CE: C.D.

; MCC/240311; Total nos of Pages: 5;

MCC 240311

REVIEW

CURRENT
OPINION The pulmonary artery catheter: is it still alive?
Daniel De Backer a and Jean-Louis Vincent b

Purpose of review
The present review discusses the current role of the pulmonary artery catheter (PAC) in the hemodynamic
monitoring of critically ill patients.
Recent findings
The PAC has an important role in the characterization and management of hemodynamic alterations in
critically ill patients. Use of the PAC has decreased in the last 30 years because of recent advances in less
invasive hemodynamic monitoring techniques, in particular transpulmonary thermodilution and
echocardiography, combined with the publication of the results of several randomized trials that failed to show
improvements in outcome with the use of the PAC in various settings. Although it is obvious that the PAC should
not be used in most critically ill patients, the PAC is still indicated in some patients with circulatory and/or
respiratory failure, especially when associated with pulmonary hypertension or left heart dysfunction. As for
any technique, optimal PAC use requires expertise in insertion, acquisition, and interpretation of measurements.
The decrease in use of the PAC may unfortunately limit exposure of junior doctors and nurses to this device, so
that they become less familiar with using the PAC, making it more complicated and less optimal.
Summary
The PAC still has an important role in the cardiopulmonary monitoring of critically ill patients.
Keywords
cardiac output, extravascular lung water, filling pressures, invasive monitoring, swan-Ganz catheter,
transpulmonary thermodilution

INTRODUCTION atrial pressure, and cardiac output. The mixed

Hemodynamic monitoring is an important process
that enables identification, characterization, and
orientation of therapeutic interventions in critically
ill patients. The pulmonary artery catheter (PAC)
was introduced in the 1970s and for a long time
remained the sole option for hemodynamic moni-
toring with arterial catheterization in the critically
ill patient. The PAC was widely used in the 1990s,
but its use then gradually decreased over time [1].
Some authors have demanded a moratorium for
PAC use [2] and others have even written an obitu-
ary [3], leading one to believe that the PAC is dead or
dying. However, there are still specific indications
for PAC use as it provides information that cannot
be obtained easily from other hemodynamic devi-
ces. In addition, recent data suggest that there may
be a revival in PAC use, at least in the United States
&&
[4 ]. In this article, we will review recent evidence
discussing the use of PAC in critically ill patients.
WHAT INFORMATION DOES THE
PULMONARY ARTERY CATHETER
PROVIDE?
The PAC enables measurement of pulmonary artery
pressure, pulmonary artery occlusion pressure, right
venous oxygen saturation (SvO2) can be measured
either intermittently by drawing blood samples or
continuously using a fiberoptic catheter. Finally,
some specific catheters can also measure right ven-
tricular volume (systolic and diastolic) and right
ventricular ejection fraction.
Hence, the PAC provides, in its most basic
form, information on blood flow and its adequacy
(cardiac output and SvO2), filling pressures of left
and right ventricles (pulmonary artery occlusion
pressure and right atrial pressure), and right
ventricular after load. Accordingly it is one of the
most integrative tools for evaluating cardiovascular
function.
a
Department of Intensive Care, CHIREC Hospitals and bDepartment of
Intensive Care, Erasme University Hospital, Université Libre de Bruxelles,
Brussels, Belgium
Correspondence to Daniel De Backer, MD, PhD, Department of Intensive
Care, CHIREC Hospitals, Boulevard du Triomphe 201, B-1160 Brus-
sels, Belgium. Tel: +32 2 434 9324; fax: +32 2 434 9312;
e-mail: ddebacke@ulb.ac.be
Curr Opin Crit Care 2018, 24:000–000
DOI:10.1097/MCC.0000000000000502

1070-5295 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: C.D.; MCC/240311; Total nos of Pages: 5;
MCC 240311
Cardiopulmonary monitoring
KEY POINTS
 PAC use has decreased over time, but there has been a
trend to a revival in use in recent years.
 The PAC still has a place in the monitoring of severely
ill patients with left and right cardiac impairment.
 Efforts should be made to maintain PAC expertise by
providing adequate training for nurses and doctors.
EVOLUTION IN PULMONARY ARTERY
CATHETER USE OVER TIME
The use of the PAC peaked in the early 1990s.
