How can the response to volume expansion in patients with spontaneous respiratory movements be predicted?

Sarah Heenen, Daniel De Backer, Jean-Louis Vincent, Sarah Heenen, Daniel De Backer, Jean-Louis Vincent

Abstract

Introduction: The aim of the study was to evaluate the ability of different static and dynamic measurements of preload to predict fluid responsiveness in patients with spontaneous respiratory movements.

Methods: The subjects were 21 critically ill patients with spontaneous breathing movements receiving mechanical ventilation with pressure support mode (n = 9) or breathing through a face mask (n = 12), and who required a fluid challenge. Complete hemodynamic measurements, including pulmonary artery occluded pressure (PAOP), right atrial pressure (RAP), pulse pressure variation (DeltaPP) and inspiratory variation in RAP were obtained before and after fluid challenge. Fluid challenge consisted of boluses of either crystalloid or colloid until cardiac output reached a plateau. Receiver operating characteristics (ROC) curve analysis was used to evaluate the predictive value of the indices to the response to fluids, as defined by an increase in cardiac index of 15% or more.

Results: Cardiac index increased from 3.0 (2.3 to 3.5) to 3.5 (3.0 to 3.9) l minute-1 m-2 (medians and 25th and 75th centiles), p < 0.05. At baseline, DeltaPP varied between 0% and 49%. There were no significant differences in DeltaPP, PAOP, RAP and inspiratory variation in RAP between fluid responders and non-responders. Fluid responsiveness was predicted better with static indices (ROC curve area +/- SD: 0.73 +/- 0.13 for PAOP, p < 0.05 vs DeltaPP and 0.69 +/- 0.12 for RAP, p = 0.054 compared with DeltaPP) than with dynamic indices of preload (0.40 +/- 0.13 for DeltaPP and 0.53 +/- 0.13 for inspiratory changes in RAP, p not significant compared with DeltaPP).

Conclusion: In patients with spontaneous respiratory movements, DeltaPP and inspiratory changes in RAP failed to predict the response to volume expansion.

Figures

Figure 1
Figure 1
Relation between the ΔPP and the maximal ΔCI after volume expansion. This relationship was not significant (R2 = 0.02, p = 0.94). Diamonds, patients breathing through a face mask; squares, patients receiving pressure support ventilation. ΔCI, change in cardiac index; ΔPP, pulse pressure variation.
Figure 2
Figure 2
Relation between PAOP at baseline and maximal ΔCI during volume expansion. ΔCI, change in cardiac index; PAOP, pulmonary artery occluded pressure.
Figure 3
Figure 3
Relation between RAP at baseline and maximal ΔCI during volume expansion. ΔCI, change in cardiac index; RAP, right atrial pressure.
Figure 4
Figure 4
Relation between ΔRAP at baseline and maximal ΔCI during volume expansion. ΔCI, change in cardiac index; ΔRAP, respiratory variation in right atrial pressure.
Figure 5
Figure 5
Prediction of fluid responsiveness by ΔPP, PAOPee, RAPee and ΔRAP. The receiver operating characteristics (ROC) curve area was significantly larger for pulmonary artery occluded pressure at end-expiration (PAOPee) than for pulse pressure variation (ΔPP; p < 0.05). ΔRAP, inspiratory variation in RAP; RAPee, right atrial pressure at end-expiration.
Figure 6
Figure 6
Relationship between right atrial pressure (RAP) and the likelihood of responding to fluid challenge.

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