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Transpulmonary thermodilution detects rapid and reversible increases in lung water induced by positive end-expiratory pressure in acute respiratory distress syndrome.
Annals of Intensive Care ( IF 8.1 ) Pub Date : 2020-03-02 , DOI: 10.1186/s13613-020-0644-2
Francesco Gavelli 1, 2, 3 , Jean-Louis Teboul 1, 2 , Danila Azzolina 3 , Alexandra Beurton 1, 2 , Temistocle Taccheri 1, 2 , Imane Adda 1, 2 , Christopher Lai 1, 2 , Gian Carlo Avanzi 3 , Xavier Monnet 1, 2
Affiliation  

PURPOSE It has been suggested that, by recruiting lung regions and enlarging the distribution volume of the cold indicator, increasing the positive end-expiratory pressure (PEEP) may lead to an artefactual overestimation of extravascular lung water (EVLW) by transpulmonary thermodilution (TPTD). METHODS In 60 ARDS patients, we measured EVLW (PiCCO2 device) at a PEEP level set to reach a plateau pressure of 30 cmH2O (HighPEEPstart) and 15 and 45 min after decreasing PEEP to 5 cmH2O (LowPEEP15' and LowPEEP45', respectively). Then, we increased PEEP back to the baseline level (HighPEEPend). Between HighPEEPstart and LowPEEP15', we estimated the degree of lung derecruitment either by measuring changes in the compliance of the respiratory system (Crs) in the whole population, or by measuring the lung derecruited volume in 30 patients. We defined patients with a large derecruitment from the other ones as patients in whom the Crs changes and the measured derecruited volume were larger than the median of these variables observed in the whole population. RESULTS Reducing PEEP from HighPEEPstart (14 ± 2 cmH2O) to LowPEEP15' significantly decreased EVLW from 20 ± 4 to 18 ± 4 mL/kg, central venous pressure (CVP) from 15 ± 4 to 12 ± 4 mmHg, the arterial oxygen tension over inspired oxygen fraction (PaO2/FiO2) ratio from 184 ± 76 to 150 ± 69 mmHg and lung volume by 144 [68-420] mL. The EVLW decrease was similar in "large derecruiters" and the other patients. When PEEP was re-increased to HighPEEPend, CVP, PaO2/FiO2 and EVLW significantly re-increased. At linear mixed effect model, EVLW changes were significantly determined only by changes in PEEP and CVP (p < 0.001 and p = 0.03, respectively, n = 60). When the same analysis was performed by estimating recruitment according to lung volume changes (n = 30), CVP remained significantly associated to the changes in EVLW (p < 0.001). CONCLUSIONS In ARDS patients, changing the PEEP level induced parallel, small and reversible changes in EVLW. These changes were not due to an artefact of the TPTD technique and were likely due to the PEEP-induced changes in CVP, which is the backward pressure of the lung lymphatic drainage. Trial registration ID RCB: 2015-A01654-45. Registered 23 October 2015.

中文翻译:

经肺热稀​​释检测急性呼吸窘迫综合征中呼气末正压引起的肺水快速和可逆增加。

目的已表明,通过募集肺区域并扩大感冒指示剂的分布体积,增加呼气末正压(PEEP)可能会导致通过经肺热稀释(TPTD)人工高估血管外肺水(EVLW) 。方法在60位ARDS患者中,我们在PEEP水平下测得的EVLW(PiCCO2装置)达到了30 cmH2O(HighPEEPstart)的平台压,并且在将PEEP降低至5 cmH2O(分别为LowPEEP15'和LowPEEP45')之后的15和45分钟。然后,我们将PEEP增加到基线水平(HighPEEPend)。在HighPEEPstart和LowPEEP15'之间,我们通过测量整个人群中呼吸系统(Crs)顺应性的变化或通过测量30名患者的肺萎缩量来估计肺萎缩的程度。我们将那些减少人数较多的患者定义为Crs变化且所测量的减少人数大于整个人群中观察到的这些变量中位数的患者。结果将PEEP从HighPEEPstart(14±2 cmH2O)降低至LowPEEP15',可使EVLW从20±4降低至18±4 mL / kg,中心静脉压(CVP)从15±4降低至12±4 mmHg,吸入氧气分数(PaO2 / FiO2)比从184±76到150±69 mmHg,肺部容积为144 [68-420] mL。EVLW下降在“大型招募者”和其他患者中相似。当PEEP重新增加到HighPEEPend时,CVP,PaO2 / FiO2和EVLW显着增加。在线性混合效应模型中,EVLW的变化仅由PEEP和CVP的变化显着确定(p <0。分别为001和p = 0.03,n = 60)。通过根据肺体积变化(n = 30)估算补充量进行相同的分析时,CVP仍与EVLW的变化显着相关(p <0.001)。结论在ARDS患者中,改变PEEP水平会引起EVLW平行,微小和可逆的变化。这些变化不是由于TPTD技术的伪影,而可能是由于PEEP引起的CVP变化,这是肺淋巴引流的后向压力。试用注册ID RCB:2015-A01654-45。2015年10月23日注册。改变PEEP水平会引起EVLW的平行,微小和可逆的变化。这些变化不是由于TPTD技术的伪影,而可能是由于PEEP引起的CVP变化,这是肺淋巴引流的后向压力。试用注册ID RCB:2015-A01654-45。2015年10月23日注册。改变PEEP水平会引起EVLW的平行,微小和可逆的变化。这些变化不是由于TPTD技术的伪影,而可能是由于PEEP引起的CVP变化,这是肺淋巴引流的后向压力。试用注册ID RCB:2015-A01654-45。2015年10月23日注册。
更新日期:2020-04-20
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