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� � ����������Vol. 34, pp. 359�368, 2006
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� �/�) 01234�5678) 9�:3;<�= �central venous pressure: CVP�) �>��
�= �pulmonary artery wedge pressure: PAWP� ?@AB�CDEFG4�5HIJ) �K�>��LM�5NJOPQR STUVW��BX �intrathoracic blood volume index: IT-BVI�) �V4YZ��BX �extravascular lung water index: EVLWI� [D8V4\]^BX�permeability index: PI� _FG4�:B�CD8`�aQ87R*�K�>��LM�bcd��eA�Zf �pulmonary edema: PE� 81 5ghD) [:!"^AijDE* klA<Z=#mn�Zf �hydrostatic pulmonary edema: hydr. PE� 2 )CV4\]^#mn�Zf �increased permeability pulmonary edema: perm. PE� 6 5�$D) %o:) ITBVI, EVLWI, PI A&pDE*ITBVI q hydr. PE _ perm. PE 5&r�sAtDE* EVLWI q%o5uq?HvE*PI q perm. PE o_�sAtDE*hydr. PEC perm. PE C:w'_) ITBVI, EVLWI) PI 5NJx(yzvE* ){5
|}EZ�4�_~QP����d�AB�C�R~C5NJx(yzR*
�����^��� �ALI�ARDS�) �K�>��LM�) �Zf) �V4YZ��) FG>{bcd�
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1996� Connors P q�>������ �pul-monary artery catheter: PA������A"7E��:234�q��:*���5�+D?7�HJH) *�) ��,A��a�RC-�DE1�*[:�) Sandham P2�) Richard P3�q) PA �
����A"7E��4�:��^A�h����
�yijDE* � ) ��:*�A��a�R~Cq?7_) PA �����5NJOE¡�dAB�CDE��4�:.¢q?7~CA-�DE*01��5k�R23£/Cq¤¥d�¦¥�§¨©0ª«¬®§¨:E¯:) FGVW�) °W�4�C;�±(:§¨©1²_³2´aQR*FGVW�3µ:B�CD8¶E CVP © PA �����5NR PAWP :"4^5·5_¸8¶E¹º) ~Q5Iv8�K�>��LM�5NRSTUVW� �ITBV: intra-thoracic blood volume�C�V4YZ�� �EVLW: extra vascular lung wa-
�������� »���������� Y��;¼V4Y��
359
147
ter� ���������� ITBV ��� � ������������ EVLW ������������������� !���"�"#$%&��'(� )*� ITBV,EVLW +,� PI ��,-� ./0012345 ICU /,-��� 8$� �6�7 �89����-��7����:�� +���;�<=,-�
�����
0012345>/,� ���?@AB"���7����-��6�7 �89� �PiCCOmonitor, Pulsion Medical Systems, AG, Munich,
Germany� C���7����:D- 8��EF?,-� GH� �6�7 �89�� PiCCO?I��JK�%&�EF?,-�L�MNO retrospec-
tive study ���� %&�PQ� #$�'(� )*�R��ST5TU��VWX�Y�?,�Z-�%&��� !� �Table 1�� ALI�ARDS [
�B"���\J;�]��� �increased perme-ability pulmonary edema: G^ perm. PE ?��� 6�?_;��� [�B"�`�a�]b����increased hydrostatic pulmonary edema: G ^hydr. PE ?��� 2 ����� perm. PE 6 �ARDS�ALI � 4 c�@Ade� 1� 1;�$� 2�f� Xg��hijk� 3� P�F ratio�300� 4� l
�amn���� ��-,��-� o-_pq%�� rs?4�� 3�� �tu>��v wx�y�����z{ �direct injury type� �|� } ;�|� ~!������ +,� 3�� sepsis �� �p,� |$;���S�3�� humoral mediator