Analysis of large administrative databases in the
United States evaluating medical admissions from
1989 to 2004 revealed that a PAC was used in 6–7/
1000 medical hospital admissions in 1994 [1]. In
1984, 20% of the patients admitted to the ICU with
an acute myocardial infarction were equipped with
a PAC [5]. Admittedly these patients were severely
ill; 96% of those monitored with a PAC had acute
heart failure, hypotension or shock, and an overall
mortality of 45% [5]. The use of the PAC begun to
decrease after publication of observational data sug-
gesting an increased risk of death with PAC use in
patients with [5] and without [6] acute myocardial
infarction. These trials generated considerable
debate. Further observational trials did not confirm
the potential harmful effects of the PAC [7]. Several
randomized studies evaluating PAC use in different
settings showed no differences in outcome in
patients managed with or without a PAC [8]. These
results, showing potential harm and no benefit,
combined with the development of alternative tech-
niques of monitoring, led to a significant decrease in
use of the PAC.
By 2004, use of the PAC had decreased to 30% of
its use in 1994 [1]. This was confirmed in another
database including 108 000 patients in 23 US hos-
pitals, with a decrease in the number of patients in
whom a PAC was inserted in the ICU from 4.2% in
2001–2003 to 2.2% in 2006–2008 [9]. The use of a
PAC in such a minority of patients suggested that
the PAC would rapidly disappear from our monitor-
ing tools.
Surprisingly, however, there has been some
revival in PAC use in recent years. The use of PAC
was reported to be stable around 15% among Euro-
pean critically ill patients included in two cohorts in
2002 and 2012 [10]. In US patients admitted for
heart failure, PAC use increased from 5 to 8/1000
hospitalizations between 2006 and 2012, these rates
&&
reaching those observed in 2001 [11 ].
2 www.co-criticalcare.com
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IS IT SURPRISING TO OBSERVE A
REVIVAL IN PULMONARY ARTERY
CATHETER USE IN UNITED STATES AND
STABLE USE IN EUROPE DESPITE THE
NEGATIVE RESULTS OF THE RANDOMIZED
TRIALS?
&&
The publication of the results by Pandey et al. [11 ]
showing increasing use of the PAC generated com-
ments of surprise over this apparent revival in PAC
use despite the negative results of multiple random-
ized trials [12].
The revival in PAC use may be explained by several
factors. First, although these trials did not demonstrate
benefit with PAC use, they also failed to confirm the
potential risk suggested by the initial observational
data. Hence, PAC use can be considered as well toler-
ated, although clearly care must be taken to minimize
the potential risks associated with PAC use.
Second, these trials included only a selected
population of patients and the most severely ill were
often not included. Indeed, the rate of inclusion was
remarkably low in these trials Fluid and Catheter
Treatment Trial (FACTT) [13] 0.78 patients with
acute respiratory distress syndrome (ARDS)/center/
month; Richard et al. [14] 0.69 shock or ARDS
patients/center/month; Singer et al. [15] 0.42
ICUs/center/month). In addition, a PAC may have
already been inserted in the most severely ill
patients so that only less severely ill patients were
randomized. The FACTT trial randomized 1001
patients with ARDS to PAC vs. control, whereas
2186 patients were excluded because they already
had a PAC in situ [13]. In the Evaluation Study of
Congestive Heart Failure and Pulmonary Artery
Catheterization Effectiveness trial, 433 patients with
heart failure were included and mortality rates were
similar in patients managed with and without a PAC
[16]. However, in a later article, the investigators
reported the outcome of the 439 patients not
included in the trial [17]. The reasons evoked for
noninclusion were that the attending physicians
considered that 62% of the patients were too sick
to be randomized and that 40% needed a PAC.
Interestingly, the patients who were screened but
not randomized had a significantly higher morta-
lity than those enrolled in the trial (34 vs. 20%,
P < 0.001). These observations suggest that bedside
physicians preferred to continue to use the PAC in
the more severe patients, in whom they considered a
PAC was necessary. The combination of low inclu-
sion rates, exclusion of many patients because they
were already equipped with a PAC or because
of physician choice, and the higher severity of
illness of nonincluded patients indicates that the
investigators may in fact have randomized only the
Volume 24  Number 00  Month 2018
CE: C.D.; MCC/240311; Total nos of Pages: 5;
MCC 240311
patients for whom they considered that a PAC
would not make any difference. Accordingly, the
patients who potentially may have benefitted most
from a PAC were not included. Indeed, observa-
tional data suggest that the most severely ill may
benefit from PAC use. In a large database of 53 312
trauma patients stratified according to injury sever-
ity, monitoring with a PAC was associated with a
decrease in mortality only in the most severely ill
patients [18].
Third, alternative methods may not always pro-
vide enough information or may lack accuracy. A
variety of less invasive devices has been developed,
including pulse wave analysis, transpulmonary ther-
modilution, and echocardiography techniques.
