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We report on a 27-year-old female patient presenting with pneumonia and developing acute respiratory distress syndrome. Using transpulmonary thermodilution, an elevated extravascular lung water was detected (17 ml/kg). Patient required lung-protective mechanical ventilation and received antibiotic therapy. Negative fluid balance was targeted. Under this treatment, respiratory function improved, inflammation parameters declined, and extravascular lung water was recurrent (10 ml/kg). Subsequently, extravascular lung water increased to 29 ml/kg.In a chest x-ray, the central venous catheter tip was dislocated into the right internal jugular vein. 7 days before, the catheter was shown to be in projection of the Vena cava superior in a previous chest x-ray.After insertion of a new central venous catheter, extravascular lung water was quantified at 10 ml/kg again. After 10 days of mechanical ventilation the patient was successfully extubated.As mechanism for this catheter dislocation, we propose a Valsalva maneuver or spontaneous movements of the upper body of the patient. Sudden increase in extravascular lung water may reflect central venous catheter tip dislocation and chest x-ray should be considered to verify catheter tip position.Wir berichten von einer 27-jährigen Patientin, die im Rahmen einer Pneumonie ein akutes Lungenversagen entwickelte. Über eine transpulmonale Thermodilutionsmethode konnte ein erhöhtes extravasales Lungenwasser (17 ml/kg) festgestellt werden. Die Patientin erhielt eine kalkulierte antibiotische Therapie, wurde Lungen-protektiv beatmet und eine Negativbilanzierung wurde angestrebt. Im Verlauf kam es zu einer respiratorischen Verbesserung bei rückläufigen Entzündungsparametern und einem reduzierten extravasalen Lungenwasser (10 ml/kg). Im weiteren Verlauf stieg jedoch das extravasale Lungenwasser deutlich an (29 ml/kg).In der Röntgen-Thorax-Aufnahme war die Spitze des zentralen Venenkatheters in die Vena jugularis interna disloziert. 7 Tage zuvor hatte sich die Katheterspitze korrekt auf die Vena cava superior projiziert.Nach Neu-Anlage des zentralen Venenkatheters konnte wieder ein extravasales Lungenwasser von 10 ml/kg gemessen werden. Nach insgesamt 10 Behandlungstagen auf Intensivstation konnte die Patientin erfolgreich extubiert werden.Als Mechanismus für die Katheterspitzen-Dislokation kommen ein Valsalva-Manöver der Patientin oder spontane Bewegungen des Oberkörpers infrage. Bei einem plötzlichen Anstieg des extravasalen Lungenwassers muss differenzialdiagnostisch eine Dislokation der Spitze des zentralen Venenkatheters in Betracht gezogen und radiologisch ausgeschlossen werden.

Zusammenfassung: Diese Fallsammlung berichtet über die Korrelation zwischen extravaskulärem Lungenwasser (EVLW) und dem arteriellen Sauerstoffpartialdruck/fraktionierten inspiratorischen Sauerstoffkonzentration (PaO2/FiO2) Quotienten bei drei Patienten mit schwerem Influenza A (H1N1)-induziertem Lungenversagen. Alle Patienten erlitten eine ausgeprägte Hypoxie (PaO2, 26-42 mmHg), mussten mit dem Biphasic Airway Pressure Mode (PEEP, 12-15 mmHg; FiO2, 0,8-1) mechanisch beatmet werden und wurden in 12 stündlichen Intervallen in die Bauchlage gedreht. Alle Patienten waren während 8-11 Tagen mit dem PICCO® System monitorisiert. Während der mechanischen Beatmung wurden ingesamt 62 simultane Bestimmungen des PaO2/FiO2 Quotienten und des EVLW durchgeführt. Es zeigte sich ein signifikanter Zusammenhang zwischen dem EVLW und dem PaO2/FiO2 Quotienten (Spearman-rho Korrelationskoeffizient, -0,852; p < 0,001). Bei allen Patienten war eine Abnahme des EVLW von einer Verbesserung der Oxygenation begleitet. Die Serumkonzentrationen der Laktatdehydrogenase waren bei allen Patienten erhöht und korrelierten signifikant mit dem EVLW während des Intensivaufenthaltes (Spearman-rho Korrelationskoeffizient, 0,786; p < 0,001). Zusammenfassend erscheint es, dass das EVLW bei Patienten mit schwerem H1N1-induziertem Lungenversagen erhöht ist und dabei eng mit Einschränkungen der Oxygenationsfunktion korreliert

