Pulmonary Artery Catheter Balloon Research Articles

A CASE OF INTRA-OPERATIVE ANAPHYLAXIS TO LATEX IN A PULMONARY ARTERY CATHETER

<h3>Introduction</h3> Perioperative anaphylaxis (POA) is a diagnostic challenge. We present a case of anaphylaxis to intravascular latex preceding aortic surgery. <h3>Case Description</h3> A 55-year-old man was admitted for aortic arch and valve repair. Upon insertion of a pulmonary artery (PA) catheter, he developed hypotension, hypoxemia with elevated airway pressures, and a non-urticarial rash without angioedema. Anaphylaxis was successfully treated with epinephrine, but surgery was canceled. The plasma tryptase levels were 15.8, 20.1, and 5.1 mcg/L at 40 minutes, 6 hours, and 10 days after the event, respectively. Eight weeks later, patient underwent skin testing with negative results to all perioperative medications and latex. Subsequent serum IgE-specific antigen testing was positive for latex and borderline positive for pholcodine, a surrogate for neuromuscular blocking agents (NMBAs). IgE was negative for morphine which argues against rocuronium-related anaphylaxis. Subsequent surgery was successful in a latex-free OR without NMBAs. The patient denied symptoms to latex balloons, condoms, or band-aids. <h3>Discussion</h3> The NAP6 reported zero confirmed latex-related anaphylaxis cases, likely due to decreased latex-use in the OR. Despite this decreased incidence, clinicians should continue to be aware of latex anaphylaxis. Latex exposures may not be apparent as in our patient who reacted to the balloon of a PA catheter. Our case adds to the five reported cases of anaphylaxis due to latex in a PA catheter balloon, all in patients with no previous history of latex allergy. The lack of standardized skin testing adds to the diagnostic complexity. We recommend both skin testing and IgE immunoCAPS in cases of POA.

Effect of pulmonary artery catheter balloon inflation on pulmonary hemodynamics.

Right heart catheterization (RHC), including a pulmonary artery wedge pressure (PAWP) determination, is necessary to categorize the hemodynamic type of pulmonary hypertension (PH). The potential hemodynamic implications of a pulmonary artery catheter (PAC) balloon inflation in PH have not been formally tested. We assessed the hemodynamic impact of the PAC balloon inflation during RHC by measuring systolic, diastolic, and mean pulmonary artery pressure (mPAP) in all patients, and cardiac output (CO) by thermodilution in a subgroup of patients. Hemodynamic measurements were obtained both with PAC balloon deflated and fully inflated (1.5 mL of air), while the PAC was free floating in the pulmonary artery before wedging. We calculated total pulmonary resistance (TPR). We included 210 patients, age 58±14 years, 134 (64%) women. Patients had no PH (n: 12, 6%), PH group 1 (n: 68, 33%), 2 (n: 86, 41%), 3 (n: 11, 5%), 4 (n: 29, 14%), and 5 (n: 3, 1%). The mean ± standard deviation (SD) at end-expiration mPAP (balloon-up minus down) (n: 209) was -0.02±1.59 mmHg (range, -5.0 to 4.0 mmHg; P=0.84), while the TPR (n: 62) was -0.27±1.2 Wood units (WU) (range, -4.8 to 2.2 WU; P=0.08); without significant variation based on the type of PH group or degree of pulmonary vascular resistance (PVR). Interestingly, the change in mPAP at end-expiration with PAC balloon inflation was higher in women (mean ± SD: 0.31±1.43 mmHg) than men (mean ± SD: -0.61±1.70 mmHg) (P<0.001). Balloon inflation of the PAC in the main pulmonary artery had no significant impact on the mPAP or TPR, even when only including patients with group 1 PH or selecting a subgroup with a higher PVR.

