Monnet Xavier, Anguel Nadia, Osman David, Hamzaoui Olfa, Richard Christian, Teboul Jean-Louis
Service de réanimation médicale, Centre hospitalier universitaire de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.
Intensive Care Med. 2007 Mar;33(3):448-53. doi: 10.1007/s00134-006-0498-6. Epub 2007 Jan 13.
To test whether assessing pulmonary permeability by transpulmonary thermodilution enables to differentiate increased permeability pulmonary edema (ALI/ARDS) from hydrostatic pulmonary edema.
Retrospective review of cases.
A 24-bed medical intensive care unit of a university hospital.
Forty-eight critically ill patients ventilated for acute respiratory failure with bilateral infiltrates on chest radiograph, a PaO(2)/FiO(2) ratio < 300 mmHg and extravascular lung water indexed for body weight >/= 12 ml/kg.
We assessed pulmonary permeability by two indexes obtained from transpulmonary thermodilution: extravascular lung water/pulmonary blood volume (PVPI) and the ratio of extravascular lung water index over global end-diastolic volume index. The cause of pulmonary edema was determined a posteriori by three experts, taking into account medical history, clinical features, echocardiographic left ventricular function, chest radiography findings, B-type natriuretic peptide serum concentration and the time-course of these findings with therapy. Experts were blind for pulmonary permeability indexes and for global end-diastolic volume.
ALI/ARDS was diagnosed in 36 cases. The PVPI was 4.7+/-1.8 and 2.1+/-0.5 in patients with ALI/ARDS and hydrostatic pulmonary edema, respectively (p<0.05). The extravascular lung water index/global end-diastolic volume index ratio was 3.0 x 10(-2)+/-1.2 x 10(-2) and 1.4 x 10(-2)+/-0.4 x 10(-2) in patients with ALI/ARDS and with hydrostatic pulmonary edema, respectively (p<0.05). A PVPI >/= 3 and an extravascular lung water index/global end-diastolic index ratio >/= 1.8 x 10(-2) allowed the diagnosis of ALI/ARDS with a sensitivity of 85% and specificity of 100%.
These results suggest that indexes of pulmonary permeability provided by transpulmonary thermodilution may be useful for determining the mechanism of pulmonary edema in the critically ill.
测试通过经肺热稀释法评估肺通透性是否能够区分通透性增加型肺水肿（急性肺损伤/急性呼吸窘迫综合征）与静水压性肺水肿。
病例回顾性研究。
某大学医院拥有24张床位的医学重症监护病房。
48例因急性呼吸衰竭接受机械通气的重症患者，胸部X光片显示双侧浸润影，动脉血氧分压/吸入氧分数值（PaO₂/FiO₂）<300 mmHg，血管外肺水指数（按体重计算）≥12 ml/kg。
我们通过经肺热稀释法获得的两个指标评估肺通透性：血管外肺水/肺血容量（PVPI）以及血管外肺水指数与全心舒张末期容积指数之比。三位专家根据病史、临床特征、超声心动图左心室功能、胸部X光片表现、B型利钠肽血清浓度以及这些表现随治疗的时间变化情况，事后确定肺水肿的病因。专家们对肺通透性指标和全心舒张末期容积不知情。
36例患者被诊断为急性肺损伤/急性呼吸窘迫综合征。急性肺损伤/急性呼吸窘迫综合征患者和静水压性肺水肿患者的PVPI分别为4.7±1.8和2.1±0.5（p<0.05）。急性肺损伤/急性呼吸窘迫综合征患者和静水压性肺水肿患者的血管外肺水指数/全心舒张末期容积指数之比分别为3.0×10⁻²±1.2×10⁻²和1.4×10⁻²±0.4×10⁻²（p<0.05）。PVPI≥3且血管外肺水指数/全心舒张末期指数之比≥1.8×10⁻²时，诊断急性肺损伤/急性呼吸窘迫综合征的敏感度为85%，特异度为100%。
这些结果表明，经肺热稀释法提供的肺通透性指标可能有助于确定重症患者肺水肿的机制。
