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Measurement of Extravascular Lung Water (EVLW) at the bedside
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Learning objectives
At the conclusion of this program, the participants will be able to:
a. Discuss the challenges of estimating lung water at the bedside
b. Identify key hemodynamic parameters to measure lung water and other cardiopulmonary variables
Measurement of Extravascular Lung Water (EVLW) at the bedside
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1. Is O2 supply sufficient?
2. Volume or catecholamines?
3. Pulmonary edema?
Key questions
Major challenges in critical care
?
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Fluids:
Pro : avoid/reduce hypovolemia, optimize preload (CO ↑?)
Con : volume overload (worsening pulmonary edema, decompensating heart)
Inotropes:
Pro : improve contractility
Con : increase oxygen consumption, provoke arrythmias
Diuretics:
Pro : avoid/reduce hypervolemia (CO ↑?)
Con : hypovolemia (impaired CO, impaired perfusion)
Vasopressors:
Pro : improve perfusion pressure
Con : increase afterload (CO ↓?)
Do nothing:
Pro : avoid wrong treatment
Con : avoid improved situation
Major challenges in critical care
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Fluid is a drug and can cause adverse reactions
Major challenges in critical care
Boulain T. and Cecconi M. Intensiv Care Med 2015. Mar, 41(3):544-6
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Volume responsiveness determination
Major challenges in critical care
Otto Frank
(1865-1944)
Ernest Henry Starling
(1866-1927)
∆V
∆V
∆V
∆SV
∆SV
Blood flow
(SV)
Volume overloadTarget zone
Cardiac preload (V)
Volume responsive
∆SV
Frank-Starling Mechanism
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• Only about 50% of hemodynamically unstable patients are
fluid responders
• This is a fundamental concept which is not widely
appreciated, and challenges the widely accepted notion that
fluid administration is the ‘cornerstone of resuscitation’
• Less than 40% of hypotensive patients with severe sepsis or
septic shock are ‘fluid responders’
Major challenges in critical care
PE Marik, X Monnet, JL Teboul, Hemodynamic parameters to guide fluid therapy, Ann Crit Care, 1 (2011), p. 1
RP Dellinger, JM Carlet, H Masur, et al., Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock Crit Care Med, 32 (2004), pp. 858–873
PiCCO technology and parameters
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The original PiCCO technology combines two methods
• Transpulmonary Thermodilution
AND
• Arterial Pulse Contour Analysis
PiCCO measurement principle
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PiCCO catheter placement
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PiCCO setup
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• Central venous indicator injection (a bolus of usually 15ml saline)
• Passage of the indicator through the left heart, the lungs and the right heart
• Detection of the dilution curve of the indicator usually in the femoral artery
• Dilution curve analysis to calculate cardiac output and volumetric parameters
• The cardiac output from thermodilution is used for the calibration of the Pulse Contour Analysis
Principle of transpulmonary thermodilution
Injection
PiCCO Catheter
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The shape of the thermodilution curve is strongly influenced by the amount of intra and extravascular volume ― the
larger the volume, the longer the passage time of the indicator and vice versa.
Determination of specific transit times of the thermal indicator enables quantification of specific volumes in the chest.
Assessment of intra-thoracic volumes
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Mean Transit time (MTt)
represents the time when half of the indicator passed the
detection point in the artery. It is determined from the
bisection of the area under the curve. It characterizes the
whole intra and extravascular volume in the cardio-
pulmonary systems including the right heart, the left heart
and the whole intra and extravascular volume in the lungs.
The multiplication of the mean transit time with Cardiac
Output represents the intrathoracic thermal volume (ITTV).
ITTV = CO x MTt
Transit time analysis
Newman EV et al. The dye dilution method for describing the central circulation. An analysis of factors shaping the time-concentration curves. Circulation 1951; Vol. IV (5): 735-746
Sakka SG et al. The transpulmonary thermodilution technique. J Clin Monit Comput 2012, DOI 10.1007/s10877-012-9378-5
MTt
Mean transit time
-T
t
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DSt
Downslope time
-T
t
Exponential downslope time (DSt)
represents the wash-out function of the indicator. It is
determined from the downslope part of the thermodilution
curve. It characterizes the volume of the largest mixing
chamber in a row of mixing chambers. In the cardio-
pulmonary systems this are the lungs.
