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Kulkarni M, Slain KN, Rotta AT, Shein SL. The Effects of Furosemide on Oxygenation in Mechanically Ventilated Children with Bronchiolitis. J Pediatr Intensive Care 2019; 9:87-91. [PMID: 32351761 DOI: 10.1055/s-0039-3400467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/16/2019] [Indexed: 12/23/2022] Open
Abstract
Fluid balance management, including diuretic administration, may influence outcomes among mechanically ventilated children. We retrospectively compared oxygenation saturation index (OSI) before and after the initial furosemide bolus among 65 mechanically ventilated children. Furosemide was not associated with a significant change in median OSI (6.25 [interquartile range: 5.01-7.92] vs. 6.06 [4.73-7.54], p = 0.48), but was associated with expected changes in fluid balance and urine output. Secondary analysis suggested more favorable effects of furosemide in children with worse baseline OSI. The reported common use of furosemide by pediatric intensivists obligates further study to better establish its efficacy, or lack thereof, in mechanically ventilated children.
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Affiliation(s)
- Mandar Kulkarni
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Katherine N Slain
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States.,Department of Pediatrics, Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
| | - Alexandre T Rotta
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, United States.,Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Children's Hospital and Health Center, Durham, North Carolina, United States
| | - Steven L Shein
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States.,Department of Pediatrics, Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
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Casey JD, Semler MW, Rice TW. Fluid Management in Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2019; 40:57-65. [PMID: 31060088 DOI: 10.1055/s-0039-1685206] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One of the defining features of acute respiratory distress syndrome (ARDS) is noncardiogenic pulmonary edema, resulting from increased permeability of the alveolar-capillary barrier and passage of protein-rich fluid into the interstitium and alveolar spaces. The loss of protein from the intravascular space disrupts the normal oncotic pressure differential and causes patients with ARDS to be particularly sensitive to the hydrostatic forces that correlate with intravascular volume. Conservative fluid management, in which diuretics are administered and intravenous fluid administration is minimized, may decrease hydrostatic pressure and increase serum oncotic pressure, potentially limiting the development of pulmonary edema. However, the cause of death in most patients with ARDS is multiorgan system failure, not hypoxemia, and the impact of conservative fluid management on the incidence of extrapulmonary organ failure during ARDS is unclear. These physiologic observations have led to a series of studies examining the impact of fluid management on the development of, resolution of, survival from, and long-term outcomes from ARDS. While questions remain, the current literature makes it clear that fluid management is an integral part of the care of patients with ARDS.
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Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Courtney Broaddus V, Berthiaume Y, Biondi JW, Matthay MA. Analytic Reviews : Hemodynamic Management of the Adult Respiratory Distress Syndrome. J Intensive Care Med 2016. [DOI: 10.1177/088506668700200404] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemodynamic management is an essential aspect of the care of patients with adult respiratory distress syn drome (ARDS). On the basis of current knowledge, our proposed goals of management are to maximize pe ripheral oxygen delivery while attempting to minimize further lung damage or dysfunction. The major patho physiologic abnormalities of ARDS are an increased lung vascular permeability, right-to-left intrapulmonary shunting, and pulmonary vascular resistance. These abnormalities must be understood to select the proper therapy. Although all patients with ARDS share these abnormalities, they differ in their associated clinical conditions and underlying cardiovascular status. Be cause each ARDS patient may respond differently to therapy, hemodynamic management must be selected empirically with the goal of therapy as a guide. We have considered available therapeutic options including posi tive end-expiratory pressure, volume depletion, volume expansion, vasopressors, and vasodilators. In the future hemodynamic management of patients with ARDS will likely change as better methods of patient assessment and treatment are developed.
