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Pulmonary edema in hypovolemic patients: How can we predict it in clinical

practice?

Article  in  Critical Care Medicine · March 2012

DOI: 10.1097/CCM.0b013e31823b8937 · Source: PubMed

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Pulmonary edema in hypovolemic patients: How can we predict it
in clinical practice?*
C ritical states and perioperative
period often are accompanied
by severe shifts in fluid balance
requiring thorough volume
management and hemodynamic optimiza-
tion. However, a combination of hypovo-
lemia with lung edema hampers the ad-
equate fluid resuscitation and the
restoration of tissue perfusion. Several
studies demonstrate that restriction of fluid
therapy aiming to counteract organ edema
positively influences the course of illness
and improves cardiopulmonary function
and outcome in different categories of pa-
tients, including those with sepsis, acute
lung injury, cardiac comorbidities, and ma-
jor surgery (1– 4). However, these patients
require volume resuscitation to maintain
adequate oxygen transport and counteract
systemic inflammation (1, 4). Thus, the
maintenance of cardiac preload and vital
organ perfusion weighed against the dele-
terious effect of a worsening pulmonary
edema remains a challenging problem.
Consequently, reliable tools for monitoring
lung fluid balance and prediction of exces-
sive lung water accumulation are necessary
for modern intensive care.
This topic has been investigated in a
recent study published in Critical Care
Medicine by Dr. Aman and colleagues (5).
The authors have evaluated predictors of
pulmonary edema formation during fluid
loading in both septic and nonseptic crit-
ically ill hypovolemic patients. For diag-
nosis of pulmonary edema, Dr. Aman and
colleagues used the increase of extravas-
cular lung water (EVLW) ⱖ10% after
fluid load that has been observed in 13
(21%) of studied 63 patients. The severity
of pulmonary edema was measured by
thermo-dye transpulmonary dilution
*See also p. 793.
Key Words: extravascular lung water; hemody-
namics; hypovolemia; pulmonary edema; transpulmo-
nary thermodilution
Dr. Birov is a member of the Medical Advisory
Board of Pulsion Medical Systems.
Copyright © 2012 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0b013e31823b8937
994
technique that can serve as a “gold stan-
dard” for the estimation of lung water at
the bedside. Thus, in previous publica-
tions it has been shown that the content
of EVLW has a clear prognostic value in
critical care (6). To increase the validity
of the results, the EVLW was indexed for
predicted body weight, as suggested in a
recent article by Philips et al (7). Al-
though other authors suppose that the
key mechanisms for lung edema include
pulmonary hypertension and capillary
leak syndrome (8), Dr. Aman and col-
leagues hypothesized that an increase of
EVLW during fluid loading is associated
with a plateau in cardiac function and
pulmonary vascular filling, rather than
with changes in permeability, cardiac fill-
ing pressures, and oncotic pressure. This
hypothesis has been confirmed by the re-
sults of their study demonstrating that a
change in EVLW ⱖ10% was predicted by
both cardiac index and pulmonary blood
volume index at baseline, as well as by
change in cardiac index, change in pul-
monary blood volume index, and change
in PaO2/FIO2 ratio during fluid load inde-
pendent of the presence of sepsis, pulmo-
nary vascular permeability, and cardiac
filling pressures. In contrast to critically
ill with a change in EVLW ⬍10%, the
patients with development of pulmonary
edema did not respond to fluids by the
increase in cardiac index, and their pul-
monary blood volume index and oxygen-
ation have decreased.
The authors have suggested that their
observations may help to prevent pulmo-
nary edema formation during fluid load-
ing. In great part, I agree with this con-
clusion and congratulate Dr. Aman and
colleagues for a nicely performed work.
However, the studied topic requires fur-
ther investigation, and some questions in
this field are still remaining unanswered.
As the authors acknowledge, some limi-
tations of this study bear mention. In
addition to small size of the study, the
patient population is heterogeneous,
which does not allow the transference of
study findings to all critically ill. Notably,
the investigation does not include cardio-
surgical patients, thus its results should
be not extrapolated to this category of
patients who are at high risk for both
cardiogenic and noncardiogenic pulmo-
nary edema. The important limitation of