Pulse wave analysis methods analyze the arterial
pulse waveform with dedicated software and derive
cardiac output from the results. These techniques
can be either calibrated (by transpulmonary ther-
&
modilution or lithium dilution) or not [19 ]. Most of
the noncalibrated techniques are sensitive to alter-
ations in vascular tone, and their reliability in
patients with shock has been questioned [20]; some
groups have derived specific analytic procedures to
try to take into account vascular tone [21,22]. The
major limitation of these noncalibrated methods
and of the lithium-calibrated method is that these
techniques usually provide minimal information
beyond cardiac output.
Transpulmonary thermodilution is an attractive
alternative because it provides, in addition to car-
diac output, measurements of global cardiac vol-
umes, extravascular lung water, and cardiac
function. Although in most cases PAC and trans-
pulmonary thermodilution would similarly help in
&
diagnosing the hemodynamic alterations [19 ,23], it
should be acknowledged that transpulmonary ther-
modilution cannot discriminate between right and
left heart dysfunction [23]. This was illustrated in a
randomized trial evaluating hemodynamic manage-
ment guided by PAC or transpulmonary thermodi-
lution in 120 patients with shock [24]. Although
ventilator-free days, length of stay, organ failure,
and 28-day mortality were similar in the whole
population with the two monitoring techniques,
in the nonseptic subgroup (this group mostly com-
prised patients with cardiogenic shock), transpul-
monary thermodilution-guided management was
associated with more days on mechanical ventila-
tion and longer ICU and hospital lengths of stay
than PAC-guided management (P ¼ 0.001). These
effects were not observed in the septic shock sub-
group. Hence, hemodynamic management can be
similarly guided by transpulmonary thermodilution
or PAC in most patients, but PAC may offer some
advantage when cardiac function is altered [25].
1070-5295 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The pulmonary artery catheter De Backer and Vincent
Echocardiography enables almost all variables
provided by the PAC to be obtained noninvasively,
except the SvO2, but central venous oxygen satura-
tion can be used as surrogate for SvO2. In addition,
echocardiography provides more insight into the
mechanisms of impaired cardiac function and is
thus an almost ideal substitute for the PAC [26].
Although the need for training is often cited as a
limitation to the use of echocardiography, courses
are increasingly available providing the means to
achieve the required level of expertise [27–29] so
that even advanced echocardiography is becoming
widely accessible. Perhaps the main limitations of
this technique are that it cannot be nurse driven
and that it is difficult to monitor several patients
simultaneously. Accordingly, current guidelines
recommend the use of a continuous monitoring
technique in addition to the echocardiographic
evaluation [30].
CAN WE CONSIDER A ‘NO MONITORING’
OPTION?
Perhaps one of the most challenging observations is
that in some cases no monitoring at all is used, even
when the hemodynamic status is not stable [31,32].
Because there has been no proof of benefit with the
use of the PAC [8] or alternative techniques [33] in
randomized trials, some clinicians elect to use no
hemodynamic monitoring at all.
Although this choice can be defended in less
severely ill patients, hemodynamic monitoring in
the most severe, more complex patients is likely to
provide important information that can help guide
therapeutic interventions.
WHAT ARE THE REMAINING INDICATIONS
FOR PULMONARY ARTERY CATHETER
USE?
A decision to inset a PAC should take into account
patient severity and need for additional informa-
tion. Although cardiac output can be measured
using different techniques, the choice of method
should be determined by the accuracy of the meas-
urements as well as by the additional variables that
can be collected (Table 1).
REMAINING CHALLENGE: AS LESS
PULMONARY ARTERY CATHETERS ARE
USED, HOW DO WE MAINTAIN
SUFFICIENT EXPERTISE IN ITS INSERTION
AND APPLICATIONS?
As the use of PACs has become less frequent, main-
taining adequate expertise in its use becomes
www.co-criticalcare.com 3
CE: C.D.; MCC/240311; Total nos of Pages: 5;
MCC 240311
Cardiopulmonary monitoring
Table 1. Suggested indications for the different monitoring techniques to measure cardiac output
Type of monitoring PWA noncalibrated
Reliability of -Modest for absolute values
measurements -Good for trending changes
in cardiac output
Additional Stroke volume variation
measurements
Ideal patient Less severely ill patient in whom
response to fluids is the most
important question
PWA, pulse wave analysis; TPD, transpulmonary thermodilution.
challenging. The problem may be less common in
ICUs admitting patients after cardiac surgery, who
are often still monitored with a PAC. In a survey of
critical care fellowship directors in the United States,
83% of the directors acknowledged a decrease in
PAC use in their program [34]. Half of the directors
declared that their fellows participate in less than 10
PAC insertion procedures during their fellowship.