��z{�_p?�����z{ �indirect injurytype� ��D-4��8��%& � �� 85�� PiCCO C����:���EF?,-� �������%&�Y�,����� ��Y" 2��_�?,� %&�#��$�,-?� ���y��,-� ���%� ��������&�� �Mm����('�ALI �ARDS �� P �F ratio 300 Gm� +,�PiCCO C����()?*AB"-��?,-� ¡��� Unpaired T-test ���-�PiCCO���_� 1� a+¢��? 2� �8
9����� ��B"�£¤¥545�� 2 !��Table 2�� �89 C��� Swan-Ganz Cathe-ter C�+"?_�P¦���� -§,�PiCCO �� ¨©23�5�ª,,-'` ¤�3��«¬UU5¥3ST5TU� 1312-8TG� "�®5¯°±����,--��²³� �7` � l³�6�� ´�7 V,-ST5TU �5Fr. thermodilution catheter, PV4046, PulsionMedical Systems AG�¨©23�5���¨©�µ¶,� 2����89 C·R��£¤¥545��������.¸¹�¹ 1 !� �Fig. 1��
Table 1. Characteristics of Study Patients
º/»0 1 ¼2 �360
148
CV �������� 15 ml 3�� �� ������������PiCCO ��������� ! 2�"#� $
��%�&� ��'�()�*�*�+�,���-� ITBV ���./ ITBVI ��ITBV�0!12�� EVLW ���./ EVLWI ��EVLW�03����4 EVLW� ITBV��567��89:;<./ �permeability index: PI�EVLW�ITBV� (=��$��5��� �>?@ 2�AB�C��4"# �Fig. 2��56DE�FG4-H�I�J(=�� KL-CV ������� �� M�NO�P ��Q�R�(STUV�� WXYZ[�� $�WXYZ[��\]�%�&� �56#�5��\]�5�-�� ^� PiCCO _0+`Na�56�b1�!"#��ITTV�CO�MTT
PTV�CO�Te�pdecGEDV�ITTV�PTVITBV�a�GEDV�b �cd�eG4- a�1.16� b�86 ml�m2�EVLW�ITTV�ITBV
ITTV: intrathoracic thermal volume �fghWij�MTT: mean transit time �k;lm�CO: cardiac output �nopj�PTV: pulmonary thermal volume �qhWij�Texpdec: exponential decay time �./r/astum�GEDV: global end-diastolic volume �nvwxyuij�ITBV: intrathoracic blood volume �fgh8zj�EVLW: extra vascular lung water �89{|j�
Table 2. The PiCCO Measures the Following Parameters
Fig. 1. Transpulmonary thermodilution method �PiCCO systems�.
q}~NOWXYE����� ��� 361
149
� �
�� ITBV � EVLW ����perm. PE�� hydr. PE�� ITBV �EVLW �
����� 3� � �Fig. 3�� perm. PE ����ITBV �������EVLW������������� ITBVI �intrathoracic blood volume index�ITBIVI�ITBV����� ����� ����700� 1000 ml �m2 �� � ITBVI � hydr. PE
�group B� 1183.5�160.7 ml�m2 perm. PE �groupA� 966.4�260.5 ml�kg� hydr. PE ���!��Fig. 4, p�0.01���� EVLWI �extravascular lung water index�EVLWI�EVLW��" ���� � ����10.0 ml�kg #$�� � perm. PE �group A�: 13.9�5.2 ml�kg, hydr. PE �group B�: 14.9�5.3 ml�kg�EVLWI �%&��'��()*�+,�� �Fig.5���� PI �permeability index�
Fig. 2. A schema of volumetric parameters obtained by PiCCO.
Fig. 3. A scatter diagram of ITBV and EVLW in permeability PE and hydrostatic PE.
�: permeability PE. : hydrostatic PE.