the study is also the definition of hypo-
volemia using central venous pressure
ⱕ12 mm Hg and pulmonary artery oc-
clusion pressure ⱕ10 mm Hg. In light of
the recent publications in this field (9),
these parameters should not be used
for the clinical decisions regarding vol-
ume management because of their poor
predictive role. As shown in Table 2 of the
article, despite low values of central ve-
nous pressure and pulmonary artery oc-
clusion pressure, the global end-diastolic
volume index measured in the study pa-
tients both in the groups with change in
EVLW ⬍10% and ⱖ10% (849 ⫾ 234
mL/m2 and 916 ⫾ 207 mL/m2, respec-
tively) did not show the evidence of hy-
povolemia at baseline, which reduces par-
tially the value of this investigation.
The thermo-dye dilution technique
used in the article for estimation of
EVLW is relatively time-consuming,
cumbersome, and expensive. For those
reasons, the method has been replaced in
clinical practice by single transpulmo-
nary thermodilution, which allows an op-
portunity both for EVLW measurements
validated in several studies (10 –12) and
for assessment of the dynamic parame-
ters of preload like pulse pressure and
stroke volume variations, which are more
sensitive predictors of fluid responsive-
ness compared with pressures (9, 13).
Thus, the measurement of dynamic pre-
load parameters for predicting response
of cardiac index on infusion therapy in
combination with assessment of EVLW
can be helpful to avoid excessive fluid
load and prevent the increase of EVLW in
potential nonresponders to fluids. In ad-
dition, it is important to mention that
different infusion solutions used by the
authors of this article have different ef-
fects on the lung fluid balance in different
categories of patients. In contrast to crys-
Crit Care Med 2012 Vol. 40, No. 3
talloids, the goal-directed fluid load by
colloids can decrease EVLW and improve
gas exchange in acute lung injury (14);
the effects of crystalloids on EVLW in
critically ill are also unequivocal (15).
Therefore, further search of the optimal
predictors of pulmonary edema and im-
plementation of the adequate therapeutic
algorithms aiming to reduce accumula-
tion of lung water should be continued.
Mikhail Y. Kirov, MD, PhD
Department of Anesthesiology
and Intensive Care Medicine
Northern State Medical
University
Arkhangelsk, Russian
Federation
Department of Anesthesiology
University Hospital of North
Norway
Department of Clinical
Medicine (Anesthesiology)
Faculty of Medicine
University of Tromsø
Tromsø, Norway
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Is lower mortality outcome and higher patient volume a genuine
clinical relationship or an application of coin-flip statistics?*
N ongamblers frequently look
dubiously at their gaming
counterparts, wondering
why they would engage in a
losing proposition. Obviously this la-
ment is not entirely true; otherwise,
casinos would have no patrons. More
likely, it is probable neither group fully
grasps that gambling is fundamentally a
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volving variations on the concepts as-
sociated with coin-flip variability: al-
*See also p. 800.
Key Words: care; critically ill; mechanical ventila-
tion; mortality outcome; volume-outcome analysis
The author has not disclosed any potential con-
flicts of interest.
Copyright © 2012 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0b013e31823e9528
Crit Care Med 2012 Vol. 40, No. 3
View publication stats
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though heads or tails have an equal
50% probability (and each flip is an
independent event), a wagering player
capitalizes on short-term variability (a
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Moran and colleagues (1) contribute a
study that challenges this evidence.
The argument that large patient vol-
umes generate better outcomes began
⬎30 yrs ago (2), but it has grown to near
axiomatic status more recently because of
the championing of evidence-based hos-
pital referral by the Leapfrog Group (3)
and the recommendations of others (4),
despite uncertainties regarding the mag-
nitude of the effect among individual pro-
cedures and conditions (5). Dr. Moran
and colleagues (1) add to this uncer-
tainty. In a statistically dense retrospec-
tive review of ⬎200,000 mechanically
ventilated patients admitted to 136 inten-
sive care units reporting to the Australian
and New Zealand Intensive Care Society
database from 1995 to 2009, the re-
searchers were unable to demonstrate
that greater patient volumes result in re-
995