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Affiliation(s)
- V. Courtney Broaddus
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, Departments of Medicine and Anesthesia, Yale University School of Medicine, New Haven, CT
| | - Yves Berthiaume
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, Departments of Medicine and Anesthesia, Yale University School of Medicine, New Haven, CT,
| | - James W. Biondi
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, Departments of Medicine and Anesthesia, Yale University School of Medicine, New Haven, CT,
| | - Michael A. Matthay
- University of California, San Francisco, San Francisco, CA 94143., Departments of Medicine and Anesthesia, Yale University School of Medicine, New Haven, CT
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Suzuki S, Fukushima R, Yamamoto Y, Ishikawa T, Hamabe L, Kim S, Yoshiyuki R, Fukayama T, Machida N, Tanaka R. Comparative Effect of Carperitide and Furosemide on Left Atrial Pressure in Dogs with Experimentally Induced Mitral Valve Regurgitation. J Vet Intern Med 2013; 27:1097-104. [DOI: 10.1111/jvim.12154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 05/24/2013] [Accepted: 07/08/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- S. Suzuki
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - R. Fukushima
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - Y. Yamamoto
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - T. Ishikawa
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - L. Hamabe
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - S. Kim
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - R. Yoshiyuki
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - T. Fukayama
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - N. Machida
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - R. Tanaka
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
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Abstract
PURPOSE OF REVIEW Through shared anatomy, pressures, and endothelial connections, the respiratory and cardiovascular systems affect each other in complex but clinically important ways. RECENT FINDINGS Lung injury has clinically important circulatory effects, especially with regards to right ventricular function. Mechanical ventilation and PEEP produce a host of circulatory consequences, some beneficial, some life-threatening. At the same time, circulatory impairments and treatments can magnify the impact of lung failure. SUMMARY Cardiopulmonary interactions underpin current views of fluid management and mechanical ventilation. Understanding cardiopulmonary interactions and their physiological basis has direct clinical relevance.
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Fluid management in acute lung injury and ards. Ann Intensive Care 2011; 1:16. [PMID: 21906342 PMCID: PMC3224488 DOI: 10.1186/2110-5820-1-16] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 05/30/2011] [Indexed: 01/04/2023] Open
Abstract
ARDS is particularly characterized by pulmonary edema caused by an increase in pulmonary capillary permeability. It is considered that limiting pulmonary edema or accelerating its resorption through the modulation of fluid intake or oncotic pressure could be beneficial. This review discusses the principal clinical studies that have made it possible to progress in the optimization of the fluid state during ARDS. Notably, a randomized, multicenter study has suggested that fluid management with the goal to obtain zero fluid balance in ARDS patients without shock or renal failure significantly increases the number of days without mechanical ventilation. On the other hand, it is accepted that patients with hemodynamic failure must undergo early and adapted vascular filling. Liberal and conservative filling strategies are therefore complementary and should ideally follow each other in time in the same patient whose hemodynamic state progressively stabilizes. At present, although albumin treatment has been suggested to improve oxygenation transiently in ARDS patients, no sufficient evidence justifies its use to mitigate pulmonary edema and reduce respiratory morbidity. Finally, the resorption of alveolar edema occurs through an active mechanism, which can be pharmacologically upregluated. In this sense, the use of beta-2 agonists may be beneficial but further studies are needed to confirm preliminary promising results.
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Roch A, Guervilly C, Papazian L. Fluid Management in Acute Lung Injury and ARDS. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bosma KJ, Lewis JF. Emerging therapies for treatment of acute lung injury and acute respiratory distress syndrome. Expert Opin Emerg Drugs 2007; 12:461-77. [PMID: 17874973 DOI: 10.1517/14728214.12.3.461] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a life-threatening form of respiratory failure that affects a heterogeneous population of critically ill patients. Although overall mortality appears to be decreasing in recent years due to improvements in supportive care, there are presently no proven, effective pharmacological therapies to treat ARDS and prevent its associated complications. The most common cause of death in ARDS is not hypoxemia or pulmonary failure, but rather multiple organ dysfunction syndrome (MODS), suggesting that improving survival in patients with ARDS may be linked to decreasing the incidence or severity of MODS. The key to developing novel treatments depends, in part, on identifying and understanding the mechanisms by which ARDS leads to MODS, although the heterogeneity and complexity of this disorder certainly poses a challenge to investigators. Novel therapies in development for treatment of ALI/ARDS include exogenous surfactant, therapies aimed at modulating neutrophil activity, such as prostaglandin and complement inhibitors, and treatments targeting earlier resolution of ARDS, such as beta-agonists and granulocyte macrophage colony-stimulating factor. From a clinical perspective, identifying subpopulations of patients most likely to benefit from a particular therapy and recognising the appropriate stage of illness in which to initiate treatment could potentially lead to better outcomes in the short term.
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Affiliation(s)
- Karen J Bosma
- University of Western Ontario, Division of Respirology, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, Ontario, N6A 5A5, Canada.
