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The clinical usefulness of extravascular lung water and pulmonary vascular permeability index to diagnose and characterize pulmonary edema: a prospective multicenter study on the quantitative differential diagnostic definition for acute lung injury/acute respiratory distress syndrome.

Kushimoto S, Taira Y, Kitazawa Y, Okuchi K, Sakamoto T, Ishikura H, Endo T, Yamanouchi S, Tagami T, Yamaguchi J, Yoshikawa K, Sugita M, Kase Y, Kanemura T, Takahashi H, Kuroki Y, Izumino H, Rinka H, Seo R, Takatori M, Kaneko T, Nakamura T, Irahara T, Saito N, Watanabe A, PiCCO Pulmonary Edema Study Gro - Crit Care (2012)

Bottom Line: The extravascular lung water index (EVLWI) and the pulmonary vascular permeability index (PVPI) were measured using the transpulmonary thermodilution method in 266 patients with PaO2/FiO2 ratio ≤ 300 mmHg and bilateral infiltration on chest radiography, in 23 ICUs of academic tertiary referral hospitals.Pulmonary edema was defined as EVLWI ≥ 10 ml/kg.UMIN-CTR ID UMIN000003627.

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is characterized by features other than increased pulmonary vascular permeability. Pulmonary vascular permeability combined with increased extravascular lung water content has been considered a quantitative diagnostic criterion of ALI/ARDS. This prospective, multi-institutional, observational study aimed to clarify the clinical pathophysiological features of ALI/ARDS and establish its quantitative diagnostic criteria.

Methods: The extravascular lung water index (EVLWI) and the pulmonary vascular permeability index (PVPI) were measured using the transpulmonary thermodilution method in 266 patients with PaO2/FiO2 ratio ≤ 300 mmHg and bilateral infiltration on chest radiography, in 23 ICUs of academic tertiary referral hospitals. Pulmonary edema was defined as EVLWI ≥ 10 ml/kg. Three experts retrospectively determined the pathophysiological features of respiratory insufficiency by considering the patients' history, clinical presentation, chest computed tomography and radiography, echocardiography, EVLWI and brain natriuretic peptide level, and the time course of all preceding findings under systemic and respiratory therapy.

Results: Patients were divided into the following three categories on the basis of the pathophysiological diagnostic differentiation of respiratory insufficiency: ALI/ARDS, cardiogenic edema, and pleural effusion with atelectasis, which were noted in 207 patients, 26 patients, and 33 patients, respectively. EVLWI was greater in ALI/ARDS and cardiogenic edema patients than in patients with pleural effusion with atelectasis (18.5 ± 6.8, 14.4 ± 4.0, and 8.3 ± 2.1, respectively; P < 0.01). PVPI was higher in ALI/ARDS patients than in cardiogenic edema or pleural effusion with atelectasis patients (3.2 ± 1.4, 2.0 ± 0.8, and 1.6 ± 0.5; P < 0.01). In ALI/ARDS patients, EVLWI increased with increasing pulmonary vascular permeability (r = 0.729, P < 0.01) and was weakly correlated with intrathoracic blood volume (r = 0.236, P < 0.01). EVLWI was weakly correlated with the PaO2/FiO2 ratio in the ALI/ARDS and cardiogenic edema patients. A PVPI value of 2.6 to 2.85 provided a definitive diagnosis of ALI/ARDS (specificity, 0.90 to 0.95), and a value < 1.7 ruled out an ALI/ARDS diagnosis (specificity, 0.95).

Conclusion: PVPI may be a useful quantitative diagnostic tool for ARDS in patients with hypoxemic respiratory failure and radiographic infiltrates.

Trial registration: UMIN-CTR ID UMIN000003627.