A 23-year-old man with left lung atelectasis treated with a targeted segmental recruitment maneuver: a\xa0case report

BackgroundLung atelectasis are nonventilated parts of lung tissue and occur as a result of the collapse of the pulmonary parenchyma (alveoli). Various therapeutic procedures for inflating the collapsed pulmonary parenchyma, such as bronchial aspiration and/or standard recruitment maneuvers, are not always successful.Case presentationWe report a case of a 23-year-old Croatian man with a parapharyngeal abscess on the left side of the neck with spreading of infection in the mediastinum and left side of the thorax and consequent major atelectasis of the left lung. The patient was mechanically ventilated. We decided to apply a new method in which a pulmonary artery catheter was placed (guided by bronchoscope) on the entrance to the lower left bronchus. The pulmonary artery catheter balloon was inflated to achieve bronchial closure. Using another respirator, we ventilated the affected lobe separately with continuously high pressure of 30 cmH2O. After 30 minutes, we removed the pulmonary artery catheter from the lower left bronchus and placed it in the upper left bronchus and repeated the procedure. Our method allowed a significantly longer duration (30 minutes) of continuously high pressure of 30 cmH2O separately to only one of the total of five lobes of the lungs while the other four lobes were simultaneously ventilated continuously with protective ventilation mode.ConclusionUse of a pulmonary artery catheter and two respirators in our patient’s case proved to be a successful method for recruiting the atelectatic lung while maintaining protective ventilation of the lung segments without atelectasis.

Culture of pulmonary artery endothelial cells from pulmonary artery catheter balloon tips: considerations for use in pulmonary vascular disease.

Endothelial dysfunction is a hallmark of pulmonary arterial hypertension (PAH) but there are no established methods to study pulmonary artery endothelial cells (PAECs) from living patients. We sought to culture PAECs from pulmonary artery catheter (PAC) balloons used during right-heart catheterisation (RHC) to characterise successful culture attempts and to describe PAEC behaviour.PAECs were grown in primary culture to confluence and endothelial cell phenotype was confirmed. Standard assays for apoptosis, migration and tube formation were performed between passages three to eight. We collected 49 PAC tips from 45 subjects with successful PAEC culture from 19 balloons (39%).There were no differences in subject demographic details or RHC procedural details in successful versus unsuccessful attempts. However, for subjects who met haemodynamic criteria for PAH, there was a higher but nonsignificant (p=0.10) proportion amongst successful attempts (10 out of 19, 53%) versus unsuccessful attempts (nine out of 30, 30%). A successful culture was more likely in subjects with a lower cardiac index (p=0.03) and higher pulmonary vascular resistance (p=0.04). PAECs from a subject with idiopathic PAH were apoptosis resistant compared to commercial PAECs (p=0.04) and had reduced migration compared to PAECs from a subject with portopulmonary hypertension with high cardiac output (p=0.01). PAECs from a subject with HIV-associated PAH formed fewer (p=0.01) and shorter (p=0.02) vessel networks compared to commercial PAECs.Sustained culture and characterisation of PAECs from RHC balloons is feasible, especially in PAH with high haemodynamic burden. This technique may provide insight into endothelial dysfunction during PAH pathogenesis.

Video Fluoroscopy for Positioning of Pulmonary Artery Catheters in Patients Undergoing Cardiac Surgery.

To determine whether video fluoroscopy combined with traditional pressure waveform analyses facilitates optimal pulmonary artery catheter (PAC) flotation and final positioning compared with the traditional pressure waveform flotation technique alone. Prospective, single-center, randomized, controlled trial. Single-center university teaching hospital. The study included 50 cardiac surgery patients at higher risk for PAC complications. Use of video fluoroscopy to facilitate optimal PAC flotation and positioning. The primary outcome was the time taken to float and position the PAC balloon in the pulmonary artery as confirmed by transesophageal echocardiography. Secondary outcomes included number of attempts at flotation, ventricular rhythm disturbances, and catheter malposition. Patients were evenly matched in baseline demographics, New York Heart Association symptoms of heart failure, severity of left and right ventricular dysfunction, end-diastolic pressures and dimensions, severity of tricuspid valvular disease, and atrial and pulmonary artery pressures. Mean (SD) time to float the PAC was significantly shorter in the video fluoroscopy group than in the usual care group: 73 seconds (SD, 65.1) versus 176 seconds (SD, 180.6), respectively; p = 0.014. The median (interquartile range [IQR]) number of attempts to successful flotation was fewer in the video fluoroscopy group than in the usual care group: 1 (IQR 1:2) attempt versus 2 (IQR 1:4) attempts, respectively; p = 0.007. The composite complication rate (malposition and arrhythmias) was lower in the video fluoroscopy group than in the usual care group (16% v 52%, respectively; p = 0.01). In cardiac surgery patients at higher risk for PAC complications, video fluoroscopy facilitated faster and safer catheter flotation and positioning compared with the traditional pressure waveform flotation technique.

