Extravascular lung water and pulmonary arterial wedge pressure for fluid management in patients with acute respiratory distress syndrome

Abstract

BackgroundExtravascular lung water (EVLW) is a sensitive prognostic indicator of pulmonary edema. Thus, EVLW may be an advantageous method of fluid management. This study aims to evaluate the outcomes of using EVLW and pulmonary artery wedge pressure (PAWP) as strategies for fluid management in patients with acute respiratory distress syndrome (ARDS).MethodsTwenty-nine patients were randomly divided into the EVLW and PAWP groups. The survival rate, ICU (Intensive Care Unit) length of stay, duration of mechanical ventilation, acute lung injury scores, and oxygenation index of the EVLW and PAWP groups were compared.ResultsNo significant difference in the survival rates at 28 and 60 days (d) after treatment was found between the two groups (p = 0.542). The duration of mechanical ventilation and ICU length of stay were significantly lower (p < 0.05) in the EVLW group than in the PAWP group. The 7 d cumulative fluid balance was -783 ± 391 ml in the EVLW group and -256 ± 514 ml in the PAWP group (p < 0.05). Compared with the PAWP group, the EVLW group showed improved oxygenation index (p = 0.006).ConclusionsEVLW for fluid management improved clinical results in patients with ARDS better than PAWP.

Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis

“…The use of random sequence generation and allocation concealment [19][20][21][22]25] and the risk of reporting bias [18,[20][21][22]25] were unclear in a number of studies. While blinding was used in only 2 studies [17,18], likely due to difficulties in concealment of the different fluid regimens and/or haemodynamic monitoring technologies employed, strict protocolisation of fluid and diuretic use was felt to ameliorate the effects of this potential bias in all but two studies [19,21].…”

“…We found increased VFDs with a conservative or deresuscitative fluid strategy in comparison with a liberal strategy or standard care (mean difference 1.82 days [95% CI interval 0.53 to 3.10 days], I 2 =9%). In addition, studies by Hu et al [21] and Wang et al [22] reported shorter duration of mechanical ventilation in a more conservative fluid strategy group compared with the liberal fluid strategy group (10.13 +/-3.02 days vs. 12.64 +/-2.89, P<0.05 and 9.62 +/-2.55 days vs 12.51 +/-2.92 days, P<0.05 respectively).…”

“…Five studies [16][17][18][19][20] took place in the United States, three in China [21][22][23], one in France [24] one in India [25] and one in Denmark and Finland [26]. Sample sizes ranged from 29 [21] to 1000 [16].…”

“…In three studies [16][17][18], protocolised diuretic use was used in the conservative / deresuscitative arm, in four the intervention strategy involved protocolised fluid restriction or minimisation [16,19,25,26]; and in five the main intervention was the use of alternative haemodynamic targets for fluid management, based on extravascular lung water (EVLW) [20][21][22], pulse pressure variation (PPV) [24], or intrathoracic blood volume index (ITBVI) [23]. In two trials hyperoncotic albumin infusions were used to potentiate diuresis in a deresuscitative group [17,18].…”

“…In two trials hyperoncotic albumin infusions were used to potentiate diuresis in a deresuscitative group [17,18]. Fluid strategies in study control arms included protocolised liberal fluid administration [16], protocolised diuretic use without hyperoncotic albumin [17] and central venous pressure (CVP) or pulmonary capillary wedge pressure (PCWP)-guided fluid administration [20,21,23,24].…”