmHg on day 21 (p=0.04), in combination with the rapid tapering and cessation of norepinephrine and the gradual use of antihypertensive drugs in the vast majority of patients. The cardiac index increased significantly from 2.8 ± 0.7 L/min/m2 on day 1 to 4.0 ± 0.8 L/min/m2 on day 21 (p < 0.001). Dobutamine was administered in only two patients. Mean markers of left ventricular contractility and peripheral perfusion, as well as lactate levels, remained within the normal range. Despite a constant fluid balance, extravascular lung water index decreased significantly from 17 ± 7 mL/kg on day 1 to 11 ± 4 mL/kg on day 21 (p < 0.001). Simultaneously, intrapulmonary right-to-left shunt fraction (Qs/Qt) decreased significantly from 27 ± 10% in week 1 to 15 ± 9% in week 3 (p=0.007). PaO2/FiO2 ratio improved from 159 ± 53 mmHg to 319 ± 53 mmHg (p < 0.001), but static lung compliance remained unchanged. Conclusions In general, this cohort of patients with COVID-19 respiratory failure showed a marked rise in blood pressure over time, not accompanied by distinctive markers of circulatory failure. Characteristically, increased extravascular lung water, vascular permeability, and intrapulmonary shunt diminished over time, concomitant with an improvement in gas exchange.

Sıvı Yönetiminde EVLW ve Önemi

Fluid management and optimization is one of the most frequently observed problems in anesthesiology and critical care. An ideal hemodynamic management increases oxygen supply to tissues, improves postoperative outcomes and decreases surgical costs. Extravascular lung water (EVLW) measurement has gained widespread acceptance in the early prediction and management of adverse effects caused by fluid treatment. The fundamental aim of acute circulatory failure treatment is to improve tissue perfusion and oxygenation while avoiding fluid overload. EVLW consists of extravascular interstitial, intracellular, alveolar and lymphatic fluid in the lungs and its normal values are 3-7 ml kg-1. Studies have reported that values above 10 ml kg-1 as a cut-off value points to pulmonary edema. Although the gold standard in EVLW measurement is the gravimetric method, lung ultrasound and transpulmonary thermodilution is more widely utilized since gravimetric measurement can only be performed post-mortem. EVLW measurement is expected to gain importance in the hemodynamic measurement of ALI/ARDS patients and future studies will benefit from focusing on EVLW based fluid therapy.

Majör Cerrahilerde Ekstravasküler Akciğer Sıvısı Ölçümünün Önemi

The incidence of postoperative pulmonary complications varies between 1-23 % and these complications can cause serious mortality. Measurement of extravascular lung water (EVLW) is beneficial not only for the prevention of complications but also in weaning, fluid management and monitorization of response to pharmacological interventions. EVLW consists of interstitial, intracellular, alveolar and lymphatic fluid in lungs except for pulmonary vasculature. Its normal range is 3-7 m/kg in healthy adults, values greater than 10 ml/kg point to pulmonary edema. Although the gold standard for measurement of EVLW is the gravimetric method, due to the fact it can only be applied postmortem, measurement methods by using ultrasonography and transpulmonary thermodilution have been developed. EVLW measurement can be affected by renal replacement therapy, extracorporeal membrane oxygenation (ECMO), pleural effusions and high PEEP. New research focusing on the effect of EVLW measurement on postoperative hemodynamic management is necessary in the future.

Association between lung comets and subendocardial viability ratio in peritoneal dialysis patients.