Comparison of a single indicator and gravimetric technique for estimation of extravascular lung water in endotoxemic pigs

To compare the single thermal indicator dilution (STID) technique for measurement of extravascular lung water (EVLW(STID)) with gravimetrically determined EVLW (EVLW(GRAV)) in anesthetized pigs under sham and endotoxemic conditions. Open experimental comparative animal study. University animal research laboratory. Fifteen anesthetized landrace pigs. Endotoxin infusion during 5 hrs in five pigs. Six animals were only anesthetized and rested for 5 hrs. In four additional animals, the impact on EVLW(STID) measurements by changes in pulmonary perfusion, ventilation, and the combination of the two was studied. The alterations in ventilation and perfusion were induced by caval balloon inflation, inflation of the pulmonary artery catheter balloon, and bronchial plugging respectively. The STID technique, with default settings of the intrathoracic blood volume (ITBV) to global end-diastolic volume (GEDV) (i.e., the extrapulmonary intravascular volume between the point of injection of the indicator, and the point of detection) relationship (ITBV = 1.25GEDV), systematically overestimated the EVLW index compared with the gravimetrical method (mean bias of 5.4 mL/kg). By adapting the ITBV to GEDV relationship to the current model (ITBV = 1.52GEDV + 49.7), the accuracy of the STID technique improved. Moreover, the measurement of EVLW(STID) proved to be reduced by manipulation of pulmonary perfusion and ventilation. However, the STID technique could detect an increase in EVLW during endotoxemia independent of the ITBV/GEDV relationship used. Despite technological improvement, the dilution techniques for the measurement of EVLW might still be influenced by changes in perfusion and ventilation. The STID technique, in addition, might demand adjustment of the ITBV/GEDV relationship to the particular condition and species subjected to measurement. The STID technique may, however, be a useful tool for monitoring changes of EVLW over time, but further studies are warranted to confirm this.

Technique to Detect Small Leaks Before Insertion of Pulmonary Artery Catheter Balloon

Technique to Detect Small Leaks Before Insertion of Pulmonary Artery Catheter Balloon

Pulmonary Artery Catheter Balloon

Pulmonary Artery Catheter Balloon

Pulmonary Capillary Pressure Measurement from Pulmonary Artery Occlusion Pressure Decay Profile Analysis in Sheep

Pulmonary capillary pressure (Ppc), the major factor responsible for pulmonary edema, cannot be directly measured in intact subjects but may be estimated by analysis of the pressure decay profile after pulmonary artery catheter balloon inflation. We compared three different methods of pulmonary artery occlusion pressure (Ppao) decay profile analysis to estimates of Ppc derived from lymph flow measurements in halothane-anesthesized sheep. The relationship between Ppc and lymph flow was first determined by increasing Ppc by left atrial balloon inflation, and was then used to determine Ppc during pulmonary hypertension produced by infusion of a thromboxane analog. All three methods of Ppao decay profile analysis demonstrated a correlation with Ppc estimated from lymph flow. However, the method using a single exponential analysis significantly overestimated Ppc, and none of the methods reliably estimated changes in the longitudinal distribution of pulmonary vascular resistance during pulmonary hypertension. These results suggest that Ppao decay profile analysis as currently performed has limited application.