Conventional sonography at 2 - 10 MHz cannot permeate the chest because ultrasound at this frequency is strongly scattered and reflected by air inclusions in the lungs. Therefore, sonography is considered impracticable for thoracic imaging. However, human thoraxes and lungs in situ were never rigorously probed with ultrasound at frequencies below 1 MHz. In addition, ultrasound is commonly applied as echo imaging rather than sound transmission.Human subjects were studied with a transducer detector pair or an elastic thorax belt equipped with 12 sensors 5 cm apart that was wrapped around the thorax and a single pulse transmitter attached to the sternum. We focused on fast ultrasound transmission from 1 kHz to 1 MHz, coupled over thoracic sonotrodes.Between 1 Hz to 1 MHz, sound transmission through thorax and lungs shows three distinct bands:1 kHz sound is transmitted at 30 - 50 m/sec, between 1 - 10 kHz sound transmission is absent and10 kHz sound is transmitted with a speed of 1500 m/sec. We demonstrate that low-frequency ultrasound (10 - 750 kHz) can permeate the thorax and permits monitoring of the air and water content of human lungs. In healthy subjects at 15 kHz, the difference in sound transmission through thorax and lungs between inspiration and expiration was dynamic and spanned several decades. Sound transmission during expiration was strongly decreased in patients suffering from pulmonary emphysema or pneumothorax, but increased in patients with pleural effusions.Sound transmission in the lungs is characterized by three distinct frequency bands. Low frequency ultrasound is transmitted through the lungs and may offer a novel non-invasive approach to real time diagnostics.

Haemodynamic monitoring of septic patients is impeded by the discrepancy between the macrohaemodynamics and the microcirculation of internal organs. Pulse contour analysis (PiCCO) provides new parameters for an improved assessment of the volume status of critically ill patients. However, changes in regional circulation, in particular those affecting the splanchnic perfusion, have proven to be especially important. The aim of our study was to compare macrohaemodynamic parameters (PiCCO) with microcirculation (OPS imaging) in severely septic patients with multiple organ failure.In seven patients suffering from septic shock and multiple organ failure (APACHE II score25) repeated examinations at a twenty-four hour interval were carried out by PiCCO monitoring and OPS imaging. OPS data were recorded for twenty seconds at 6 different buccal and sublingual localisations, adequately reflecting microvascular perfusion of the liver and the small intestine. Data were videotaped for off-line analysis, calculating current velocity in small and large venules (25 and25 microm), as well as functional capillary density.Significant correlations were found for current velocity in small venules with systemic vascular resistance (r(2) = 0.252, p0.05), mean arterial blood pressure (r(2) = 0.259, p0.05), and pH value (r(2) = 0.265, p0.05). In addition, a significant correlation was found between the oxygen transport index and the density of small vessels (r(2) = 0.355; p0.05).According to our findings, data acquired through PiCCO monitoring may be used for a rough estimation of the microcirculation during severe sepsis and multiple organ failure. For an assessment of the local conditions of perfusion, however, there are limits in the use of the parameters that were the object of our research. For the measurement at localisations which are accessible non-invasively and representative of the splanchnic perfusion, OPS is the more accurate method for characterisation of the microcirculation, although a more extensive and time-consuming analysis is needed.