Interpretation of data may also be problematic with
decreased PAC use, by nurses and doctors. In the
above mentioned survey [34], only 55% of the
fellowship directors considered training in data
interpretation adequate.
Hence, efforts should be made to maintain a
high level of expertise in PAC use. Training is of
paramount importance. Simulation may be useful to
compensate for the decrease in patients with a PAC.
CONCLUSION
Even though its use has markedly decreased over the
years, the PAC still has an important place in car-
diopulmonary monitoring of the critically ill
patient. In complex and severely ill patients, the
PAC can provide information that other monitoring
techniques do not offer. To maintain adequate
standards in PAC use, training in PAC insertion
and acquisition and interpretation of measurements
should continue to be provided to trainee intensiv-
ists and nurses, in patients as well as through simu-
lation. The selection of the optimal hemodynamic
monitoring technique should be guided by patient
condition and by the need for additional measure-
ments in the individual patient.
Acknowledgements
None.
Financial support and sponsorship
D.D.B. has received honoraria for lectures from Edwards
LifeSciences, Fresenius Kabi, Griffols.
4 www.co-criticalcare.com
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
PWA and TPD Pulmonary artery catheter
-Excellent for TPD Excellent
-PWA reliability decreases
with time after calibration
-Stroke volume variation -Pulmonary artery pressure
-volumetric measurements of preload -Pulmonary artery occlusion pressure
-Extravascular lung water -Mixed-venous O2 saturation
Complex patient without major Severely ill patient with marked
left or right cardiac dysfunction left or right cardiac dysfunction
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in
the United States, 1993–2004. JAMA 2007; 298:423–429.
2. Robin ED. Death by pulmonary artery flow-directed catheter. Time for a
moratorium? Chest 1987; 92:727–731.
3. Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive
Care 2013; 3:38.
4. Ikuta K, Wang Y, Robinson A, et al. National trends in use and outcomes of
&& pulmonary artery catheters among Medicare beneficiaries, 1999–2013.
JAMA Cardiol 2017; 2:908–913.
Analysis of a large database of Medicare patients. A cohort of 457 193 patients
hospitalized with heart failure admissions. Although PAC use decreased from
1999 to 2009, there was a rebound in use in PAC in 2009, with increase in use in
PAC from 2009 to 2013.
5. Gore JM, Goldberg RJ, Spodick DH, et al. A community-wide assessment of
the use of pulmonary artery catheters in patients with acute myocardial
infarction. Chest 1987; 92:721–727.
6. Connors AF, McCaffree DR, Gray BA. Evaluation of right-heart catheterization
in the critically ill patient without acute myocardial infarction. N Engl J Med
1983; 308:263–267.
7. Sakr Y, Vincent JL, Reinhart K, et al. Use of the pulmonary artery catheter is
not associated with worse outcome in the ICU. Chest 2005; 128:
2722–2731.
8. Rajaram SS, Desai NK, Kalra A, et al. Pulmonary artery catheters for adult
patients in intensive care. Cochrane Database Syst Rev 2013; (2):
CD003408.
9. Gershengorn HB, Wunsch H. Understanding changes in established prac-
tice: pulmonary artery catheter use in critically ill patients. Crit Care Med
2013; 41:2667–2676.
10. Vincent JL, Lefrant JY, Kotfis K, et al. Comparison of European ICU
patients in 2012 (ICON) versus 2002 (SOAP). Intensive Care Med
2018.
11. Pandey A, Khera R, Kumar N, et al. Use of pulmonary artery catheterization in
&& US patients with heart failure, 2001–2012. JAMA Intern Med 2016;
176:129–132.
Analysis of data from 15 786 patients hospitalized with acute heart failure in a large
US national database. Although PAC use decreased from 1999 to 2009, there
was a rebound in use in PAC in 2009, with increase in use in PAC from 2009 to
2013 The use of PAC initially decreased from 2001 to 2007 but subsequently
increased from 2007 to 2012.
12. Angus DC. Ongoing use of pulmonary artery catheters despite negative trial
findings. JAMA Intern Med 2016; 176:133–134.
13. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syn-
drome (ARDS) Clinical Trials Network. Wheeler AP, Bernard GR, Thompson
BT, et al. Pulmonary-artery versus central venous catheter to guide treatment
of acute lung injury. N Engl J Med 2006; 354:2213–2224.
