Monitoring Of Extravascular Lung Water Research Articles

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.

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.

Effects of Orthostatic Position in Point of Care Lung Ultrasound in Acute Decompensated Heart Failure; a Potential for Simple Interventions

Introduction Point of care lung ultrasound (LUS) has been applied for the bedside assessment of B-lines. B-lines are reverberation artifacts, originating from water-thickened pulmonary interlobular septa that may help in the detection and monitoring of extravascular lung water. In this context, the purpose of this research was to assess the dynamic features of B-line measurements during changes in position in patients with heart failure. Methods and Results The study population consisted of individuals who were nearing completion of in-hospital decongestion for acute decompensated heart failure, Screened patients met the inclusion criteria of having no more than grade 1 peripheral edema and JVP Conclusions These preliminary results underscore the dramatic and rapid effects of patient positioning upon B-line scores among patients with heart failure. These results have implications for the use of lung ultrasound for patient triage in the emergency department, decisions about timing of hospital discharge and for potential applications related to experimental therapeutics.

Extravascular lung water monitoring for thoracic and lung transplant surgeries

Excessive accumulation of extravascular lung water (EVLW) resulting in pulmonary edema is the most feared complication following thoracic surgery and lung transplant. ICUs have long relied on chest radiography to monitor pulmonary status postoperatively but the increasing recognition of the limitations of bedside plain films has fueled development of newer technologies, which offer earlier detection, quantitative assessments, and can aide in preoperative screening of surgical candidates. In this review, we focus on the emergence of transpulmonary thermodilution (TPTD) and lung ultrasound with a focus on the clinical integration of these modalities into current intraoperative and critical care practices. Recent studies demonstrate transpulmonary thermodilution and lung ultrasound provide greater sensitivity and earlier detection of lung water accumulation and are useful to guide clinical management. Assessments from these techniques have predictive value of postoperative outcome. Further, EVLW assessment shows promise as a preoperative screening tool in lung transplant patients. Monitoring EVLW in the perioperative period offers clinicians a powerful tool to guide fluid therapy and manage pulmonary edema. Both TPTD and lung ultrasound have unique attributes in the care of thoracic surgery and lung transplant patients.

Do not drown the patient: appropriate fluid management in critical illness

Administering intravenous fluids to support the circulation in critically ill patients has been a mainstay of emergency medicine and critical care for decades, especially (but not exclusively) in patients with distributive or hypovolemic shock. However, in recent years, this automatic use of large fluid volumes is beginning to be questioned. Analysis from several large trials in severe sepsis and/or acute respiratory distress syndrome have shown independent links between volumes of fluid administered and outcome; conservative fluid strategies have also been associated with lower mortality in trauma patients. In addition, it is becoming ever more clear that central venous pressure, which is often used to guide fluid administration, is a completely unreliable parameter of volume status or fluid responsiveness. Furthermore, 2 recently published large multicenter trials (ARISE and ProCESS) have discredited the “early goal-directed therapy” approach, which used prespecified targets of central venous pressure and venous saturation to guide fluid and vasopressor administration. This article discusses the risks of “iatrogenic submersion” and strategies to avoid this risk while still giving our patients the fluids they need. The key lies in combining good clinical judgement, awareness of the potential harm from excessive fluid use, restraint in reflexive administration of fluids, and use of data from sophisticated monitoring tools such as echocardiography and transpulmonary thermodilution. Use of smaller volumes to perform fluid challenges, monitoring of extravascular lung water, earlier use of norepinephrine, and other strategies can help further reduce morbidity and mortality from severe sepsis.

A different use of the CHA2DS2-VASc: Risk stratification of early recurrence of atrial fibrillation

line, deepening posteriorly and moving synchronously with respiration) allows semiquantification and monitoring of extravascular lung water, and B-line score at admission has been identified as a prognostic factor in patients hospitalised for HF. Objective: Aim of our study was to evaluate if LUS performed at patient's discharge could predict 90-day readmission or death in HF patients. Methods: Consecutive patients hospitalised for HF exacerbation were enrolled from September 2011 to September 2012. Exclusion criteria were: bedridden patients, acute coronary syndromes, pneumonia in the last month, and pulmonary fibrosis. All patients received conventional treatments as suggested by the guidelines. Echocardiography was performed in each patient. At discharge LUS was performed through longitudinal scans following anatomical lines; B lines were counted in each intercostal space; as previously described in literature, 72 segments were considered (28 anteriorly, and 44 posteriorly). Sector was considered positive when at least two B-lines were recognized. The percentage of positive sectors was calculated. Phone-call follow-up at 90 days was performed and events of readmission or death were registered. A logistic regression analysis was performed to evaluate the association between the percentage of positive sectors and 90 day events. Data are expressed as mean ± SD. Results: Eighty patients were enrolled (59% females; age 78 ± 9 yrs); NYHA class II or III patients were 87%; ejection fraction was 45 ± 17. Twenty-four events were recorded (18 readmissions, 6 deaths). B lines were significantly associated with events (OR = 1.05, 95%CI 1.02–1.08; p = 0.0007). This association was confirmed when the model was adjusted for age, EF, left atrial volume, E/E′, haemoglobin, creatinine. Conclusions: B lines at discharge may represent a prognostic factor for readmission and death at 90 days in HF patients.