The transpulmonary thermal-dye dilution (TDD) is the clinical gold standard for measurement of intrathoracic blood volume (ITBV) and extravascular lung water (EVLW). Recently, experimental and clinical studies found that ITBV and EVLW can be derived reliably by single transpulmonary thermodilution (TD), however, dependency from various factors of lung function has been discussed.We retrospectively analyzed data from 174 critically ill patients who had undergone hemodynamic monitoring by TDD. We calculated the differences of simultaneous TD and TDD determined by ITBV or EVLW measurements. Bias and standard deviations (SD) were calculated and extended Bland-Altman regression analyses were performed. Association of the differences and the potential confounders gender, age, PEEP, p(a)O(2)/F(I)O(2) ratio and the corresponding TDD measurement were analyzed by multiple linear regression and LOWESS regression.Overall results (bias+/-SD) were 1+/-58 ml/m(2) for ITBV and 0.0+/-1.4 ml/kg bw for EVLW, but TD overestimated TDD results in patients with higher ITBV and underestimated those for lower ITBV values. The deviations were small, and the dependence of ITBV could be explained completely by dependence on PEEP and age. However, low values of EVLW are overestimated by TD.Single transpulmonary thermodilution for estimation of ITBV or EVLW is reliable in patients with severe lung injury for normal and higher values.

and pulmonary haemodynamics in patients undergoing coronary artery bypass surgery. Objective: The aim of this study was the measurement of extravascular lung water (EVLW) and to evaluate the effects of a corticosteroid pretreatment in patients undergoing coronary artery bypass surgery with extracorporeal circulation on pulmonary edema formation by suppression of inflammatory response. Methods: Twenty patients undergoing elective surgery were studied in a randomized double blind trial. Preoperatively, ten patients received placebo and the other ten 1 mg kg -1 dexamethasone. In all patients a pulmonary artery catheter and a combined fiberoptic/ thermistor catheter were placed via internal jugular vein and femoral artery, respectively. EVLW was assessed by a modified transpulmonary double indicator dilution method. Perioperative management was standardized as far as possible, measurements were performed after initation of anesthesia and 1, 6, and 20 h post surgery. Results: Over the entire study period EVLW was in the normal range (up to 6 ml kg -1 ) in both groups, only at 20 h EVLW in the dexamethasone group was significantly lower (4,6 vs. 5,8 ml kg -1 ). In the dexamethasone group less positive total fluid balances and a lower increase in pulmonary artery pressure were observed compared to the control. Conclusion: Even with highly positive total fluid balances no relevant increases in EVLW were observed after coronary artery bypass surgery. Impaired oxygenation in patients undergoing cardiac surgery seems to be caused by other pathophysiological mechanisms. Preoperative treatment with dexamethasone possibly has effects on cumulative fluid balances, pulmonary artery pressure, and pulmonary vascular resistance.

Our data suggest that the indicator dilution technique allows differentiated and early prediction of cardiopulmonary complications during the postoperative period. This leads to significant changes in fluid therapy to prevent organ failure.

To investigate the agreement (and its potential dependency on extra-vascular lung water) between transpulmonary (TPID) and standard pulmonary artery (PAID) thermodilution cardiac output measurements.One hundred and sixty simultaneous cardiac output measurements using transpulmonary and pulmonary artery thermodilution techniques were retrospectively compared in 18 patients with acute respiratory distress syndrome. In addition, extravascular lung water was determined using a double indicator technique (temperature and indocyanine green).Mean (+/- SD) difference ("bias") was 0.03 L/min (+/- 1.04 L/min), linear regression analysis resulted in TPID = 0.87 PAID + 1.16 (r = 0.91). Mean extra vascular lung water was 1625 mL (minimum-maximum: 403-3266 mL) and therefore markedly elevated as could have been expected in patients with ARDS. Bias (PAID-TPID) was not dependent on extravascular lung water.Transpulmonary and pulmonary artery thermodilution methods can be used interchangeably. The results demonstrate for the first time in humans that transpulmonary thermodilution provides valid cardiac output values in patients with markedly increased fluid content of the lungs.

