Extravascular lung water is an independent prognostic factor in patients with acute respiratory distress syndrome*

Jozwiak, Mathieu; Silva, Serena; Persichini, Romain; Anguel, Nadia; Osman, David; Richard, Christian; Teboul, Jean‐Louis; Monnet, Xavier

doi:10.1097/ccm.0b013e31826ab377

Cited by 219 publications

(161 citation statements)

References 40 publications

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“…The clinical literature does not clearly differentiate between alveolar collapse [36,78], inflammation [85] and early vs. late increased water content [13,86] (details in [5]). More work has been devoted to alveolar collapse and the loss of respiratory muscle/diaphragmatic tone and position as opposed to increased lung water.…”

Section: Diffuse Vs Focal Ardsmentioning

confidence: 99%

“…Nevertheless, atelectasis is widely used in the ARDS literature. Condensation is presumably different from lung water accumulation [13]. Furthermore, compression and re-absorption atelectasis are different [80]: Table 6.…”

Section: Cardiac Functionmentioning

confidence: 99%

“…As a result, the alveoli are not adequately perfused (low CO: presumably capillary de-recruitment), the hypoxic vasoconstriction is impaired in the unventilated dependent areas: this is due to a massive loss of aeration, surfactant injury, or high permeability type edema (flooded alveoli with high water content up to pulmonary edema). Extravascular lung water is associated with an outcome independent of the P/F changes [13]. Circulatory optimization requires volume infusion to generate ventilatory stabilization in early ARDS, especially when septic shock is present.…”

Section: Cardiac Functionmentioning

confidence: 99%

“…Circulatory optimization requires volume infusion to generate ventilatory stabilization in early ARDS, especially when septic shock is present. As this review addresses only early ARDS, late ARDS in inflated patients [13,14] is not considered. Obviously, following the stabilization of the acute cardio-ventilatory distress, early extra renal replacement (EER) [24] or diuretics will lower the weight and/or extra vascular lung water towards normal levels.…”

Section: Cardiac Functionmentioning

confidence: 99%

“…PEEP ≥ 10− -24 cm H 2 O according to the NIH table; Table 4, part I) should be set early [8]. PEEP should be guided first by echocardiography [9], then, ideally by an esophageal catheter ("balloon") [10−12], or as a second-best by "trial" PEEP to minimize the effects of overdistension and PEEP (i.e., right ventricular (RV) failure, hypotension, positive fluid balance [13,14], and baro-trauma: Table 5, part I)]. ARDS is a very heterogeneous syndrome which combines an acute onset of cyanosis that is refractory to O 2, tachypnea, dyspnea/polypnea (i.e., increased ventilatory demands [15]), reduced compliance, diffuse alveolar infiltration (which becomes more or less severe as a function of the progression or regression of the disease) and an improvement with PEEP = 5−10 cm H 2 O [16].…”

mentioning

confidence: 99%

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Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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Severe acute respiratory distress syndrome (ARDS, PaO 2 /FiO 2 < 100 on PEEP ≥ 5 cm H 2 O) is treated using controlled mechanical ventilation (CMV), recently combined with muscle relaxation for 48 h and prone positioning. While the amplitude of tidal volume appears set £ 6 mL kg -1 , the level of positive end-expiratory pressure (PEEP) remains controversial. This overview summarizes several salient points, namely: a) ARDS is an oxygenation defect: consolidation/difuse alveolar damage is reversed by PEEP and/or prone positioning, at least during the early phase of ARDS b) ARDS is a dynamic disease and partially iatrogenic. This implies that the management of the ventilator may be a life-saver by reducing the duration of mechanical ventilation, or detrimental by extending this duration, leading into critical care-acquired diseases. Indeed, a high PEEP (10−24 cm H 2 O) appears to be a life-saver in the context of early severe diffuse ARDS; c) tidal volume and plateau pressure cannot be identical for all patients; d) the only remaining rationale for CMV and muscle relaxation is to suppress patient-ventilator asynchrony and to lower VO 2 , during the acute cardio-ventilatory distress. Therefore, in early severe diffuse ARDS, this review argues for a combination of a high PEEP (preferably titrated on transpulmonary pressure) with spontaneous ventilation + pressure support (or newer modes of ventilation). However, conditionalities are stringent: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone. As these propositions require evidence-based demonstration, the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation, and prone position.

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Section: Diffuse Vs Focal Ardsmentioning

confidence: 99%

Section: Cardiac Functionmentioning

confidence: 99%

Section: Cardiac Functionmentioning

confidence: 99%

Section: Cardiac Functionmentioning

confidence: 99%

mentioning

confidence: 99%

See 3 more Smart Citations

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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Diagnosis and Treatment of Acute Respiratory Distress Syndrome

Tagami

Sakka²,

Monnet

2018

JAMA

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Effect of Fluid Bolus Therapy on Extravascular Lung Water Measured by Lung Ultrasound in Children With a Presumptive Clinical Diagnosis of Sepsis

Long

O’Brien

Duke

et al. 2018

J of Ultrasound Medicine

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Objectives Fluid bolus therapy for the treatment of sepsis may lead to the accumulation of extravascular lung water (EVLW) and result in respiratory dysfunction. We aimed to assess changes in EVLW using lung ultrasound (US) in children with a presumptive clinical diagnosis of sepsis after fluid bolus therapy and correlate these changes with respiratory signs. Methods This work was a prospective observational study set in the emergency department of the Royal Children's Hospital. Children meeting international consensus criteria for sepsis receiving fluid bolus therapy were included. Respiratory signs were recorded, and lung US examinations were performed immediately before, 5 minutes after, and 60 minutes after fluid bolus therapy. A pediatric emergency physician blinded to the participants’ identities and timing of US calculated an EVLW score from lung US. Results—Fifty fluid boluses were recorded in 41 children. The lung US score (range, 0–8) increased over the study period: median, 1 (interquartile range, 0–2) before fluid bolus therapy, 1 (interquartile range, 0–3) 5 minutes after fluid bolus therapy, and 3 (interquartile range, 1–4) 60 minutes after fluid bolus therapy. Respiratory effort, but not the respiratory rate or the presence of rales, increased over the study period and was correlated with the lung US score (ρ = 0.33; P = .02). Conclusions Extravascular lung water as measured by lung US increased after fluid bolus therapy in septic children and was correlated with an increase in the respiratory distress score. The respiratory rate and the presence of rales did not change over the study period. The role of lung US for titrating fluid bolus therapy in sepsis warrants further investigation.

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Extravascular lung water is an independent prognostic factor in patients with acute respiratory distress syndrome*

Abstract: Extravascular lung water index and pulmonary vascular permeability index measured by transpulmonary thermodilution are independent risk factors of day-28 mortality in patients with acute respiratory distress syndrome.

Cited by 219 publications

References 40 publications

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Diagnosis and Treatment of Acute Respiratory Distress Syndrome

Effect of Fluid Bolus Therapy on Extravascular Lung Water Measured by Lung Ultrasound in Children With a Presumptive Clinical Diagnosis of Sepsis

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