The multiplication of the downslope time with Cardiac Output
represents the pulmonary thermal volume (PTV)
PTV = CO x DSt
Transit time analysis
Newman EV et al. The dye dilution method for describing the central circulation. An analysis of factors shaping the time-concentration curves. Circulation 1951; Vol. IV (5): 735-746
Sakka SG et al. The transpulmonary thermodilution technique. J Clin Monit Comput 2012, DOI 10.1007/s10877-012-9378-5
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PiCCO parameter overview
Thermodilution
(intermittent)
Pulse Contour Analysis
(continuous)
Flow Cardiac Index (CI) Pulse Continuous Cardiac Index (PCCI)
Stroke Volume Index (SVI)
Preload /
Volume responsiveness
Global End-diastolic Volume Index (GEDI)
Intrathoracic Blood Volume Index (ITBI)
Stroke Volume Variation (SVV)
Pulse Pressure Variation (PPV)
Afterload System Vascular Resistance Index (SVRI)
Contractility Global Ejection Fraction (GEF)
Cardiac Function Index (CFI)
Cardiac Power Index (CPI)
Organ Function Extravascular Lung Water Index (ELWI)
Pulmonary Capillary Permeability Index (PVPI)
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• Prediction of the response of blood flow to
volume loading
• Quantification of fluctuations in the arterial
pressure curve due to mechanical ventilation.
• Requirements:
- Controlled mechanical ventilation
- Tidal volume of ≥ 8 ml/kg predicted body
weight
- Sinus rhythm, no artifact on pressure curve
• Parameters:
- Stroke Volume Variation (SVV)
• Pulse Pressure Variation (PPV)
Volume responsiveness
Perel A et al. Respiratory variations in the arterial pressure during mechanical ventilation reflect volume status and fluid responsiveness. Intensive Care med 2014.
Blo
od
flo
w (
SV
)Cardiac preload (V)
Responsive
SVV > 10%
PPV > 10%
SVV 0-10%
PPV 0-10%
Non-responsive
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Definition Physiology Characteristics
• Extravascular Lung Water (EVLW) is
the interstitial, intracellular, alveolar
and lymphatic fluid in in the lungs,
outside the pulmonary vasculature
• By indexing EVLW to the predicted
body weight it becomes comparable
between individuals (ELWI)
• EVLW is controlled by the lymphatic
drainage system of the lung to
protect alveoli from fluids
• EVLW can change as result of
pressure changes in the lung or
increased permeability of the
alveo-locapillary barrier
• Reported normal value of ELWI
<10 ml/kg
• Predictor of mortality in severe
sepsis, ARDS, burned patients and
critically ill patients 5,6,11,12
• Marker for pulmonary edema
(indicates the severity of the
pulmonary leak)
•
PiCCO therapeutic approach
Extravascular Lung Water (ELWI)
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? ? ?
• Quantification of the intracellular, interstitial and intra-alveolar water content of the lungs (not pleural effusion)
• Direct and easy bedside measurement and tracking of pulmonary edema in contrast to the estimation by chest x-ray
Extravascular Lung Water Index (ELWI)
ELWI = 8 ml/kg
No pulmonary edema
ELWI = 14 ml/kg
Moderate pulmonary edema
ELWI = 19 ml/kg
Sever pulmonary edema
Lemson J et al. Eexsetarrcah vascular lung water index measurement in critically ill children does not correlate with a chest x-ray score of pulmonary edema. Critical Care 2010, 14:R105.
Saugel B et al. Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary thermodilution–derived hemodynamic parameters in critically ill patients: A prospective
trial. J Crit Care 2010; 2011 26(4):402-10.
Organ function
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From the subtraction of the Pulmonary Thermal
Volume (PTV) from the Intrathoracic Thermal
Volume (ITTV) the Global End-Diastolic Volume
(GEDV) is derived, which represents the end-
diastolic filling volume of all four heart chambers.