Pulmonary congestion is a direct result of either general overhydration or cardiac dysfunction. Lung ultrasonography (LUS) with lung B-lines (LUS comets) can be used to assess extravascular lung water in patients with end-stage renal disease on hemodialysis or peritoneal dialysis (PD). Subendocardial viability ratio (SEVR) is a pulse wave analysis parameter that is a non-invasive measure of coronary perfusion and is related to cardiac work and oxygen consumption. Our aim was to investigate the association between LUS comets and SEVR in PD patients. We performed an observational study in 25 PD patients in a single dialysis center. Extravascular lung water was quantified by the number of LUS comets, using a portable ultrasound (US) device. LUS comets were recorded in each intercostal space and defined as hyperechoic US bundles at a narrow base extending from the transducer to the edge of the screen. The sum of LUS comets yields a score reflecting the extent of water accumulation in the lungs. SEVR was determined non-invasively by radial applanation tonometry. Mean age of patients was 54.7 ± 10.7 years, mean PD vintage 27 ± 33 (1 - 167) months, 60% were men. The mean number of LUS comets was 13 ± 19 (0 - 71), and the mean SEVR was 153 ± 40%. We found a statistically significant negative correlation between the number of LUS comets and SEVR (r = -0.467; p = 0.019). Multiple regression analysis with LUS comets as dependent variable, and SEVR and age as independent variables showed a statistically significant relationship between SEVR and the number of LUS comets (β = -0.467, p = 0.021). Higher number of LUS comets is associated with lower SEVR in PD patients.

Protective effect of extracorporeal membrane pulmonary oxygenation combined with cardiopulmonary resuscitation on post-resuscitation lung injury.

Cardiac arrest (CA) is a critical condition that is a concern to healthcare workers. Comparative studies on extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) technologies have shown that ECPR is superior to CCPR. However, there is a lack of studies that compare the protective effects of these two resuscitative methods on organs. Therefore, we aim to perform experiments in swine models of ventricular fibrillation-induced CA to study whether the early application of ECPR has advantages over CCPR in the lung injury and to explore the protective mechanism of ECPR on the post-resuscitation pulmonary injury. Sixteen male swine were randomized to CCPR (CCPR; n=8; CCPR alone) and ECPR (ECPR; n=8; extracorporeal membrane oxygenation with CCPR) groups, with the restoration of spontaneous circulation at 6 hours as an endpoint. For the two groups, the survival rates between the two groups were not statistically significant (P>0.05), the blood and lung biomarkers were statistically significant (P<0.05), and the extravascular lung water and pulmonary vascular permeability index were statistically significant (P<0.01). Compared with the ECPR group, electron microscopy revealed mostly vacuolated intracellular alveolar type II lamellar bodies and a fuzzy lamellar structure with widening and blurring of the blood-gas barrier in the CCPR group. ECPR may have pulmonary protective effects, possibly related to the regulation of alveolar surface-active proteins and mitigated oxidative stress response post-resuscitation.

Physiologic and hemodynamic changes in patients undergoing open abdominal cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

ObjectiveWe aimed to determine the physiological and hemodynamic changes in patients who were undergoing hyperthermic intraperitoneal chemotherapy (HIPEC) cytoreductive surgeries.MethodsThis prospective, observational study enrolled 21 patients who were undergoing elective cytoreductive surgery with HIPEC at our hospital over 2 years. We collected vital signs, hemodynamic parameters including global end-diastolic volume index (GEVI) and extravascular lung water index (ELWI) using the VolumeView™ system, and arterial blood gas analysis from all patients. Data were recorded before skin incision (T1); 30 minutes before HIPEC initiation (T2); 30 (T3), 60 (T4), and 90 (T5) minutes after HIPEC initiation; 30 minutes after HIPEC completion (T6); and 10 minutes before surgery completion (T7).ResultsPatients showed an increase in body temperature and cardiac index and a decrease in the systemic vascular resistance index. GEDI was 715.4 (T1) to 809.7 (T6), and ELWI was 6.9 (T1) to 7.3 (T5).ConclusionsHIPEC increased patients’ body temperature and cardiac output and decreased systemic vascular resistance. Although parameters that were extracted from the VolumeView™ system were within their normal ranges, transpulmonary thermodilution approach is helpful in intraoperative hemodynamic management during open abdominal cytoreductive surgery with HIPEC.Trial registry name: ClinicalTrials.govTrial registration number: NCT02325648URL: https://clinicaltrials.gov/ct2/results?cond=NCT02325648&term

The prognosis evaluation of sICAM-1, KL-6 combined with EVLWI in severe pneumonia patients with acute respiratory distress syndrome