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Comparison of pulmonary vascular permeability index. Comparison of pulmonary vascular permeability index (PVPI) of patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), cardiogenic edema, and pleural effusion with atelectasis on the day of enrollment and the maximal value during the study period. (A) PVPI was higher in ALI/ARDS patients than in cardiogenic edema and pleural effusion with atelectasis patients. There was no difference in the index between cardiogenic edema and pleural effusion with atelectasis patients. (B) Differences were found when the maximal index value was compared between day 0 and day 2. Data presented as median (interquartile range). *P < 0.01 vs. pleural effusion with atelectasis and cardiogenic edema. PVPI-0, pulmonary vascular permeability index on the day of enrollment; maxPVPI, maximal value of pulmonary vascular permeability index from days 0 to 2.
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Figure 3: Comparison of pulmonary vascular permeability index. Comparison of pulmonary vascular permeability index (PVPI) of patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), cardiogenic edema, and pleural effusion with atelectasis on the day of enrollment and the maximal value during the study period. (A) PVPI was higher in ALI/ARDS patients than in cardiogenic edema and pleural effusion with atelectasis patients. There was no difference in the index between cardiogenic edema and pleural effusion with atelectasis patients. (B) Differences were found when the maximal index value was compared between day 0 and day 2. Data presented as median (interquartile range). *P < 0.01 vs. pleural effusion with atelectasis and cardiogenic edema. PVPI-0, pulmonary vascular permeability index on the day of enrollment; maxPVPI, maximal value of pulmonary vascular permeability index from days 0 to 2.

Mentions: The EVLWI on the day of enrollment was significantly higher in ALI/ARDS patients than in patients with pleural effusion with atelectasis (18.5 ± 6.8 vs. 8.3 ± 2.1; P < 0.01) or cardiogenic edema (14.4 ± 4.0; P < 0.01) (Figure 2). The PVPI on the day of enrollment was higher in the ALI/ARDS patients than in cardiogenic edema or pleural effusion with atelectasis patients (3.2 ± 1.4, 2.0 ± 0.8, and 1.6 ± 0.5, respectively). Although the EVLWI was higher in the cardiogenic edema than in pleural effusion with atelectasis patient (Figure 2), there was no significant difference in PVPI between those groups (Figure 3).


The clinical usefulness of extravascular lung water and pulmonary vascular permeability index to diagnose and characterize pulmonary edema: a prospective multicenter study on the quantitative differential diagnostic definition for acute lung injury/acute respiratory distress syndrome.

Kushimoto S, Taira Y, Kitazawa Y, Okuchi K, Sakamoto T, Ishikura H, Endo T, Yamanouchi S, Tagami T, Yamaguchi J, Yoshikawa K, Sugita M, Kase Y, Kanemura T, Takahashi H, Kuroki Y, Izumino H, Rinka H, Seo R, Takatori M, Kaneko T, Nakamura T, Irahara T, Saito N, Watanabe A, PiCCO Pulmonary Edema Study Gro - Crit Care (2012)

Comparison of pulmonary vascular permeability index. Comparison of pulmonary vascular permeability index (PVPI) of patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), cardiogenic edema, and pleural effusion with atelectasis on the day of enrollment and the maximal value during the study period. (A) PVPI was higher in ALI/ARDS patients than in cardiogenic edema and pleural effusion with atelectasis patients. There was no difference in the index between cardiogenic edema and pleural effusion with atelectasis patients. (B) Differences were found when the maximal index value was compared between day 0 and day 2. Data presented as median (interquartile range). *P < 0.01 vs. pleural effusion with atelectasis and cardiogenic edema. PVPI-0, pulmonary vascular permeability index on the day of enrollment; maxPVPI, maximal value of pulmonary vascular permeability index from days 0 to 2.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3672621&req=5