Quantification of the preload volume
Baudendistel LJ et al. Evaluation of Extravascular Lung Water by single thermal indicator. Crit Care Med 14(1): 52-56.
Sakka S et al. Assessment of cardiac preload and Extravascular Lung Water by single transpulmonary thermodilution. Intensive Care Med 2000; 26(2): 180-187.
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• Pulmonary edema or Extravascular
Lung Water (EVLW) is the difference
between Intrathoracic Thermal
Volume (ITTV) and Intrathoracic
Blood Volume (ITBV).
• ITBV is the blood volume in the
heart plus the Pulmonary Blood
Volume (PBV).
• It has been found that ITBV is
consistently 25% bigger than GEDV
(ITBV = GEDV x 1.25).
Quantification of pulmonary edema
Baudendistel LJ et al. Evaluation of Extravascular Lung Water by single thermal indicator. Crit Care Med 14(1): 52-56.
Sakka S et al. Assessment of cardiac preload and Extravascular Lung Water by single transpulmonary thermodilution. Intensive Care Med 2000; 26(2): 180-187.
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Conclusions: Perioperative Extravascular Lung Water indexed to
predicted body weight is an early marker that predicts risk of clinically
significant postoperative pulmonary edema in at-risk surgical patients.
Pulmonary vascular permeability index effectively discriminated
postoperative acute respiratory distress syndrome from cardiogenic
pulmonary edema. These measures will aid in the early detection of
subclinical lung injury in at-risk surgical populations.
(Crit Care Med 2015; 43:665–673)
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The accuracy of the measurement of Extravascular Lung Water index (ELWI) by PiCCO has been demonstrated in
several experimental and clinical studies. All of them showed close agreement between the PiCCO ELWI and
gravimetric values or lung weight.
Validation of the PiCCO lung water measurement
Kuzkov VV et al. Extravascular lung water after neumonectomy
and one-lung ventilation in sheep. Crit Care Med 2007, 35(6):
1550-1559.
Tagami T et al. Validation of Extravascular Lung Water
measurement by single transpulmonary thermodilution:
human autopsy study. Crit Care 2010, 14(5): R162.
Katzenelson R et al. Accuracy of transpulmonary
thermodilution versus gravimetric measurement of
extravascular lung water. Crit Care Med 2004, 32(7):
1550-1554.
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Quantification of pulmonary edema = Pulmonary Vascular Permeability Index (PVPI)
The PVPI can help to distinguish between cardiogenic and permeability caused pulmonary edema.
The equations for the calculated parameter:
PVPI = EVLW / PBV
where PVPI = Pulmonary Vascular Permeability Index (no unit)
EVLW = Extravascular Lung Water (ml)
PBV = Pulmonary Blood Volume (ml) (ITBV - GEDV)
Pulmonary Vascular Permeability Index (PVPI)
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Two main types of pulmonary edema
Pulmonary Vascular Permeability Index (PVPI)
• PVPI is able to differentiate the diagnosis
of cardiogenic pulmonary edema vs
permeability pulmonary edema
• Cardiogenic pulmonary edema a
negative fluid balance is sought, while in
permeability pulmonary edema treating
the cause of inflammation is the priority
• PVPI value in the range of 1 to 3 points
to cardiogenic pulmonary edema and
PVPI greater than 3 suggests a
permeability pulmonary edema.
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PVPI* – Pulmonary Vascular Permeability Index
• PVPI represents the ratio between Extravascular Lung
Water (EVLW) and Pulmonary Blood Volume (PBV)
• In case of increased lung water, it enables differentiation
between:
Cardiogenic pulmonary edema (fluid overloading,
cardiac insufficiency)
Permeability pulmonary edema (sepsis, inflammatory
response, ARDS)
Organ function
Pulmonary Vascular Permeability Index (PVPI)
Monnet X et al. Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS. Intensive Care Med 2007.
Kushimoto S et al. 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. Crit Care 2011; 16(6): R232.