Objective To evaluate the prognostic value of extravascular lung water index (EVLWI), soluble intercellular adhesion molecule-1(sICAM-1) and Krebs yon den lungen-6 (KL-6) in severe pneumonia patients with Severe Acute Respiratory Syndrome (ARDS). Methods A prospective study was conducted in Respiratory Intensive Care Unit of the Affiliated Zhengzhou Central Hospital of Zhengzhou University from October 2017 to February 2020. The study included 65 severe pneumonia patients with ARDS, who was performed by measurement of pulse index continuous cardiac output and survived more than 3days after admission. The Extravascular Lung Water Index（EVLWI）, sICAM-1, KL-6 and Oxygenation Index(OI) on 1st, 3rd and 5th day were detected. APACHE Ⅱ score, patient survival events (days) and survival outcome were recorded. Correlation analysis between EVLWI, sICAM-1, KL-6 and OI was performed on the 1st，3rd and 5th day after admission. Independent risk factors of mortality in severe pneumonia patients with ARDS were analyzed by multiple logistic regression. Receiver operating characteristic curve was drawn，and the prognostic value of each parameter was assessed finally. Results The PCT, EVLWI, sICAM-1, KL-6 and APACHE Ⅱ score in the death group were significantly higher than those in the survival group (P 0.05）. These parameters including levels of EVLWI, sICAM-1, KL-6, Procalcitonin and APACHE Ⅱ score in the death group were significantly higher than those in the survival group on the 1st，3rd and 5th day (P<0.05), whereas the OI was significantly lower than that of the survival group on the 3rd and 5th day (P<0.05). Logistic regression analysis showed that EVLWI, sICAM-1, KL-6 level were significantly related with the mortality of these patients. The levels of sICAM-1, kl-6 and EVLWI on 1st，3rd and 5th day after RICU admission showed a significant negative correlation with OI (P<0.001). Whereas, The levels of sICAM-1, kL-6 on 1st，3rd and 5th day showed a significant positive correlation with EVLWI (P<0.001). The sensitivity and specificity of sICAM-1, KL-6 combined with EVLWI in prognosis evaluation on 1st，3rd and 5th day were 75.0%，84.4%, 85.0%，66.7%，80.0%，86.7%, respectively. The AUC was 0.864，0.881，0.892 on 1st，3rd and 5th day, respectively (P<0.001), which had a better prognostic value than each of them. Conclusions EVLWI, sICAM-1 and KL-6 were independent risk factors for the prognosis of severe pneumonia patients with ARDS. The combination of EVLWI, sICAM-1 and KL-6 might be important in early predicting the prognosis of the 28d mortality. © 2021 Chinese Medical Association. All rights reserved.

Characterization of pulmonary impairment associated with COVID-19 in patients requiring mechanical ventilation.

ObjectiveTo detect early respiratory and hemodynamic instability to characterize pulmonary impairment in patients with severe COVID-19.MethodsWe retrospectively analyzed data collected from COVID-19 patients suffering from acute respiratory failure requiring intubation and mechanical ventilation. We used transpulmonary thermodilution assessment with a PiCCO™ device. We collected demographic, respiratory, hemodynamic and echocardiographic data within the first 48 hours after admission. Descriptive statistics were used to summarize the data.ResultsFifty-three patients with severe COVID-19 were admitted between March 22nd and April 7th. Twelve of them (22.6%) were monitored with a PiCCO™ device. Upon admission, the global-end diastolic volume indexed was normal (mean 738.8mL ± 209.2) and moderately increased at H48 (879mL ± 179), and the cardiac index was subnormal (2.84 ± 0.65). All patients showed extravascular lung water over 8mL/kg on admission (17.9 ± 8.9). We did not identify any argument for cardiogenic failure.ConclusionIn the case of severe COVID-19 pneumonia, hemodynamic and respiratory presentation is consistent with pulmonary edema without evidence of cardiogenic origin, favoring the diagnosis of acute respiratory distress syndrome.

