Laveena Munshi, MD, MSc November 2018 Interdepartmental Division of Critical Care Medicine Mount Sinai Hospital/University Health Network University of Toronto Toronto, Canada The Utility of Extravascular Lung Water Measurements Following Bilateral Lung Transplant
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Laveena Munshi, MD, MSc
November 2018
Interdepartmental Division of Critical Care MedicineMount Sinai Hospital/University Health NetworkUniversity of Toronto
Toronto, Canada
The Utility of
Extravascular Lung Water Measurements
Following
Bilateral Lung Transplant
Disclosures
Ontario Thoracic Society Grant
No Relevant Financial Disclosures
Pulmonary Edema Remains the Hallmark of ARDS
The accurate detection and quantification of pulmonary edema has important clinical implications
Methods of estimating pulmonary edema and/or
volume status are numerous but fraught with error
Extravascular Lung Water Intravascular Volume Status
• Transpulmonary thermodilution and extravascular lung water
• Evolution of evidence surrounding extravascular lung water
• The utility of extravascular lung water following bilateral lung transplant
Objectives
Transpulmonary
Thermodilution:
Extravascular Lung Water
Mean Transit Time
Down slope timeCardiac Output
Extravascular Lung Water
Global End Diastolic Volume
Pulmonary Vascular Permeability Index
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EVLW ≥ 10 cc/kg Associated with Clinically Significant
Pulmonary Edema
The Evidence: Validation
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The Evidence: EVLW Distinguishes Between Causes of
Acute Respiratory Failure
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Acute Respiratory Failure Following Lung Transplant is Not
Uncommon
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PRIMARY
GRAFT
DYSFUNCTION
Severed Lymphatics
During Transplant
Diffuse Pulmonary Infiltrates in 72 hours Post Lung Transplant:
Primary Graft Dysfunction (PGD)
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Diamond et al The Journal of Heart and Lung Transplant 2017
Diffuse pulmonary infiltrates in first 72 hours following transplant
• Grade 1 PGD (PaO2/FiO2 ratio >300)
• Grade 2 PGD (PaO2/FiO2 200-300)
• Grade 3 PGD (PaO2/FiO2 <200)
Evaluated at time 0, 24 hours, 48 hours, 72 hours following transplant
Incidence of grade 3 PGD at any time point after transplant ~30%
Associated with increased LOS, mortality and BOS – with later scores correlating better with outcomes
Utility of PGD
classification
Lack precise
methods to predict
development and
prognosticate
outcome
Emerging Utility of
EVLW
Pulmonary edema
may be more
challenging to
manage post LTx
PGD classification
issues and inability
to predict PGD
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The Utility of Extravascular Lung Water
Following Bilateral Lung Transplant
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OBJECTIVES
AIM 1: Evaluate the associationbetween EVLW and PGD
AIM 2: Evaluate whether early measurements of EVLW are associated with greater severities of PGD at later time points
AIM 3: Evaluate whether early EVLW is associated with duration of mechanical ventilation independent of PGD
PGD 1
PGD 2
PGD 3
EVL
WT
XPGD PGD PGD
METHODS
Prospective observational study of all adult consecutive bilateral
lung transplant at TGH
Exclusion Criteria: Immediate need for post operative ECMO, contraindication to femoral
arterial catheterization, single lung transplant instead of double