Development and experimental validation of a method tor the quantification of pulmonary oedema by measurement of total lung water and intravascular lung water and by calculation of extravascular lung water.Isolated sheep lung preparations with unilateral pulmonary oedema were perfused (pulsatile pump) and examined under ventilatory arrest and during ventilation. Total lung water was calculated from proton density obtained from a multi-spin echo sequence and gravimetrically (reference method). Pulmonary intravascular volume was calculated from signal intensity histograms obtained from 3D-TOF MR-angiograms before and after application of the macromolecular contrast medium gadolinium-DTPA-polylysine. The reference method was a dye-dilution technique. Extravascular lung water was calculated as the difference between total lung water and pulmonary intravascular volume.Under ventilatory arrest, the magnetic resonance technique for the measurement of extravascular lung water correlated well with the reference technique (r = 0.89, n = 42 lungs). In 10 lungs the correlation coefficients were r = 0.95 (ventilatory arrest) and r = 0.92 (ventilated lungs).The results demonstrate that magnetic resonance imaging enhanced by a macromolecular contrast medium may be applicable for quantification of pulmonary oedema.

Prostaglandin E1 (PGE1) is a physiologic vasodilator, which is broadly used in the therapy of peripheral arterial occlusive disease. In addition, the successful use of PGE1 in patients with severe heart failure has been described in several studies, where a decrease in pulmonary artery pressure and an increase in cardiac output were observed. In contrast to these positive effects, the development of lung edema was reported in individual cases after the infusion of PGE1 in patients with heart disease. We therefore conducted a double-blind study to evaluate the effect of PGE1 on extravascular lung water (EVLW) in patients with heart failure (NYHA III-IV) and borderline increased EVLW. Seven patients received an infusion of PGE1 (Prostavasin) at a dosage of 60 micrograms over 2 hours, while in 6 patients (control group) isotonic saline was given as placebo. EVLW was measured using a double indicator method at time points -15 h, -9 h before and at the start of the infusion, 1 h and 2 h during infusion, as well as +1 h, +4 h, +7 h, and +22 h after termination of the infusion. Infusion of PGE1 did not alter EVLW both in comparison to pre-study values (9.8 +/- 4.3 ml/kg bw preinfusion. 9.3 +/- 3.2 ml/kg bw after 1 hour and 9.4 +/- 3.5 ml/kg bw after 2 hours) or to the control group (6.5 +/- 3.3 ml/kg bw preinfusion, 7.1 +/- 2.7 ml/kg bw after 1 hour and 7.0 +/- 3.2 ml/kg bw after 2 hours). We conclude that there is no evidence that PGE1 might contribute to the development, or worsening of lung edema by inducing extravascular lung water accumulation and can, thus, be savely given to patients with even a severe degree of heart failure (NYHA III-IV).

In the treatment of posttraumatic adult respiratory distress syndrome (ARDS) so far no breakthrough has been achieved. In several cases of severe ARDS we have seen improvements of lung function by means of continuous body positioning. We therefore compared the effect of kinetic positioning (KIN) on lung function and hemodynamics in ARDS patients to conventional (KON) supine positioning. 22 ARDS patients with multiple trauma treated by supportive continuous body positioning (KIN) (KCI-Mediscus) and without continuous positioning (KON) were investigated daily. Pulmonary and systemic hemodynamics were determined on the basis of pulmonary artery catheter measurements. Oxygenation ratio (PaO2/FiO2) and pulmonary shunt (Qs/Qt,%) were calculated. Extravascular lung water (EVLW, ml/kg body weight) was determined by double indicator thermodilution technique. Total injury severity by injury severity score (ISS) was 29.6 +/- 6 points (KIN) and 31.6 +/- 5 points (KON). The oxygenation ratio (PaO2/FiO2) increased significantly from 140 +/- 45 (day 0) to 237 +/- 40 (p0.05) [day 5] (KIN), in KON patients no improvement (143 +/- 48 [day 0], 133 +/- 44 [ay 5]) was seen (p0.05 between groups). There were no significant changes of systemic hemodynamics between the groups or compared to day 0. Pulmonary shunt decreased significantly from 26.6 +/- 4% (day 0) to 12.5 +/- 2% (day 5) (p0.05) in KIN patients and was 36.6 +/- 6% at day 0 and 31.4 +/- 2% at day 5 in KON patients (p0.05 between groups). EVLW was 11.1 +/- 2 ml/kg body weight at day 0 and 9.4 +/- 1 ml/kg body weight at day 5 (KIN)-EVLW was 12.9 +/- 2 ml/kg body weight at day 0 and 17.4 +/- 3 ml/kg body weight at day 5 (KON) (not significant). We found no hemodynamic side effects from continuous body positioning. In ARDS-patients submitted to body positioning oxygenation and pulmonary shunt improved significantly and were significantly better compared to those with conventional supine positioning. Continuous body positioning appears to represent a promising supportive treatment regimen in posttraumatic ARDS.