Lung ultrasound, hemoglobin, and NT-proBNP in peritoneal dialysis patients

Lung ultrasound (LUS) is a non-invasive technique for estimating extravascular lung water in patients with end-stage renal disease and heart diseases. In this study, we examined an association between the severity of lung congestion as detected by LUS B-lines (LUS comets), anemia, and serum biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP) in peritoneal dialysis (PD) patients. 19 patients, who were treated with PD in our dialysis center were enrolled. On the day of their routine check-up, we performed a lung auscultation, LUS on 28 typical locations and determined blood levels of hemoglobin and NT-proBNP. The average age of patients was 54 (range 30 - 71) years, the average duration of PD treatment was 53 (range 10 - 194) months, 63% (12) of the patients were male. Nine (47.4%) patients had peripheral edema, and only 1 (5.3%) patient had inspiratory crackles. Using LUS, we found mean 17 (range 1 - 87) lung comets. Mean hemoglobin level was 108.6 g/L (SD ± 10.4), mean NT-proBNP level 1,151 pmol/L (SD ± 1,077). We found a statistically significant correlation between the number of lung comets and hemoglobin level (r = -0.655; p = 0.002) and NT-proBNP (r = 0.759; p < 0.0001). Multiple regression analysis with the number of lung comets as dependent variable and hemoglobin and NT-proBNP levels as independent variables confirmed a statistically significant association between the number of lung comets and NT-proBNP (β = 0.572; p = 0.009). In PD patients, the number of LUS comets is associated with hemoglobin and NT-proBNP.

Effect of losartan on performance and physiological responses to exercise at high altitude (5035 m)

ObjectiveAltitude-related and exercise-related elevations in blood pressure (BP) increase the likelihood of developing pulmonary hypertension and high-altitude illness during high-altitude sojourn. This study examined the antihypertensive effect and potential exercise...

Ultrasonographic Assessment of Extravascular Lung Water in Hospitalized Patients Requiring Hemodialysis: A Prospective Observational Study

Introduction: Sonographic technologies can estimate extravascular lung water (EVLW) in hemodialysis (HD) patients. This study investigated the suitability of a handheld scanner in contrast to a portable scanner for quantifying EVLW in hospitalized patients requiring HD. Methods: In this prospective study, 54 hospitalized HD patients were enrolled. Bedside lung ultrasound was performed within 30 min before and after dialysis using handheld (phased array transducer, 1.7–3.8 MHz) and portable (curved probe, 5–2 MHz) ultrasound devices. Eight lung zones were scanned for total B-lines number (TBLN). The maximum diameter of inferior vena cava (IVC) was measured. We performed Passing-Bablok regression, Deming regression, Bland-Altman, and logistic regression analysis. Results: The 2 devices did not differ in measuring TBLN and IVC (p > 0.05), showing a high correlation (r = 0.92 and r = 0.51, respectively). Passing-Bablok regression had a slope of 1.11 and an intercept of 0 for TBLN, and the slope of Deming regression was 1.02 within the CI bands of 0.94 and 1.11 in the full cohort. TBLN was logarithmically transformed for Bland-Altman analysis, showing a bias of 0.06 (TBLN = 1.2) between devices. The slope and intercept of the Deming regression in IVC measurements were 0.77 and 0.46, respectively; Bland-Altman plot showed a bias of −0.07. Compared with predialysis, TBLN significantly (p < 0.001) decreased after dialysis, while IVC was unchanged (p = 0.16). Univariate analysis showed that cardiovascular disease (odds ratio [OR] 8.94 [2.13–61.96], p = 0.002), smoking history (OR 5.75 [1.8–20.46], p = 0.003), and right pleural effusion (OR 5.0 [1.2–25.99], p = 0.03) were strong predictors of EVLW indicated by TBLN ≥ 4. Conclusion: The lung and IVC findings obtained from handheld and portable ultrasound scanners are comparable and concordant. Cardiovascular disease and smoking history were strong predictors of EVLW. The use of TBLN to assess EVLW in hospitalized HD patients is feasible. Further studies are needed to determine if TBLN can help guide volume removal in HD patients.

Can the assessment of ultrasound lung water in haemodialysis patients be simplified?