Decreasing the risk of pulmonary artery rupture with a pressure relief balloon

A pressure relief balloon has been recommended as one way to decrease catheter-related pulmonary artery rupture (PAR). There are approximately 1 to 2 PARs per 1,000 pulmonary artery catheter (PAC) insertions, resulting in significant morbidity and mortality. A new pressure relief balloon (PRB) introduced by Biosensors International (Singapore) was studied for its efficacy in increasing safety during PAC flotation balloon (FB) inflations. Ten human placentae were used for the experiment. The Biosensors PACs and the commonly used Baxter-Edwards (Irvine, CA) catheters were placed in placental veins and their FBs were gradually inflated with a maximum of 1.5 mL of air. Data revealed that PRBs consistently inflated when resistance was met by FBs and inflation pressure reached 1,000 mmHg. When PRBs were removed, the FBs inflated asymmetrically and distended beyond the catheter lumen or protruded through the vessel wall, causing bleeding upon deflation. Without the PRB, pressures reached up to 1,700 mmHg. In addition, the PRB gave visual evidence of resistance to the FB. In conclusion, the PRB is a safety device that limits overinflation of the distal PAC balloon, thus preventing vessel rupture. The device deserves serious consideration and outcome analysis.

Catheter-induced pulmonary artery haemorrhage resulting from a pneumothorax

We present a case of pulmonary artery perforation in a patient who developed a pneumothorax after cardiac surgery. In the process of inserting a chest tube the patient became tachypnoeic, and developed haemoptysis. The trachea was intubated, and right bronchial intubation was performed with persistent bleeding. The pulmonary artery catheter was gently withdrawn and the balloon inflated, with cessation of bleeding. The patient was taken to the operating room, a bronchial blocker was placed in the right lower lobe bronchi, and the pulmonary artery catheter was removed. The bronchial blocker was removed the following day with no bleeding. The aetiology of perforation was secondary to the pneumothorax, which caused a shift of the mediastinum to the right, elevated pulmonary artery pressures, and the distal migration of the catheter through the pulmonary artery. It is recommended that treatment include tracheal intubation, inflation of the pulmonary artery catheter balloon, and the placement of a right lower lobe bronchial blocker.

Device to limit inflation of a pulmonary artery catheter balloon

The most serious complication seen with pulmonary artery catheters is rupture of the pulmonary artery. The effectiveness of an external safety balloon added to the pulmonary artery balloon inflation port was tested. The external balloon is designed to inflate and absorb excess volume from the inflation syringe after the internal balloon contacts the vessel wall. When the catheter tip is in a small pulmonary artery, expansion of the external balloon indicates that the catheter tip is in a noncompliant or small vessel. The external balloon was tested in a bench simulation. None. The pulmonary artery balloon was slowly inflated inside 2.6-, 3.0-, 4.7-, 8.6-, and 11.6-mm internal diameter polyvinyl chloride tubes, with and without the external safety device in place. Without the external balloon, the average balloon pressure was 1647 +/- 145 (SD) mm Hg in the 2.6-mm vessel. With the external balloon in use, the maximum pulmonary artery balloon pressure was 473 +/- 7.2 mm Hg in the 2.6-mm vessel. The external balloon can limit balloon pressures within the pulmonary artery and identify when excessive volumes are being forced into the pulmonary artery balloon.

In vitro reappraisal of the pulmonary artery catheter balloon volume-pressure relationship: comparison of four different catheters

The most serious risk of the use of the flow-directed pulmonary artery (PA) catheter is PA rupture due to high balloon inflation pressure of the catheter. Previously reported measurements of PA catheter intra-balloon pressure and volume during balloon inflation were performed mostly in a static fashion, that is, measurements were performed after a certain volume of air had been injected into the balloon. In this study, simultaneous measurements of pressure and volume, in addition to a static study, were performed in vitro using four PA catheters (Abbott Opticath, Arrow Hands-Off, Baxter Edwards and Spectramed). The peak intra-balloon pressure was recorded immediately before loss of resistance was felt in the inflating syringe. Contrary to previously reported studies, the peak intra-balloon pressure was not the pressure exerted on the pulmonary artery wall unless the tip of the catheter was already in the peripheral pulmonary artery. The loss of resistance volume which was constant for each catheter could be used reliably as an indicator of instantaneous balloon inflation. The slower the rate of injection, the lower were the peak pressure and the injection volume at the peak pressure. The Abbott, Edwards and Spectramed catheters had similar characteristics of inflation volume and intra-balloon pressure. The Arrow catheter had higher balloon opening and plateau pressures, and a smaller balloon volume compared with the other three catheters.

