Extravascular lung water measurements in acute respiratory distress syndrome: why, how, and when?

Takashi Tagami, Marcus Eng Hock Ong, Takashi Tagami, Marcus Eng Hock Ong

Abstract

Purpose of review: Increase in pulmonary vascular permeability accompanied with accumulation of excess extravascular lung water (EVLW) is the hallmark of acute respiratory distress syndrome (ARDS). Currently, EVLW and pulmonary vascular permeability index (PVPI) can be quantitatively measured using the transpulmonary thermodilution (TPTD) technique. We will clarify why, how, and when EVLW and PVPI measurements should be performed.

Recent findings: Although the Berlin criteria of ARDS are simple and widely used, several criticisms of them have been published. The last 2 decades have witnessed the introduction and evolution of the TPTD technique for measuring EVLW and PVPI. Several publications have recommended to evaluate EVLW and the PVPI during the treatment of critically ill patients. Accurate and objective diagnoses can be made for ARDS patients using EVLW and PVPI. EVLW more than 10 ml/kg is a reasonable criterion for pulmonary edema, and EVLW more than 15 ml/kg for a severe condition. In addition to EVLW more than 10 mL/kg, PVPI more than three suggests increased vascular permeability (i.e., ARDS), and PVPI less than 2 represent normal vascular permeability (i.e., cardiogenic pulmonary edema).

Summary: EVLW and PVPI measurement will open the door to future ARDS clinical practice and research, and have potential to be included in the future ARDS definition.

Figures

Box 1
Box 1
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FIGURE 1
FIGURE 1
Estimation of extravascular lung water and pulmonary permeability index by TPTD method. TPTD method requires the injection of a 15–20 ml bolus of cold (

FIGURE 2

Diagnostic framework for pulmonary edema.…

FIGURE 2

Diagnostic framework for pulmonary edema. Pulmonary edema: EVLW more than 10 ml/kg. Cardiogenic…

FIGURE 2
Diagnostic framework for pulmonary edema. Pulmonary edema: EVLW more than 10 ml/kg. Cardiogenic pulmonary edema: EVLW more than 10 ml/kg and PVPI less than 2.0. ARDS: EVLW more than 10 ml/kg and PVPI more than 3.0. Combined pulmonary edema (e.g., cardiogenic pulmonary edema, reduced cardiac function or fluid overload, and permeability lung injury secondary to the generation of inflammatory mediators): EVLW more than 10 ml/kg and PVPI of 2.0–3.0.
FIGURE 2
FIGURE 2
Diagnostic framework for pulmonary edema. Pulmonary edema: EVLW more than 10 ml/kg. Cardiogenic pulmonary edema: EVLW more than 10 ml/kg and PVPI less than 2.0. ARDS: EVLW more than 10 ml/kg and PVPI more than 3.0. Combined pulmonary edema (e.g., cardiogenic pulmonary edema, reduced cardiac function or fluid overload, and permeability lung injury secondary to the generation of inflammatory mediators): EVLW more than 10 ml/kg and PVPI of 2.0–3.0.

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Source: PubMed

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