Lung ultrasound (US) reliably estimates lung water and it is increasingly applied in clinical practice in dialysis patients. A semi-quantitative US score summing up the US-B lines (an equivalent of B lines in the standard chest X-ray) at 28 sites in the intercostal spaces (Jambrik et al. Usefulness of ultrasound lung comets as a non-radiologic sign of extravascular lung water. Am J Cardiol 2004; 93: 1265-1270) is the most used score. We compared the prognostic performance for death, and cardiovascular (CV) events of the 28-sites US score with a score restricted to eight sites in a cohort of 303 haemodialysis (HD) patients. The 8- and the 28-sites scores were highly inter-related (Spearman's ρ = 0.93, P < 0.001), and their concordance index was fairly good (k = 0.79, 95% confidence interval 0.74-0.84). During a mean follow-up of 3 years, 112 patients died, and 129 experienced a CV event. At univariate and multivariate analysis, both scores were associated with mortality (P ≤ 0.01) and CV events (P ≤ 0.05). The explained variances (R2) for death and CV events of the 28-sites score in multivariate models including major risk factors for these outcomes in the end-stage kidney disease (ESKD) population were 3.9 and 2.2%, and those of the 8-sites score were 3.1 and 2.4%, respectively. The median time needed to perform the examination was 3.05 min [interquartile range (IQR) 2.22-5.00 min] for the 28-sites score and 1.35 min (IQR 1.16-2.00 min) for the 8-sites score. The 8-sites score is tightly related to the classical Jambrik 28-sites score and this score holds an almost identical predictive power to the reference score. Even though the 28-sites score can be completed just in ∼3 min, the 8-sites score requires only ∼1.30 min, and it is, therefore, better suited for application in everyday clinical practice in HD units.

Second-order grey-scale texture analysis of pleural ultrasound images to differentiate acute respiratory distress syndrome and cardiogenic pulmonary edema

Discriminating acute respiratory distress syndrome (ARDS) from acute cardiogenic pulmonary edema (CPE) may be challenging in critically ill patients. Aim of this study was to investigate if gray-level co-occurrence matrix (GLCM) analysis of lung ultrasound (LUS) images can differentiate ARDS from CPE. The study population consisted of critically ill patients admitted to intensive care unit (ICU) with acute respiratory failure and submitted to LUS and extravascular lung water monitoring, and of a healthy control group (HCG). A digital analysis of pleural line and subpleural space, based on the GLCM with second order statistical texture analysis, was tested. We prospectively evaluated 47 subjects: 16 with a clinical diagnosis of CPE, 8 of ARDS, and 23 healthy subjects. By comparing ARDS and CPE patients’ subgroups with HCG, the one-way ANOVA models found a statistical significance in 9 out of 11 GLCM textural features. Post-hoc pairwise comparisons found statistical significance within each matrix feature for ARDS vs. CPE and CPE vs. HCG (P ≤ 0.001 for all). For ARDS vs. HCG a statistical significance occurred only in two matrix features (correlation: P = 0.005; homogeneity: P = 0.048). The quantitative method proposed has shown high diagnostic accuracy in differentiating normal lung from ARDS or CPE, and good diagnostic accuracy in differentiating CPE and ARDS. Gray-level co-occurrence matrix analysis of LUS images has the potential to aid pulmonary edemas differential diagnosis.

A quantitative CT parameter for the assessment of pulmonary oedema in patients with acute respiratory distress syndrome.

ObjectivesThe aim of this study was to establish quantitative CT (qCT) parameters for pathophysiological understanding and clinical use in patients with acute respiratory distress syndrome (ARDS). The most promising parameter is introduced.Materials and methods28 intubated patients with ARDS obtained a conventional CT scan in end-expiratory breathhold within the first 48 hours after admission to intensive care unit (ICU). Following manual segmentation, 137 volume- and lung weight-associated qCT parameters were correlated with 71 clinical parameters such as blood gases, applied ventilation pressures, pulse contour cardiac output measurements and established status and prognosis scores (SOFA, SAPS II).ResultsOf all examined qCT parameters, excess lung weight (ELW), i.e. the difference between a patient’s current lung weight and the virtual lung weight of a healthy person at the same height, displayed the most significant results.ELW correlated significantly with the amount of inflated lung tissue [%] (p<0.0001; r = -0.66) and was closely associated with the amount of extravascular lung water (EVLW) (p<0.0001; r = 0.72). More substantially than the oxygenation index (PaO2/FiO2) or any other clinical parameter it correlated with the patients’ mean SOFA- (p<0.0001, r = 0.69) and SAPS II-Score (p = 0.0005, r = 0.62). Patients who did not survive intensive care treatment displayed higher values of ELW in the initial CT scans.ConclusionsELW could serve as a non-invasive method to quantify the amount of pulmonary oedema. It might serve as an early radiological marker of severity in patients with ARDS.