Kor DJ et al. Extravascular lung water and pulmonary vascular permeability index as markers predictive of postoperative acute respiratory distress syndrome: A prospective cohort investigation. Crit Care Med 2014;
43(3): 665-73.
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A clear normal range is available for all PiCCO parameters. Based on the measured values, the decision about the
most appropriate individual and goal directed therapy can be done faster and easier.
PiCCO supports therapeutic decision finding
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PiCCO helps provide a complete picture of the
patients hemodynamic situation and can help
determine hemodynamic instability, unclear
volume status and therapeutic conflicts in
intensive care patients. Those situations are usually
present in:
• Septic shock
• ARDS (acute lung failure)
• Cardiogenic shock
• Severe burn injury
• Multiple trauma (hypovolemic shock)
• Subarachnoid Hemorrhage (SAH)
• Pediatric intensive care
PiCCO applications
Clinical studies
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Includes:
• Goal-directed hemodynamic therapy in patients with cardiac surgery
Findings:
• Early goal-directed hemodynamic therapy based on cardiac index, stroke volume
variation, and optimised global end-diastolic volume index reduces complications and
length of ICU stay after cardiac surgery
Goepfert, et al. 2013
Cardiac Surgery
Goepfert M, Prichter HP, Eulenburg C, et al. Individually Optimized Hemodynamic Therapy Reduces Complications and Length of Stay in the Intensive Care Unit. Anesthesiology 2013; 119:824-36
Most
important
PiCCO
outcome
study!
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Includes:
• 29 intensive care patients with, or at risk of developing, Acute Lung Injury (ALI)
Finding:
• EVLWI predicts progression to ALI in patients with risk factors for development of acute
lung injury 2.6 +/- 0.3 days before the patients meet American European Consensus
Committee criteria for it. These 2.6 days may then represent missed opportunity for
therapeutic intervention and improved outcome.
LeTourneau, et al. 2012 — USA
Important publications — PiCCO
LeTourneau JL, Pinney J, Phillips CR. Extravascular lung water predicts progression to acute lung injury in patients with increased risk. Crit Care Med 2012; 40(3): 947-54
Benefit of
measuring
ELWI in
ARDS
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Includes:
• 200 pts with Acute Respiratory Distress Syndrome monitored with PiCCO
• Extravascular Lung Water Index and Pulmonary Vascular Permeability Index recorded
during the Acute Respiratory Distress Syndrome (ARDS) episode
Findings:
• Mortality rate was 70% in pts with a maximum ELWI >21mL/kg
• ELWI and PVPI are independent risk factors of day-28 mortality in patients with ARDS
Jozwiak, et al. 2013 — France
Important publications — PiCCO
Jozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, Teboul JL, Monnet X. Extravascular lung water is and independent prognostic factor in patients with acute respiratory distress syndrome.
CCM 2013. Feb; 41(2): 472-80
ELWI
predicts
outcome in
ARDS
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Benefits of monitoring in the ICUCardiogenic Shock
6
A
u
g
u
s
t
2
0
2
0
P
a
g
e
3
4
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• High or low preload?
• Is the patient volume responsive?
(Does an increase in preload lead to a higher CO)?
• High or low afterload?
• High or low contractility?
…to learn about therapeutic options!
Some questions of interest
Vasopressors? Vasodilators? Fluids? Inotropes?
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1. Insufficient preload volume is treated with volume
administration
2. Optimizing preload may increase CO to a maximum
3. Further volume administration beyond this point will
not improve CO but increase Lung Water
The role of EVLW
7
CO
EVLW
3
5
3
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Fluids — when to start — when to stop
When to stop giving fluids?
When to start giving fluids?
SVV/PPV high, GEDI low
ELWI increasing with fluids
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Cardiac Index / Output (O2 Delivery) determinants
O2 Delivery
DO2
Stroke Volume
Lung Water
ELWI
Gas exchange?
SaO2
O2 Transport?
Hb
Flow?
CO/CI
Afterload
HR
Preload Contractility
X
!
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• 65-year-old male
• After Christmas party sudden chest pain and weakness
• Smoker (40 cig/d)
• 178 cm (5′ 10″), 92 kg (202 lbs.)