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Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF, Hite RD, Harabin AL. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354:2564-75. [PMID: 16714767 DOI: 10.1056/nejmoa062200] [Citation(s) in RCA: 2215] [Impact Index Per Article: 123.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Optimal fluid management in patients with acute lung injury is unknown. Diuresis or fluid restriction may improve lung function but could jeopardize extrapulmonary-organ perfusion. METHODS In a randomized study, we compared a conservative and a liberal strategy of fluid management using explicit protocols applied for seven days in 1000 patients with acute lung injury. The primary end point was death at 60 days. Secondary end points included the number of ventilator-free days and organ-failure-free days and measures of lung physiology. RESULTS The rate of death at 60 days was 25.5 percent in the conservative-strategy group and 28.4 percent in the liberal-strategy group (P=0.30; 95 percent confidence interval for the difference, -2.6 to 8.4 percent). The mean (+/-SE) cumulative fluid balance during the first seven days was -136+/-491 ml in the conservative-strategy group and 6992+/-502 ml in the liberal-strategy group (P<0.001). As compared with the liberal strategy, the conservative strategy improved the oxygenation index ([mean airway pressure x the ratio of the fraction of inspired oxygen to the partial pressure of arterial oxygen]x100) and the lung injury score and increased the number of ventilator-free days (14.6+/-0.5 vs. 12.1+/-0.5, P<0.001) and days not spent in the intensive care unit (13.4+/-0.4 vs. 11.2+/-0.4, P<0.001) during the first 28 days but did not increase the incidence or prevalence of shock during the study or the use of dialysis during the first 60 days (10 percent vs. 14 percent, P=0.06). CONCLUSIONS Although there was no significant difference in the primary outcome of 60-day mortality, the conservative strategy of fluid management improved lung function and shortened the duration of mechanical ventilation and intensive care without increasing nonpulmonary-organ failures. These results support the use of a conservative strategy of fluid management in patients with acute lung injury. (ClinicalTrials.gov number, NCT00281268 [ClinicalTrials.gov].).
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Pellett AA, Lord KC, Champagne MS, deBoisblanc BP, Johnson RW, Levitzky MG. Pulmonary capillary pressure during acute lung injury in dogs. Crit Care Med 2002; 30:403-9. [PMID: 11889320 DOI: 10.1097/00003246-200202000-00023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To measure pulmonary capillary pressure and pulmonary artery occlusion pressures both during control conditions and during acute lung injury and to evaluate the effects of inotropic therapy and volume loading on these measurements after lung injury. DESIGN Prospective, randomized, controlled laboratory trial. SETTING University research laboratory. SUBJECTS Eighteen heartworm-free mongrel dogs. INTERVENTIONS Dogs were anesthetized (sodium pentobarbital, 30 mg/kg intravenously), intubated, and mechanically ventilated. A femoral artery and vein and the right external jugular vein were cannulated. After a median sternotomy, two pulmonary artery catheters were inserted via the jugular vein into the left and right lower lobar pulmonary arteries. Oleic acid (0.03 mL/kg) was administered to all dogs via the left pulmonary artery catheter, whereas the right lower lobe served as control. A baseline group of dogs received no further interventions, whereas two additional groups were given dobutamine (30-60 microg x kg(-1) x min(-1)intravenously) or saline boluses (1-2 L) before measurements were obtained after oleic acid lung injury. MEASUREMENTS AND MAIN RESULTS Capillary pressure was estimated in both lower lung lobes by using the pulmonary artery occlusion method. Pulmonary capillary and pulmonary artery occlusion pressures were measured before and 2 hrs after oleic acid administration. Left lower lobar capillary pressure increased in all three groups, as did the difference between capillary pressure and pulmonary artery occlusion pressure. Capillary pressure in the control right lower lobe increased significantly only in the saline-loaded dogs, whereas the difference between the right-sided capillary and occlusion pressures increased only in the dogs given dobutamine. CONCLUSIONS Oleic acid lung injury increases pulmonary capillary pressure independent of pulmonary artery occlusion pressure. The gradient between the two pressures was not significantly affected by volume loading or dobutamine infusion.
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Affiliation(s)
- Andrew A Pellett
- Department of Cardiopulmonary Science, Louisiana State University Health Sciences Center, New Orleans, LA 70112-1393, USA.