Fluid administration and monitoring in ARDS: which management?

Modalities of fluid management in patients sustaining the acute respiratory distress syndrome (ARDS) are challenging and controversial. Optimal fluid management should provide adequate oxygen delivery to the body, while avoiding inadvertent increase in lung edema which further impairs gas exchange. In ARDS patients, positive fluid balance has been associated with prolonged mechanical ventilation, longer ICU and hospital stay, and higher mortality. Accordingly, a restrictive strategy has been compared to a more liberal approach in randomized controlled trials conducted in various clinical settings. Restrictive strategies included fluid restriction guided by the monitoring of extravascular lung water, pulmonary capillary wedge or central venous pressure, and furosemide targeted to diuresis and/or albumin replacement in hypoproteinemic patients. Overall, restrictive strategies improved oxygenation significantly and reduced duration of mechanical ventilation, but had no significant effect on mortality. Fluid management may require different approaches depending on the time course of ARDS (i.e., early vs. late period). The effects of fluid strategy management according to ARDS phenotypes remain to be evaluated. Since ARDS is frequently associated with sepsis-induced acute circulatory failure, the prediction of fluid responsiveness is crucial in these patients to avoid hemodynamically inefficient—hence respiratory detrimental—fluid administration. Specific hemodynamic indices of fluid responsiveness or mini-fluid challenges should be preferably used. Since the positive airway pressure contributes to positive fluid balance in ventilated ARDS patients, it should be kept as low as possible. As soon as the hemodynamic status is stabilized, correction of cumulated fluid retention may rely on diuretics administration or renal replacement therapy.

B-Lines Scores Derived From Lung Ultrasound Provide Accurate Prediction of Extravascular Lung Water Index: An Observational Study in Critically Ill Patients.

Introduction:Visualization of B-lines via lung ultrasound provides a non-invasive estimation of pulmonary hydration. Extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) assessed by transpulmonary thermodilution (TPTD) represent the most validated parameters of lung water and alveolocapillary permeability, but measurement is invasive and expensive. This study aimed to compare the correlations of B-lines scores from extensive 28-sector and simplified 4-sector chest scan with EVLWI and PVPI derived from TPTD in the setting of intensive care unit (primary endpoint).Methods:We performed scoring of 28-sector and 4-sector B-Lines in 50 critically ill patients. TPTD was carried out with the PiCCO-2-device (Pulsion Medical Systems SE, Maquet Getinge Group). Median time exposure for ultrasound procedure was 12 minutes for 28-sector and 4 minutes for 4-sector scan.Results:Primarily, we found close correlations of 28-sector as well as 4-sector B-Lines scores with EVLWI (R2 = 0.895 vs. R2 = 0.880) and PVPI (R2 = 0.760 vs. R2 = 0.742). Both B-lines scores showed high accuracy to identify patients with specific levels of EVLWI and PVPI. The extensive 28-sector B-lines score revealed a moderate advantage compared to simplified 4-sector scan in detecting a normal EVLWI ≤ 7 (28-sector scan: sensitivity = 81.8%, specificity = 94.9%, AUC = 0.939 versus 4-sector scan: sensitivity = 81.8%, specificity = 82.1%, AUC = 0.902). Both protocols were approximately equivalent in prediction of lung edema with EVLWI ≥ 10 (28-sector scan: sensitivity = 88.9%, specificity = 95.7%, AUC = 0.977 versus 4-sector scan: sensitivity = 81.5%, specificity = 91.3%, AUC = 0.958) or severe pulmonary edema with EVLWI ≥ 15 (28-sector scan: sensitivity = 91.7%, specificity = 97.4%, AUC = 0.995 versus 4-sector scan: sensitivity = 91.7%, specificity = 92.1%, AUC = 0.978). As secondary endpoints, our evaluations resulted in significant associations of 28-sector as well as simplified 4-sector B-Lines score with parameters of respiratory function.Conclusion:Both B-line protocols provide accurate non-invasive evaluation of lung water in critically ill patients. The 28-sector scan offers a marginal advantage in prediction of pulmonary edema, but needs substantially more time than 4-sector scan.