Figure 3: Comparison of pulmonary vascular permeability index. Comparison of pulmonary vascular permeability index (PVPI) of patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), cardiogenic edema, and pleural effusion with atelectasis on the day of enrollment and the maximal value during the study period. (A) PVPI was higher in ALI/ARDS patients than in cardiogenic edema and pleural effusion with atelectasis patients. There was no difference in the index between cardiogenic edema and pleural effusion with atelectasis patients. (B) Differences were found when the maximal index value was compared between day 0 and day 2. Data presented as median (interquartile range). *P < 0.01 vs. pleural effusion with atelectasis and cardiogenic edema. PVPI-0, pulmonary vascular permeability index on the day of enrollment; maxPVPI, maximal value of pulmonary vascular permeability index from days 0 to 2.
Mentions: The EVLWI on the day of enrollment was significantly higher in ALI/ARDS patients than in patients with pleural effusion with atelectasis (18.5 ± 6.8 vs. 8.3 ± 2.1; P < 0.01) or cardiogenic edema (14.4 ± 4.0; P < 0.01) (Figure 2). The PVPI on the day of enrollment was higher in the ALI/ARDS patients than in cardiogenic edema or pleural effusion with atelectasis patients (3.2 ± 1.4, 2.0 ± 0.8, and 1.6 ± 0.5, respectively). Although the EVLWI was higher in the cardiogenic edema than in pleural effusion with atelectasis patient (Figure 2), there was no significant difference in PVPI between those groups (Figure 3).

Bottom Line: The extravascular lung water index (EVLWI) and the pulmonary vascular permeability index (PVPI) were measured using the transpulmonary thermodilution method in 266 patients with PaO2/FiO2 ratio ≤ 300 mmHg and bilateral infiltration on chest radiography, in 23 ICUs of academic tertiary referral hospitals.Pulmonary edema was defined as EVLWI ≥ 10 ml/kg.UMIN-CTR ID UMIN000003627.

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is characterized by features other than increased pulmonary vascular permeability. Pulmonary vascular permeability combined with increased extravascular lung water content has been considered a quantitative diagnostic criterion of ALI/ARDS. This prospective, multi-institutional, observational study aimed to clarify the clinical pathophysiological features of ALI/ARDS and establish its quantitative diagnostic criteria.

Methods: The extravascular lung water index (EVLWI) and the pulmonary vascular permeability index (PVPI) were measured using the transpulmonary thermodilution method in 266 patients with PaO2/FiO2 ratio ≤ 300 mmHg and bilateral infiltration on chest radiography, in 23 ICUs of academic tertiary referral hospitals. Pulmonary edema was defined as EVLWI ≥ 10 ml/kg. Three experts retrospectively determined the pathophysiological features of respiratory insufficiency by considering the patients' history, clinical presentation, chest computed tomography and radiography, echocardiography, EVLWI and brain natriuretic peptide level, and the time course of all preceding findings under systemic and respiratory therapy.

Results: Patients were divided into the following three categories on the basis of the pathophysiological diagnostic differentiation of respiratory insufficiency: ALI/ARDS, cardiogenic edema, and pleural effusion with atelectasis, which were noted in 207 patients, 26 patients, and 33 patients, respectively. EVLWI was greater in ALI/ARDS and cardiogenic edema patients than in patients with pleural effusion with atelectasis (18.5 ± 6.8, 14.4 ± 4.0, and 8.3 ± 2.1, respectively; P < 0.01). PVPI was higher in ALI/ARDS patients than in cardiogenic edema or pleural effusion with atelectasis patients (3.2 ± 1.4, 2.0 ± 0.8, and 1.6 ± 0.5; P < 0.01). In ALI/ARDS patients, EVLWI increased with increasing pulmonary vascular permeability (r = 0.729, P < 0.01) and was weakly correlated with intrathoracic blood volume (r = 0.236, P < 0.01). EVLWI was weakly correlated with the PaO2/FiO2 ratio in the ALI/ARDS and cardiogenic edema patients. A PVPI value of 2.6 to 2.85 provided a definitive diagnosis of ALI/ARDS (specificity, 0.90 to 0.95), and a value < 1.7 ruled out an ALI/ARDS diagnosis (specificity, 0.95).

Conclusion: PVPI may be a useful quantitative diagnostic tool for ARDS in patients with hypoxemic respiratory failure and radiographic infiltrates.

Trial registration: UMIN-CTR ID UMIN000003627.

Show MeSH
Related in: MedlinePlus