Hemodynamic effects of lobar pulmonary artery occlusion in a porcine sepsis model

We induced severe pulmonary hypertension and acute lung injury in 6 pigs by Pseudomonas aeruginosa infusion. We studied the effect of pulmonary artery catheter balloon inflation on hemodynamics. After bacterial infusion, inflation of a pulmonary artery catheter balloon in the left lower lobar pulmonary artery was accompanied by a significant ( p < 0.05, paired t test) increase in pulmonary artery pressure, a decrease in left atrial pressure, a decrease in cardiac output, and a decrease in mean arterial pressure. No significant changes occurred when the catheter was advanced into the wedged position without balloon inflation. Balloon inflation had no significant effect on these variables before bacterial infusion. We conclude that with sufficiently severe pulmonary hypertension in association with diffuse lung injury, lobar pulmonary artery occlusion may cause alterations in cardiac output and left atrial pressure. This may confuse interpretation of pulmonary artery catheter measurements.

The range of pulmonary artery catheter balloon inflation pressures

Pulmonary artery catheters are frequently used and may be the cause of pulmonary artery rupture. The “feel” of balloon inflation, a clinical sign of a “wedged” catheter, was noted to vary among different manufacturers' catheters. The inflation pressures of five catheters from four manufacturers were examined in the laboratory. Peak pressures ranged from 475 ± 10 mm Hg to 1,037 ± 36.8 mm Hg. Plateau pressures ranged from 220 ± 4 mm Hg to 495 ± 2.9 mm Hg. Catheters with high inflation pressures may make detection of a wedged catheter by feel impossible and, thus, may increase the risk of a pulmonary artery rupture.

Pulmonary blood flow reduction by prostaglandin F2 alpha and pulmonary artery balloon manipulation during one-lung ventilation in dogs.

The purpose of this experimental study was to compare two methods of pulmonary blood flow manipulation during one-lung ventilation (OLV), either reducing pulmonary blood flow to the non-ventilated lung by inflation of a pulmonary artery catheter balloon (PAB) or by infusion of prostaglandin F2 alpha (PGF2 alpha). Seven anaesthetized dogs were intubated with a Kottmeier endobronchial tube and ventilated with 66% O2. Systemic and pulmonary pressures and blood gases, cardiac output and airway pressure were measured, and the venous admixture (QSP/QT) was calculated. During two-lung ventilation (TLV) Pao2 was 43.6 +/- 1.9 kPa (mean +/- s.d.) and (QSP/QT) was 11 +/- 3%. OLV reduced Pao2 to 12.1 +/- 1.6 kPa (P less than or equal to 0.001) and increased QSP/QT to 40 +/- 4% (P less than or equal to 0.001). Mean pulmonary artery pressure and airway pressure increased. PAB inflation caused an increase in Pao2 to 19.9 +/- 2.9 kPa (P less than or equal to 0.02) and a decrease in QSP/QT to 27 +/- 6% (P less than or equal to 0.001). PGF2 alpha infusion (1.2 micrograms kg-1 min-1) into the pulmonary artery of the non-ventilated lung increased Pao2 to 22.4 +/- 3.3 kPa (P less than or equal to 0.001) and decreased QSP/QT to 25 +/- 4 (P less than or equal to 0.001). PGF2 alpha infusion resulted in a small increase in mean systemic and pulmonary artery pressures. During the infusion of 1.2 micrograms kg-1 min-1 of PGF2 alpha no signs of bronchoconstriction were observed. PAB inflation and PGF2 alpha infusion were equally effective in improving oxygenation and reducing venous admixture during OLV.(ABSTRACT TRUNCATED AT 250 WORDS)