Transcervical minimally invasive esophagectomy: hemodynamic study on an animal model.

BackgroundTranscervical esophagectomy is a less invasive procedure performed within mediastinum. However, the mediastinum offers limited surgical space and the surgery via this route differs from conventional minimally invasive esophagectomy. Therefore, the physiological study of this surgical approach on an animal model would be necessary before the procedure gained more popularity.MethodsWe conducted transcervical minimally invasive esophagectomy on animal model (swine) under CO2 pneumomediastinum. The hemodynamic parameters were monitored using float catheter cannulated via right jugular vein. At different anatomical level (the upper, middle, and lower thoracic part of the animal esophagus), increased artificial pneumomediastinal pressures (0, 4, 8, 12, and 16 mmHg) were consecutively allocated to record the intra-operative changes of blood pressure, cardiac output (CO), central venous pressure (CVP), pulmonary artery pressure (PAP) and extravascular lung water (EVLW). Meanwhile, the surgical field under different pneumomediastinum pressure was recorded and balanced with animals’ hemodynamic changes to determine the optimal pressure for transcervical minimally invasive esophagectomy.ResultsThe animal procedures were accomplished without conversions. During the upper thoracic stage, increased CO2 pressures did not lead to significant changes in hemodynamic parameters including the blood pressure, CO, CVP, PAP or the level of EVLW. During the middle thoracic stage, pneumomediastinum under 4–12 mmHg did not lead to significant changes in hemodynamic parameters. However, pneumomediastinum at 16 mmHg resulted in lower CO (P=0.038) when compared to 0–12 mmHg. During lower thoracic stage, as the pneumomediastinum pressures increased from 0 to 16 mmHg, significant decrease in CO (P=0.022), and increase in CVP (P=0.036) was recorded. In compared to 4 mmHg pneumomediastinum, the surgical field under 8–16 mmHg artificial CO2 pneumomediastinum was suitable for mediastinal manipulation.ConclusionsDuring transcervical minimally invasive esophagectomy on animal model, the mobilization of swine thoracic esophagus with optimal pneumomediastinum pressure 8–12 mmHg is safe and effective based on hemodynamic analysis.

Right ventricular function and its coupling with the pulmonary circulation in acute heart failure