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Tibayan FA, Chesnutt AN, Folkesson HG, Eandi J, Matthay MA. Dobutamine increases alveolar liquid clearance in ventilated rats by beta-2 receptor stimulation. Am J Respir Crit Care Med 1997; 156:438-44. [PMID: 9279221 DOI: 10.1164/ajrccm.156.2.9609141] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Although it is well known that beta-adrenergic agonist stimulation increases alveolar epithelial sodium and fluid transport, it is not known whether the beta-1 or the beta-2 receptor mediates this effect. Two clinically relevant beta-adrenergic agonists, dopamine (beta-1 agonist) and dobutamine (beta-1 and beta-2 agonist) were used to define the contribution of these two beta-receptors to beta-adrenergic stimulated fluid clearance from the air spaces of the lungs. Alveolar fluid clearance was measured in anesthetized, ventilated rats over one hour after instilling an isosmolar 5% albumin solution in Ringer's lactate with 3 microCi 125I-albumin. The concentrations of the labeled and unlabeled albumin were used to quantify alveolar liquid clearance. Dopamine, whether given intra-alveolar (10(-4) M) or intravenously (5-10 micrograms/kg/min), had no effect. However, both intra-alveolar (10(-4) M) and intravenous (5 micrograms/kg/min) dobutamine increased alveolar liquid clearance by approximately 50% over one hour compared to controls. ICI 118,551, a potent and specific beta-2 antagonist, blocked the effect of dobutamine. The dobutamine effect was blocked by amiloride (10(-3) M), an inhibitor of sodium uptake. In summary, the beta-2 receptor mediates beta-adrenergic stimulation of alveolar epithelial sodium and fluid transport.
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Affiliation(s)
- F A Tibayan
- Cardiovascular Research Institute, University of California, San Francisco 94143-0130, USA
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13
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Schuster DP. What is the Mortality of ARDS? YEARBOOK OF INTENSIVE CARE AND EMERGENCY MEDICINE 1995. [DOI: 10.1007/978-3-642-79154-3_6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Mitchell JP, Schuller D, Calandrino FS, Schuster DP. Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1992; 145:990-8. [PMID: 1586077 DOI: 10.1164/ajrccm/145.5.990] [Citation(s) in RCA: 451] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We performed a randomized, prospective trial to evaluate whether fluid management that emphasized diuresis and fluid restriction in patients with pulmonary edema could affect the development or resolution of extravascular lung water (EVLW), as well as time on mechanical ventilation and time in the intensive care unit (ICU), in critically ill patients requiring pulmonary artery catheterization (PAC). PAC was performed on 101 patients. A total of 52 patients were randomized to an EVLW management group using a protocol based on bedside indicator-dilution measurements of EVLW. The other 49 patients were randomized to a wedge pressure (WP) management group in whom fluid management decisions were guided by WP measurements. A total of 89 patients had pulmonary edema (defined as EVLW greater than 7 ml/kg ideal body weight). Except for a clinically unimportant difference in mean age, the two groups were entirely comparable at baseline. The study groups were managed differently, as evidenced by cumulative input-output of 2,239 +/- 3,695 ml (median = 1,600 ml) in the WP group versus 142 +/- 3,632 ml (median = 754 ml) in the EVLW group (p = 0.001). EVLW decreased significantly, and ventilator-days and ICU days were significantly shorter only in patients from the EVLW group. No clinically significant adverse effect occurred as a result of following the EVLW group algorithm. Thus, a lower positive fluid balance, especially in patients with pulmonary edema regardless of cause, is associated with reduced EVLW, ventilator-days, and ICU days.
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Affiliation(s)
- J P Mitchell
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
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Wickerts CJ, Blomqvist H, Berg B, Rösblad PG, Hedenstierna G. Furosemide, when used in combination with positive end-expiratory pressure, facilitates the resorption of extravascular lung water in experimental hydrostatic pulmonary oedema. Acta Anaesthesiol Scand 1991; 35:776-83. [PMID: 1763601 DOI: 10.1111/j.1399-6576.1991.tb03390.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The study aimed to establish whether furosemide given intravenously improved resorption of hydrostatic pulmonary oedema in 14 dogs mechanically ventilated with positive end-expiratory pressure (PEEP). Hydrostatic pulmonary oedema was created by simultaneous inflation of a left atrial balloon and rapid intravenous infusion of isotonic saline. The hydrostatic process was terminated by deflating the balloon and reducing the infusion rate. A PEEP of 10 cmH2O (1.0 kPa) was applied in all animals; in seven, furosemide was administered (diuretic group), 1 mg/kg intravenously as a bolus followed by an infusion of 0.5 mg/kg per hour, while the remaining seven dogs served as a control group. All dogs were studied for a period of 4 h. The extravascular lung water measured with the double indicator dilution technique was 28.3 +/- 3.8 (diuretic group) and 28.2 +/- 6.8 ml/kg (control group) during maximum oedema. It was reduced to 16.4 +/- 2.2 (diuretic group) vs 19.8 +/- 3.7 ml/kg (control group) after 4 h of resorption, P less than 0.05. Postmortem gravimetric values of extravascular lung water were 9.1 +/- 3.4 (diuretic group) vs 12.6 +/- 5.0 g/kg (control group). In the diuretic group the urinary output increased threefold, and haemoglobin and serum protein concentrations were higher than in the control group. There was a significantly greater decrease in cardiac output and central blood volume in the diuretic group. In conclusion, furosemide given intravenously improved lung fluid resorption in hydrostatic pulmonary oedema, probably by increasing the plasma colloid osmotic pressure.