• BP 130/80, HR 100
• No peripheral edema
• Reduced general health
Case study I cardiogenic shock
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Revascularization
Next step
Coronary angiography with PTCA
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• HR = 106
• MAP = 63 mmHg
• CVP = 10 mmHg
• ScvO2 = 57%
Still in cardiogenic shock...
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MAP 63 mmHg : Vasopressors?
HR 106/min : Fluids? No inotropes?
CVP 10 mmHg : No fluids?
ScvO2 57% : Inotropes?
Chest X-Ray : Normal heart size, congestion? pleural effusion ?
-> No fluids? Diuresis?
Auscultation : Moderate crackles (signs of pulmonary edema?)
-> No fluids?/ Diuresis?
Our information so far...
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Fluids:
Pro: avoid/reduce hypovolemia, optimize preload (CO ↑?)
Con: volume overload (worsening pulmonary edema, decompensating heart)
Inotropes:
Pro: improve contractility
Con: increase oxygen consumption, provoke arrythmias
Diuretics:
Pro: avoid/reduce hypervolemia (CO ↑?)
Con: hypovolemia (impaired CO, impaired perfusion)
Vasopressors:
Pro: improve perfusion pressure
Con: increase afterload (CO ↓?)
Do nothing:
Pro: avoid wrong treatment
Con: avoid improved situation
What to do next
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PiCCO measurement
CI SVRI ELWI GEDI ScvO2 CFI
1.6 2700 8 610 57 3.1
CI
ScvO2
GEDI
ELWI
CFI
Blood flow
(+ Hb 11.5 g/dl, SpO2 98%) -> blood flow inadequate
low preload
no pulmonary edema
low contractility
-> fluids-> fluids safe
-> inotropes
-> low
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Benefits of monitoring in the ICUCardiogenic Shock
Sepsis (ARDS)
6
A
u
g
u
s
t
2
0
2
0
P
a
g
e
4
5
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• Antibiotics
• 4 liters of crystalloid
• Brief period of norepinephrine
A 65-yr-old man with gram negative sepsis
Case study II septic shock (ARDS)
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Case study II septic shock (ARDS)
Blood Pressure 82/45
Heart Rate 132
CVP 8 to 15 mmHg
ScvO2 68%
Urine Output 0ml/hour
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Case study II septic shock (ARDS)
Cardiac Index 6.5 L/min/m2
GEDI 1200 ml/m2
PPV 10%
EVLWI 11ml/kg
Septic but with adequate preload and CI
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Patient is “assumed” to be hypovolemic
and receives:
• 1 unit of PC (Hb~10.0)
• 1.5 L crystalloids
• 0.5 L of colloids
• Norepinephrine increased to a higher dose and
vasopressin added
73-yr-old woman, 36 h following aortic valve replacement. Patient becomes unstable.
Case study III septic shock (ARDS)
BP 85/60 mmHg
HR 120 bpm
CVP 8-10 mmHg
Lactate 6.8
Urine output 10 ml/h
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• Fluids?
• Inotropes?
• Vasopressors?
Patient is in a positive fluid balance of 12 liters from surgery. Received 6 liters in the last 14 hours!
Case study III septic shock (ARDS)
BP 94/50 mmHg
HR 110 bpm (a-fib)
CVP 11 mmHg
ScvO2 56%
Echo Not available
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Fluids?
Inotropes?
Vasopressors?
Case study III septic shock (ARDS)
CI 1.7 L/min/m2 LOW
GEDI 455 ml/m2 LOW
SVRI4600
dyn*s*cm-5 *m2 HIGH
EVLWI 6 ml/kg NORMAL
XX
!
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Case study III septic shock (ARDS)
CI 1.7 L/min/m2 2.4 L/min/m2
GEDI 455 ml/m2 580 ml/m2
SVRI4600
dyn*s*cm-5 *m2
3260
dyn*s*cm-5 *m2
EVLWI 6 ml/kg 6 ml/kg
Urine 20 ml/h 70 ml/h
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