Volume 24  Number 00  Month 2018
CE: C.D.; MCC/240311; Total nos of Pages: 5;
MCC 240311
14. Richard C, Warszawski J, Anguel N, et al. Early use of the pulmonary
artery catheter and outcomes in patients with shock and acute respiratory
distress syndrome: a randomized controlled trial. JAMA 2003; 290:
2713–2720.
15. Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effective-
ness of pulmonary artery catheters in management of patients in intensive care
(PAC-Man): a randomised controlled trial. Lancet 2005; 366:472–477.
16. Binanay C, Califf RM, Hasselblad V, et al., ESCAPE Investigators and
ESCAPE Study Coordinators. Evaluation study of congestive heart failure
and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA
2005; 294:1625–1633.
17. Allen LA, Rogers JG, Warnica JW, et al. High mortality without ESCAPE: the
registry of heart failure patients receiving pulmonary artery catheters without
randomization. J Card Fail 2008; 14:661–669.
18. Friese RS, Shafi S, Gentilello LM. Pulmonary artery catheter use is
associated with reduced mortality in severely injured patients: a National
Trauma Data Bank analysis of 53,312 patients. Crit Care Med 2006; 34:
1597–1601.
19. Teboul JL, Saugel B, Cecconi M, et al. Less invasive hemodynamic monitoring
& in critically ill patients. Intensive Care Med 2016; 42:1350–1359.
Interesting review written by a selected group of experts from the cardiovascular
section of the European Society of Intensive Care (ESICM).
20. Taton O, Fagnoul D, De Backer D, Vincent JL. Evaluation of cardiac output in
intensive care using a noninvasive arterial pulse contour technique (Nexfin1)
compared with echocardiography. Anaesthesia 2013; 68:917–923.
21. De Backer D, Marx G, Tan A, et al. Arterial pressure-based cardiac output
monitoring: a multicenter validation of the third-generation software in septic
patients. Intensive Care Med 2011; 37:233–240.
22. Scolletta S, Bodson L, Donadello K, et al. Assessment of left ventricular
function by pulse wave analysis in critically ill patients. Intensive Care Med
2013; 39:1025–1033.
1070-5295 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The pulmonary artery catheter De Backer and Vincent
23. De Backer D, Fagnoul D, Herpain A. The role of invasive techniques in
cardiopulmonary evaluation. Curr Opin Crit Care 2013; 19:228–233.
24. Trof RJ, Beishuizen A, Cornet AD, et al. Volume-limited versus pressure-
limited hemodynamic management in septic and nonseptic shock. Crit Care
Med 2012; 40:1177–1185.
25. Zhang Z, Lu B, Ni H, et al. Prediction of pulmonary edema by plasma protein
levels in patients with sepsis. J Crit Care 2012; 27:623–629.
26. Hemodynamic monitoring using echocardiography in the critically ill. Heidel-
berg Dordrecht London New York: Springer; 2011
27. International consensus statement on training standards for advanced critical
care echocardiography. Intensive Care Med 2014 May;40(5):654-66
28. Millington SJ, Goffi A, Arntfield RT. Critical care echocardiography: a certi-
fication pathway for advanced users. Can J Anaesth 2018; 65:345–349.
29. https://www.esicm.org/education/edec-2/. [Accessed 27 February 2018]
30. Cecconi M, De Backer D, Antonelli M, et al. Consensus on Circulatory Shock
and Hemodynamic Monitoring. Task Force of the European Society of
Intensive Care Medicine. Intensive Care Med 2014; 40:1795–1815.
31. Funcke S, Sander M, Goepfert MS, et al., ICU-CardioMan Investigators.
Practice of hemodynamic monitoring and management in German, Austrian,
and Swiss intensive care units: the multicenter cross-sectional ICU-Cardio-
Man Study. Ann Intensive Care 2016; 6:49.
32. Cecconi M, Hofer C, Teboul JL, et al., FENICE Investigators; ESICM Trial
Group. Fluid challenges in intensive care: the FENICE study: a global
inception cohort study. Intensive Care Med 2015; 41:1529–1537.
33. Takala J, Ruokonen E, Tenhunen JJ, et al. Early noninvasive cardiac output
monitoring in hemodynamically unstable intensive care patients: a multicenter
randomized controlled trial. Crit Care 2011; 15:R148.
34. Tukey MH, Wiener RS. The current state of fellowship training in pulmonary
artery catheter placement and data interpretation: a national survey of
pulmonary and critical care fellowship program directors. J Crit Care
2013; 28:857–861.
www.co-criticalcare.com 5