Acute Crit Care.  2022 Nov;37(4):571-579. 10.4266/acc.2022.00423.

Extravascular lung water index, pulmonary vascular permeability index, and global end-diastolic volume index in mechanically ventilated COVID-19 patients requiring prone position ventilation: a preliminary retrospective study

• De Rosa RC
• Romanelli A
• Gallifuoco M
• Messina G
• Di Costanzo M
• Corcione A

• KMID: 2540145
• DOI: http://doi.org/10.4266/acc.2022.00423

Abstract

Background
There is a lack of data on extravascular lung water index (EVLWi), pulmonary vascular permeability index (PVPi), and global end-diastolic volume index (GEDVi) during prone position ventilation (PPV) in coronavirus disease 2019 (COVID-19) patients. The objectives of this study were to analyze trends in EVLWi, PVPi, and GEDVi during PPV and the relationships between these parameters and PaO2/FiO2. Methods: In this preliminary retrospective observational study, we performed transpulmonary thermodilution (TPTD) in seven mechanically ventilated COVID-19 patients without cardiac and pulmonary comorbidities requiring PPV for 18 hours, at specific times (30 minutes pre-PPV, 18 hours after PPV, and 3 hours after supination). EVLWi, PVPi and GEDVi were measured. The relationships between PaO2/FiO2 and EVLWi, and PVPi and GEDVi values, in the supine position were analyzed by linear regression. Correlation and determination coefficients were calculated. Results: EVLWi was significantly different between three time points (analysis of variance, P=0.004). After 18 hours in PPV, EVLWi was lower compared with values before PPV (12.7±0.9 ml/kg vs. 15.3±1.5 ml/kg, P=0.002). Linear regression showed that only EVLWi was correlated with PaO2/FiO2 (β =–5.757; 95% confidence interval, –10.835 to –0.679; r=–0.58; R2 =0.34; F-test P=0.029). Conclusions: EVLWi was significantly reduced after 18 hours in PPV and values measured in supine positions were correlated with PaO2/FiO2. This relationship can help clinicians discriminate whether deterioration in gas exchange is related to fluid overload or disease progression. Further clinical research should evaluate the role of TPTD parameters as markers to stratify disease severity and guide clinical management.

Keyword

acute respiratory distress syndrome; COVID-19; prone position; thermodilution

Figure

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  Figure 1. Boxplot for extra vascular lung water index (EVLWi). The boxplot for EVLWi noted at 30 minutes before pronation (30-min pre-pronation), 18 hours after pronation (18-hr post-pronation), and at three hours post-supination (3-hr post-supination). EVLWi values decreased from 15.3±1.5 ml/kg (30 min pre-pronation) to 12.7±0.9 ml/kg (18 hr after-pronation), returning to 13.5±0.6 ml/kg (3 hr post-supination). Analysis of variance for repeated measurements showed a statistically significant trend (P=0.004). a) Subgroup analysis revealed that variation between EVLWi values noted at 30 minutes pre-pronation and at 18 hours after-pronation was statistically significant, with a mean difference –2.54±0.15 ml/kg (95% confidence interval, –3.83 to –1.26 ml/kg; Bonferroni corrected P=0.002). No other differences were statistically significant. The outlier appears as the square box to the outside of the box plot.

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  Figure 2. Scatter (A) and residual (B) plots. (A) The scatter plot, with regression line (black line), 95% confidence interval (CI) curves (black dotted curves) and 95% prediction lines (red lines). Linear regression analysis (n=14) showed that extravascular lung water index values noted in the supine position were able to predict PaO2/FiO2. The linear regression equation for the model was: PaO2/FiO2=156.08 (intercept 95% CI, 82.6–229.6; t-statistic=4.626; P<0.001) –5.76 (β 95% CI, –10.83 to –0.68; t-statistic=–2.470; P=0.029) × EVLWi. F-test showed that the linear relationship between EVLWi and PaO2/FiO2 was statistically significant (P=0.029), with R2=0.34. (B) Plot for residual analysis. Shapiro-Wilk test showed that residuals followed a normal distribution (W=0.924, P=0.249). EVLWi: extra vascular lung water index.

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