Lung ultrasound: a new tool for the cardiologist

For many years the lung has been considered off-limits for ultrasound. However, it has been recently shown that lung ultrasound (LUS) may represent a useful tool for the evaluation of many pulmonary conditions in cardiovascular disease. The main application of LUS for the cardiologist is the assessment of B-lines. B-lines are reverberation artifacts, originating from water-thickened pulmonary interlobular septa. Multiple B-lines are present in pulmonary congestion, and may help in the detection, semiquantification and monitoring of extravascular lung water, in the differential diagnosis of dyspnea, and in the prognostic stratification of chronic heart failure and acute coronary syndromes.

Interventional lung assist in an experimental model of apneic ventilation: haemodynamics, intrathoracic blood volume and extravascular lung water monitoring

Interventional lung assist in an experimental model of apneic ventilation: haemodynamics, intrathoracic blood volume and extravascular lung water monitoring

Do the data obtained by the PiCCO system enable one to differentiate between direct ALI/ARDS and indirect ALI/ARDS?

It is known that measurement of the intrathoracic blood volume (ITBV) is a more accurate estimate of cardiac preload than pressure measurements using central venous or pulmonary artery occlusion pressures. Extravascular lung water (EVLW) is defined as the value of the intrathoracic thermal volume minus the ITBV. An increase in EVLW is the pathophysiological basis for the development of pulmonary edema (PE). There is evidence to suggest that therapy to reduce EVLW may improve outcome in the critically ill patient. The bedside assessment of EVLW may be very useful in identifying and quantifying PE, and hence in selecting patients who might benefit from a fluid restriction/depletion therapeutic strategy based on EVLW monitoring. The PiCCO (Pulsion, Munich, Germany) provides an estimate of the ITBV, EVLW, and permeability index (PI) via a single transpulmonary thermodilution technique. PE is defined as the abnormal accumulation of fluid in the extravascular space of the lung. ALI/ARDS is characterized by pulmonary edema. PE consists of increased hydrostatic PE (cardiogenic PE) and increased permeability PE (ALI/ARDS). Increased permeability PE (ALI/ARDS) is further classified into direct lung injury type and indirect lung injury type. PI was calculated as the ratio of EVLW to ITBV, which was previously shown to reflect permeability of the alveolar-capillary barrier. The early recognition and differential diagnosis of direct lung injury and indirect lung injury may be challenging.

Granulocyte colony-stimulating factor-induced capillary leak syndrome confirmed by extravascular lung water measurements

The study purpose was to report the first case of granulocyte colony-stimulating factor (G-CSF)-induced capillary leak syndrome (CLS) in which serial extravascular lung water (EVLW) measurements were performed and to compare this case with previously reported cases. To identify previously reported cases, we performed a literature search, using PubMed with the following search terms: CLS, EVLW, G-CSF, granulocyte-macrophage colony-stimulating factor (GM-CSF) and stem cell transplantation and the references in the bibliographies of the papers retrieved. To obtain additional information about these cases, we contacted the authors by e-mail. We describe the case of a 68-year-old woman who developed severe CLS during G-CSF treatment after autologous haematological stem cell transplantation. CLS is caused by damage to the endothelial cells, resulting in extravasation of plasma proteins and fluid from the capillaries into the extravascular space. This is illustrated by high values of EVLW and pulmonary vascular permeability, necessitating mechanical ventilation. We found five other case reports in the literature. The white blood cell count at the onset of the CLS varied from very low (zero) to very high (90,500/mul). The symptoms began on day 5-9 of the G-CSF treatment. All patients had fever. Three patients were mechanically ventilated and four received renal replacement therapy. Two patients died. Treatment with G-CSF can induce fatal CLS. Monitoring of EVLW in patients with severe CLS may be useful to guide fluid therapy and improve oxygenation.

Intrathoracic blood volume, pulmonary capillary wedge pressure and extravascular lung water monitoring during liver transplantation

de Nadal, M.; Mora, A.; Bosch, C.; Camps, A.; Armadans, L.; Cortes, C. Author Information