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Affiliation(s)
- C J Wickerts
- Department of Anaesthesia and Intensive care, Danderyd Hospital, Sweden
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Donaldson LL. A review of the pathophysiology of exercise-induced pulmonary haemorrhage in the equine athlete. Vet Res Commun 1991; 15:211-26. [PMID: 1882515 DOI: 10.1007/bf00343226] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In the United States, more than 75% of equine athletes are reported to suffer from exercise-related haemorrhage of the respiratory tract (Voynick and Sweeney, 1986; Sweeney et al., 1990). Fiberoptic endoscopy has traced the source of blood to beyond the bifurcation of the trachea. In 1981, the term exercise-induced pulmonary haemorrhage (EIPH) was introduced (Pascoe et al., 1981). Racehorses of all breeds, polo ponies and three-day event horses of mixed heritage, even foxhunters, may 'bleed' (Voynick and Sweeney, 1986; Pascoe et al., 1981; Sweeney and Soma, 1983; Hillidge, 1986). Any horse working at speeds greater than 240 m/min is at risk (Voynick and Sweeney, 1986). The impact of exercise-induced pulmonary haemorrhage is difficult to assess. Most attempts to demonstrate statistically a negative correlation between EIPH and performance have been unrewarding, largely due to the number of uncontrollable variables (Pascoe et al., 1981; Raphel and Soma, 1982). In racing thoroughbreds (Mason et al., 1983) and standard breeds (MacNamara et al., 1990) approximately half as many EIPH-positive as EIPH-negative horses were placed in their races. Based on extensive intrapulmonary haemorrhage, a 3-year prospective study of sudden deaths in exercising thoroughbreds concluded that 9 out of 11 deaths were attributable to EIPH (Gunson et al., 1988). By correlation of clinical signs, thoracic radiographs, ventilation/perfusion scintigraphy, gross and subgross pathology and histopathology in 26 affected thoroughbreds, EIPH has been associated with chronic small airway inflammation, proliferation of subpleural, peribronchial and septal bronchial arterioles, interstitial connective tissue fibrosis and alveolar septal disruption in the dorsocaudal lung lobes (O'Callaghan et al., 1987). From this work it was proposed that the initial insult of EIPH started as focal, dorsocaudal pulmonary peribronchial inflammation which resulted in bronchial arterial neovascularization. Haemorrhage then occurred when, during exercise, bronchial blood pressure increased in fragile capillary buds. The incidence of bronchitis/bronchiolitis, regardless of aetiology, has been estimated to be 30% in non-racing equine athletes and close to 100% in one group of racing thoroughbreds (Sweeney et al., 1989). Histological study of lungs from horses with mild, moderate and severe chronic small airway disease consistently revealed a greater density of lesions in the diaphragmatic lobes (Winder and von Fellenberg, 1988). To understand further the aetiology and/or pathophysiology of EIPH, we will first explore some aspects of general mammalian and specific equine pulmonary and bronchial vascular anatomy and physiology. Exercise-related changes in these systems in normal and EIPH-positive horses will be briefly reviewed.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- L L Donaldson
- Marion duPont Scott Equine Medical Center, Virginia-Maryland Regional College of Veterinary Medicine, Leesburg 22075
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Calvin JE. Right ventricular afterload mismatch during acute pulmonary hypertension and its treatment with dobutamine: A pressure segment length analysis in a canine model. J Crit Care 1989. [DOI: 10.1016/0883-9441(89)90064-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hasinoff I, Ducas J, Prewitt RM. Increased cardiac output increases lung water in canine permeability pulmonary edema. J Crit Care 1988. [DOI: 10.1016/0883-9441(88)90106-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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