The results of measurements of the electrical resistance of lung tissue are reported in order to estimate quantitatively the influence of air and blood filling on the conductivity. Experiments were done on isolated lung tissue of fetal and infantile guinea pigs. The ohmic resistance was measured by a minimised 4-electrode technique: isolated fetal lungs empty of air, or artificially aerated ones on the one hand, isolated lungs of infantile animals with spontaneous respiration and normal lung blood flow on the other hand. The increase of the electrical resistance produced by aeration is reduced by at least 50% by the synchronously increasing blood flow in spontaneously respired lungs. These experiments in the described animal model offer an opportunity for a more precise interpretation of the electrocardiogram of human adults changing with respiratory phases.

In patients with multiple injuries, the development of permeability edema can be assumed. However, no uniform shape of this fluid accumulation can be found even in the presence of severe injuries. Based on the first clinical observations, our aim was to search for correlations between the development of extravascular lung water (EVLW) and the individual injury pattern in severely traumatized ICU patients. PATIENTS and METHODS. Our investigations were performed in 48 artificially ventilated ICU patients. According to the prevailing injury pattern patients were divided into three groups: group A: 18 patients (mean age: 32 years, mean Injury Severity Score (ISS) = 29) with isolated thoracic trauma; group B: 10 patients (mean age: 27 years, mean ISS = 42) with severe multiple trauma but without any thoracic injury; group C: 20 patients (mean age: 33 years, mean ISS = 43) with severe multiple trauma and concomitant thoracic trauma. In all patients (group A, B, C), EVLW was determined by means of a double indicator method on a daily basis from the patient's admission to the ICU (day of trauma) until day 10. Additionally, the hemodynamic parameters (heart rate, mean arterial pressure, mean pulmonary arterial pressure, pulmonary capillary wedge pressure and cardiac index) were determined at the same time. RESULTS. As shown in Fig 1, EVLW was slightly elevated on day 1. However, on day 2 EVLW decreased within normal values and remained in that range until the end of the observation period. On day 3 a slight and fleeting increase of EVLW, but within normal range, can be seen. In group B (Fig.2), EVLW can be observed within normal range within a period of 4 days. Starting from day 5 until day 7 a marked increase (p greater than 0.01) in EVLW can be seen. From that maximum point EVLW development reverses slightly until day 10--however, without returning to the normal range. In group C, a marked biphasic pattern can be seen due to EVLW maximum values on post-traumatic days 3 and 7. However, in this group the EVLW was in the pathological range during the whole observation period. No statistically significant differences could be seen, when looking at hemodynamic variables. CONCLUSION. Isolated thoracic trauma will not lead to a marked pathological elevation of EVLW within the lungs. Moreover, EVLW decreases rapidly within a short time period. Based on our results, it seems that severe extrathoracic injuries will intensify microvascular injury in the initial period, as shown in our patients in group C. Increase of EVLW at a later time (day 7), as observed in groups B and C, is possibly the expression of a mediator and activator-induced "septiformal" injury of the microvascular endothelium. This may be caused by the underlying massive peripheral soft-tissue trauma. Specific elevations of EVLW subsequent to the individual injury pattern can indicate that that process has begun and is responsible for the origin of the microvascular injuries.