Extravascular lung water in critical care: recent advances and clinical applications

Abstract

Extravascular lung water (EVLW) is the amount of fluid that is accumulated in the interstitial and alveolar spaces. In lung oedema, EVLW increases either because of increased lung permeability or because of increased hydrostatic pressure in the pulmonary capillaries, or both. Increased EVLW is always potentially life-threatening, mainly because it impairs gas exchange and reduces lung compliance. The only technique that provides an easy measurement of EVLW at the bedside is transpulmonary thermodilution. The validation of EVLW measurements by thermodilution was based on studies showing reasonable correlations with gravimetry or thermo-dye dilution in experimental and clinical studies. EVLW should be indexed to predicted body weight. This indexation reduces the proportion of ARDS patients for whom EVLW is in the normal range. Compared to non-indexed EVLW, indexed EVLW (EVLWI) is better correlated with the lung injury score and the oxygenation and it is a better predictor of mortality of patients with acute lung injury or acute respiratory distress syndrome (ARDS). Transpulmonary thermodilution also provides the pulmonary vascular permeability index (PVPI), which is an indirect reflection of the integrity of the alveolocapillary barrier. As clinical applications, EVLWI and PVPI may be useful to guide fluid management of patients at risk of fluid overload, as during septic shock and ARDS. High EVLWI and PVPI values predict mortality in several categories of critically ill patients, especially during ARDS. Thus, fluid administration should be limited when EVLWI is already high. Whatever the value of EVLWI, PVPI may indicate that fluid administration is particularly at risk of aggravating lung oedema. In the acute phase of haemodynamic resuscitation during septic shock and ARDS, high EVLWI and PVPI values may warn of the risk of fluid overload and prevent excessive volume expansion. At the post-resuscitation phase, they may prompt initiation of fluid removal thereby achieving a negative fluid balance.

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     Compton F, Hoffmann C, Zidek W, Schmidt S, Schaefer JH. Volumetric hemodynamic parameters to guide fluid removal on hemodialysis in the intensive care unit. Hemodial Int. 2007;11:231-237.

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     Teboul JL, Monnet X, Richard C. Weaning failure of cardiac origin: recent advances. Crit Care. 2010;14:211.

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     Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care. 2013;3:38.

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     Dres M, Teboul JL, Anguel N, Guerin L, Richard C, Monnet X. Extravascular lung water, B-type natriuretic peptide, and blood volume contraction enable diagnosis of weaning-induced pulmonary edema. Crit Care Med. 2014;42:1882-1889.

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     Teboul JL. Weaning-induced cardiac dysfunction: where are we today? Intensive Care Med. 2014;40:1069-1079.

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     Yeung JC, Cypel M, Machuca TN, et al. Physiologic assessment of the ex vivo donor lung for transplantation. J Heart Lung Transplant. 2012;31:1120-1126.

     Not in our library10.1016/j.healun.2012.08.016

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     Venkateswaran RV, Patchell VB, Wilson IC, et al. Early donor management increases the retrieval rate of lungs for transplantation. Ann Thorac Surg. 2008;85:278-286.

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     Venkateswaran RV, Dronavalli V, Patchell V, et al. Measurement of extravascular lung water following human brain death: implications for lung donor assessment and transplantation. Eur J Cardiothorac Surg. 2013;43:1227-1232.

     Not in our library10.1093/ejcts/ezs657

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     Trebbia G, Sage E, Fadel E, Sakka SG, Cerf C. Ex vivo assessment of extravascular lung water with transpulmonary thermodilution. J Heart Lung Transplant. 2013;32:840-842.

     Not in our library10.1016/j.healun.2013.05.006

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     Not in our library10.1007/s00134-002-1248-z

Cited by papers we hold 3

• Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy · 2018
  No notice
• Transpulmonary thermodilution: advantages and limits · 2017
  No notice
• Prediction of fluid responsiveness: an update · 2016
  No notice

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