Abstract Background The right ventricle (RV) is extremely sensitive to hemodynamic changes and increased impedance. In acute heart failure (AHF), the development of pulmonary venous congestion and the increase of left ventricular (LV) filling pressures favors pulmonary vascular adverse remodeling and ultimately RV dysfunction, leading to the onset of symptoms and to a further decay of cardiac dynamics. Purpose The aim of the study was to evaluate RV morphology and functional dynamics at admission and discharge in patients hospitalized for AHF, analyzing the role and the response to treatment of the RV and its coupling with pulmonary circulation (PC). Methods Eighty-one AHF patients (mean age 75.75±10.6 years, 59% males) were prospectively enrolled within 24–48 hours from admission to the emergency department (ED). In either the acute phase and at pre-discharge all patients underwent M-Mode, 2-Dimensional and Doppler transthoracic echocardiography (TTE), as well as lung ultrasonography (LUS), to detect an increase of extravascular lung water (EVLW) and development of pleural effusion. Laboratory tests were performed in the acute phase and at pre-discharge including the evaluation of NT-proBNP. Results At baseline we observed a high prevalence of RV dysfunction as documented by a reduced RV systolic longitudinal function [mean tricuspid annular plane systolic excursion (TAPSE) at admission of 16.47±3.86 mm with 50% of the patients exhibiting a TAPSE&amp;lt;16mm], a decreased DTI-derived tricuspid lateral annular systolic velocity (50% of the subjects showed a tricuspid s' wave&amp;lt;10 cm/s) and a reduced RV fractional area change (mean FAC at admission of 36.4±14.6%). Furthermore, an increased pulmonary arterial systolic pressure (PASP) and a severe impairment in terms of RV coupling to PC was detected at initial evaluation (mean PASP at admission: 38.8±10.8 mmHg; average TAPSE/PASP at admission: 0.45±0.17 mm/mmHg). At pre-discharge a significant increment of TAPSE (16.47±3.86 mm vs. 17.45±3.88; p=0.05) and a reduction of PASP (38.8±10.8 mmHg vs. 30.5±9.6mmHg, p&amp;lt;0.001) was observed. Furthermore, in the whole population we assisted to a significant improvement in terms of RV function and its coupling with PC as demonstrated by the significant increase of TAPSE/PASP ratio (TAPSE/PASP: 0.45±0.17 mm/mmHg vs 0.62±0.20 mm/mmHg; p&amp;lt;0.001). Patients significantly reduced from admission to discharge the number of B-lines and NT-proBNP (B-lines: 22.2±17.1 vs. 6.5±5 p&amp;lt;0.001; NT-proBNP: 8738±948 ng/l vs 4227±659 ng/l p&amp;lt;0.001) (Figure 1). Nonetheless, no significant changes of left atrial and left ventricular dimensions and function were noted. Conclusions In AHF, development of congestion and EVLW significantly impact on the right heart function. Decongestion therapy is effective for restoring acute reversal of RV dysfunction, but the question remains on how to impact on the biological properties of the RV. Funding Acknowledgement Type of funding source: None

A Preclinical Safety Study of Thyroid Hormone Instilled into the Lungs of Healthy Rats-an Investigational Therapy for ARDS.

Acute respiratory distress syndrome (ARDS) is a severe, life-threatening form of respiratory failure characterized by pulmonary edema, inflammation, and hypoxemia due to reduced alveolar fluid clearance (AFC). Alveolar fluid clearance is required for recovery and effective gas exchange, and higher rates of AFC are associated with reduced mortality. Thyroid hormones play multiple roles in lung function, and L-3,5,3'-triiodothyronine (T3) has multiple effects on lung alveolar type II cells. T3 enhances AFC in normal adult rat lungs when administered intramuscularly and in normal or hypoxia-injured lungs when given intratracheally. The safety of a commercially available formulation of liothyronine sodium (synthetic T3) administered intratracheally was assessed in an Investigational New Drug Application-enabling toxicology study in healthy rats. Instillation of the commercial formulation of T3 without modification rapidly caused tracheal injury and often mortality. Intratracheal instillation of T3 that was reformulated and brought to a neutral pH at the maximum feasible dose of 2.73 µg T3 in 300 µl for 5 consecutive days had no clinically relevant T3-related adverse clinical, histopathologic, or clinical pathology findings. There were no unscheduled deaths that could be attributed to the reformulated T3 or control articles, no differences in the lung weights, and no macroscopic or microscopic findings considered to be related to treatment with T3. This preclinical safety study has paved the way for a phase I/II study to determine the safety and tolerability of a T3 formulation delivered into the lungs of patients with ARDS, including coronavirus disease 2019-associated ARDS, and to measure the effect on extravascular lung water in these patients. SIGNIFICANCE STATEMENT: There is growing interest in treating lung disease with thyroid hormone [triiodothyronine (T3)] in pulmonary edema and acute respiratory distress syndrome (ARDS). However, there is not any published experience on the impact of direct administration of T3 into the lung. An essential step is to determine the safety of multiple doses of T3 administered in a relevant animal species. This study enabled Food and Drug Administration approval of a phase I/II clinical trial of T3 instillation in patients with ARDS, including coronavirus disease 2019-associated ARDS (T3-ARDS ClinicalTrials.gov Identifier NCT04115514).