Unilateral Lung Lavage

The authors attempted to favorably manipulate the distribution of pulmonary blood flow during unilateral atelectasis and during unilateral lung lavage by nonocclusive inflation of an ipsilateral pulmonary artery catheter balloon (PAB). Six mongrel dogs were anesthetized, intubated with a double-lumen endotracheal tube, and following a thoracotomy, pulmonary artery and left lung blood flows (Qt and QLL/Qt, respectively) were measured electromagnetically; right lung blood flows (QRL/Qt) were derived by difference. A PAB was positioned in the right main pulmonary artery. The experimental sequence consisted of seven steps: 1) both lungs ventilated; 2) ventilation of the left lung (LL vent), right lung (RL) atelectatic, PAB deflated; 3) LL vent, RL atelectatic, PAB inflated; 4) LL vent, RL lavaged, PAB deflated; 5) LL vent, RL lavaged, PAB inflated; 6) LL vent, RL drained, PAB deflated; and 7) LL vent, RL drained, PAB inflated. At each step the shunt fraction (Qs/Qt) was determined. Inflation of the PAB during LL vent and RL atelectatic (step 3) caused QRL/Qt and Qs/Qt to decrease and QLL/Qt and PaO2 to increase significantly (compared to step 2). There were no significant differences in QRL/Qt, QLL/Qt, Qs/Qt, and PaO2 during RL lavage with the PAB deflated (step 4) compared to RL lavage with the PAB inflated (step 5). Inflation of the PAB during RL drainage (step 7) caused QRL/Qt to decreased and QLL/Qt to increase significantly compared to their values during periods of RL drainage with the PAB deflated (step 6). This resulted in a significant increase in PaO2 and decrease in Qs/Qt. These results demonstrate that the distribution of pulmonary blood flow in dogs can be favorably manipulated by nonocclusive ipsilateral PAB inflation and support a trial of use in selected patients during one-lung anesthesia and ventilation.

Improving Oxygenation during One-lung Ventilation in Dogs

During one-lung ventilation in dogs, the authors studied the individual and combined effects of 5, 10, and 15 cm H2O of O2 PEEP to the nonventilated lung and nonocclusive inflation of a pulmonary artery catheter balloon (PAB) in the main pulmonary artery of the nonventilated lung on Pao2 °Q°/°Q°, and blood flow to the nonventilated lung (°Qtest/°Q°). Periods of one-lung ventilation alone resulted in Pao2 of 61 ° 5 torr (mean ° SE), °Q°/°Q° of 50 ° 3 per cent, and °Qtest/°Q° of 41 ° 6 per cent. They found that 5 and 10 cm H2O of O2 PEEP caused a greatly decreased °Q°/°Q°, (22 ° 4 and 21 ° 4 per cent, respectively) and increased Pao2 (327 ° 43 and 330 ° 40 torr, respectively) while °Qtest/°Q° remained unchanged, whereas 15 cm H2O of O2 PEEP caused similar Pao2 and °Q°/°Q° changes while °Qtest/°Q°, significantly decreased (to 19 ° 6). Nonocclusive inflation of the PAB alone caused moderate favorable changes in Pao2 and °Q°/°Q° (but less than those caused by any level of O2 PEEP) which were due to a decreased °Qtest/°Q°, (to 22 ° 5 percent). Inflation of the PAB during any level of O2 PEEP did not change Pao2 or °Q°/°Q° significantly, but still decreased °Qtest/°Q° significantly. Probable mechanisms of efficacy of nonventilated lung manipulations are as follows: low levels of O2 PEEP maintain the patency of airways, allowing nonventilated lung alveoli to participate in gas exchange; high levels of O2 PEEP act by this mechanism as well as by causing blood flow diversion to the ventilated lung; PAB inflation acts by blood flow diversion to the ventilated lung alone. The authors conclude that low levels of O2 PEEP to the nonventilated lung should be used when possible if hypoxemia occurs during one-lung ventilation. Flow diversion caused by PAB inflation may be uniquely useful in situations in which O2 PEEP to the nonventilated lung is impractical (e.g., surgical interference, pulmonary hemorrhage) or impossible (e.g., pulmonary lavage).