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Extravascular lung water in acute respiratory distress syndrome and the Berlin definition: time for real change
Critical Care volume 17, Article number: 463 (2013)
I echo the call for a real change in the diagnosis of acute respiratory distress syndrome (ARDS), as put forward in the recent editorial by Phillips . Whilst there are real limitations regarding availability, feasibility and interpretation of extravascular lung water (EVLW), it remains one of the few clinically available quantitative parameters for assessment of the severity of lung injury.
We and others have shown the relationship between different EVLW indices and lung injury . Moreover, our previously published results in this journal support the results of Jozwiak and colleagues showing a twofold increase in the odds ratio for ICU mortality when the pulmonary vascular permeability index was increased . In our study, the area under the curve for the pulmonary vascular permeability index as a predictor for mortality was 0.682 (95% confidence interval 0.505 to 0.859), which is higher than that reported for the Berlin definition of ARDS.
The case for EVLW as a criterion for ARDS definition has been challenged on the grounds of its lack of predictive value and feasibility. Whether EVLW reflects increased hydrostatic or inflammatory edema has been investigated recently, and the pulmonary vascular permeability index appears to be a useful indicator [4, 5]. In my opinion, a clear pathophysiological and prognostic relationship exists between EVLW and lung injury [2–6]. Current data support the need for larger, multicenter trials identifying which EVLW index and cutoff values should be applied for diagnoses, and whether EVLW-driven management protocols can improve outcomes in ARDS.
Acute respiratory distress syndrome
Extravascular lung water.
Phillips CR: The Berlin definition: real change or the emperor’s new clothes? Crit Care 2013, 17: 174. 10.1186/cc12761
Chew MS, Ihrman L, During J, Bergenzaun L, Ersson A, Unden J, Ryden J, Akerman E, Larsson M: Extravascular lung water index improves the diagnostic accuracy of lung injury in patients with shock. Crit Care 2012, 16: R1. 10.1186/cc10599
Jozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, Teboul JL, Monnet X: Extravascular lung water in an independent prognostic factor in patients with acute respiratory distress syndrome. Crit Care Med 2013, 41: 472-480. 10.1097/CCM.0b013e31826ab377
Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul J-L: Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS. Int Care Med 2007, 33: 448-453. 10.1007/s00134-006-0498-6
Chung FT, Lin HC, Kuo CH, Yu CT, Chou CL, Lee KY, Kuo HP, Lin SM: Extravascular lung water correlates with multiorgan dysfuntion and mortality in sepsis. PloS One 2010, 5: e15265. 10.1371/journal.pone.0015265
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, Kaneko T, Nakamura T, Irahara T, Saito N, Watanabe A, PiCCO Pulmonary Edema Study Group: 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 2012, 16: R232. 10.1186/cc11898
MSC has received travel reimbursements from Pulsion AG, Munich, Germany.
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Chew, M.S. Extravascular lung water in acute respiratory distress syndrome and the Berlin definition: time for real change. Crit Care 17, 463 (2013). https://doi.org/10.1186/cc13099
- Confidence Interval
- Emergency Medicine
- Lung Injury
- Current Data
- Multicenter Trial