-./0 1 23 4362
150
PI � EVLW �ITBV ������� perm. PE�group A�: 0.60�0.28� hydr. PE �group B�: 0.41�0.14 � perm. PE ��� �� �Fig. 6, p�0.01��
� �
�� ����������������� hydrostatic pul-monary edema �hydr. PE: ����� ���� �increased permeability pulmonary edema �perm.PE: !"#�� ���� �$%���� &��'(����)*��$%+,-.� /01234�5��67,-��89:;� hydr. PE ��<=�>?��$@��A(���� �B�C�,-.DE#����FG���� H1 perm. PE ��� �IJKLMN�B.C�IJO�PQA(�9.IJKRS�$@����,-.� ALI�ARDS �FG���� perm. PE ��S��T� UV#�T9W��XYPQZ:.[\8� direct injury �XYPQ� ALI�ARDS � sepsis 9W��]^_���`
Fig. 4. Comparison of ITBVI between group A �perme-ability PE� and group B �hydrostatic PE�. ITBVIwas significantly higher in hydrostatic PE than
those in permeability PE �p�0.01�.
Fig. 5. Comparison of EVLWI etween group A �perme-ability PE� and group B �hydrostatic PE�. Therewas no significant di#erence between group A
and B.
Fig. 6. Comparison of PI between group A �permeabi-lity PE� and group B �hydrostatic PE�. PI inpermeability PE was significantly higher than
those in hydrostatic PE �p�0.01�.
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�������� humoral mediator ���indirect injury � ���� ����������������������������
�� �� CVP� PAWP �PAOP� �� ������!"�#�$� perm. PE � hydr. PE ��%���&'( �� �)*+","������-�.��������/,��"� 0�0�1#�$�)����2��,� CVP, PAWP ���.�+3 �!"4#�5���6���7�+89� �:�;�<����� �<�=)���2�+>?��"� @#�A�"�4 ITBV� B EVLW +C�� !�!�"#�D�� #��$"EFG��;��H���IJ���Marik 5�� CVP �%�<�������&K�� CVP ��<����� ��L�MN1OPQR� PAWP 1$"STU'VW���2����:X���JY"� ��0Z PAOP �STU'VW[ �LVEDP� �2��D:� STU'VW���LVEDV� �2������ #�(\�)4 PA �]�EFG+2��,"�������*I�^��_�D��$�JY���6���� ALI�ARDS ����ARDS �`�abc+�,+��de�� ALI �`�
���� ��� 1967- Ashbaugh 57�4f�g������4� hijkB=����./,�`�ab�0+1���2+/3,� @�I Petty 58�4�labc+�de �Adult respiratory distress syn-drome� �45,"�1992-� 6mn7g�op �ATS� �qrs8.
�op �ESICM� ����t9u:p �AECC� ����� ALI�ARDS �!v� w;xy� /<z{�*I� �&|}�~?=��4$�?5�"9��ARDS�ALI�����>�?�<��@� �>'@��A��B~�x��Cf_��)*�D�10����2�1� perm. PE2 �ALI�ARDS�����PI 4D��+1 ���+�,� hydr. PE ��<�?A�����+E;��,"��� ����� �ITBV� �������EVLW�1992-� Lichtwarck-Ascho#511�� CI� � CVP@,� PCWP �PAWP� ��MN�5� CVP �PCWP �PAWP��fFGH��2��,��IJ�D:� ITBV4DK�2��D�#�+K�,"�
@�I9L�K�4.!� �-fF�GH�2��,� CVP B PAWP �M0:� n��<����ITBV� ��;�4�N�����12������������ <������1��<�=)��� !�� �����s8.�����-�O�P��)*� ab�0�/<+QR�S���H)����.�=�+�!,� @�TJ�+U�'�%���D�� ,�, PAWP �Cf_�@,�f_���)*�2��,��v4V�#�4���"13�15��#�$� PAWP 4Sf��GH�2��,�W�5��!"�XPY����#����� ��0Z� <��P+��SfT���GH��STU'ZW���D�4� fT�[���MN4[��D���!���STU'ZW[�MW�!�� �5�� \]^g�4�-��STU'ZW[�_�S`[�MW�!�� PCWP D��� PAOP �� �ab�4c��dt+��VZ<���D�#�+eW,� fgD���� F�h¡��:�ab�[ij+¢;���� _�S`[�£¤_¥��#�+�XPY��,���16�� ��0Z[���MN4[��D���!,�STU'ZW[�5GH���+¦!,��"� �#§4�&2��kR,1[�MN4�l,��#�4�m�D��Mitchell 517�� PAWP �M0 ��<�=)�
� �EVLW� +2��,"����4���ab¨noW ��© ICU ªTp«+¬�Q��K�,"��)*�w;����� EVLW �n7®��¯�°��:18±�4�� 18�� $" EVLW ��2��qr���� EVLW ������*I2���:²��1K���"19��0�0�1"#��:�)*�"��D�
EVLW+G�³´F�U�#�4�!� n7 X [���#���� �)*�sªP�ytµ�BuW/<+U�#�4�!� �&P�v!�wl ���� ¶·��� ITBV,� EVLW� IP+ !,� )�x¸�� y���Mz�¹ J":�{|�� {|}����~º��»º������+�!,������ EVLW ����������� �� ������� �: single transpulmonary thermodi-lution ��)*�!�P��#�,� gravimetric ��
��¼� _ �� 5364
152
��� gold standard ������� ���� ������ ��� �������EVLW������������� double indicator������ �������� � !"��� EVLW��"�#���$�� %""� �&��'�()��*������ ���+ � ,!��-����� "��.�������: singletranspulmonary thermodilution � �PiCCO, Pul-sion Medical Systems, Munich, Germany� ����2004�� Katzenelson � 5����"/0123
�� 4567839� perm. PE 9� ,�� hydr.PE9"�:�;��%� PiCCO�� EVLWI�� gold standard ���<=���EVLW �����)�>��!��?� ��� perm.PE� hydr. PE���� ITBV, EVLW�PI
ITBVI � CVP @ PAWP �A�#�� !B�?�������12������"28C�%� " 3 ?� ���perm. PE 9�� ITBV �,�DEF��?�:�% EVLW �F)� G " 6�?� �� PI �hydr. PE 9#HF��?� � !�� perm. PE9;�����$%� !B�?� ITBVI �I&�� ���'JK�� ��(L�I) �PI������M"��*N �456783��!��O+��A� perm. PE ",-�����./P�(L�01�23��Q4�"56��R)?S���2004 �� Katzenelson �5���7/0�� perm.PE "89T�/P"��"U:��V" EVLWI� hydr. PE " EVLWI �#W� perm. PE ;��F��?�!��?� �X�Y�"��28C��� EVLWI � perm.PE � hydr. PE ;9Z���+ � !��� [0<� perm. PE 989,��\9T�/P�]^!��_`�=���� ,"ab�>cd�e+���fg"?�� U:h`��89T�/P" EVLWI �@"89T;�i\9T�/P#H�AjF��?�!��BC����� ��� ��k����Dl� �X9"E-�]�� EVLW� PI m��,�n�FG�?��op���� qr� perm. PE ��� ALI�ARDS �%_`E-�A ITBV, @ EVLW �FG"����?�!��HI��� !��gC��!��Q
4JK�sL���op� tMu�����./P"I&�����.(L�: PI ��
perm. PE9� hydr. PE9#H�AjZ�%+�F��?� � Nv�wx�O Py�� !�G���<;����"zE-"{�� PI �AQC� R|��)� ����"R|�}~�������perm. PE "�E-��5�6��5� ��6��5� S�����C8��E����.$����� ,��p��$%@�"�����:��%Tp�!��U���$%��\�� �VM"*NM8���� X�� hydr. PE����.�������� �E-�����."�%�W�)Tp L��%� �!B�A�~���$J��*N���op���� !"!����(L�/P"I&��� PI �� perm. PE ;�� hydr.PE �AF��?�_`�op������������ hydr. PE X����7���� �5��E"YZ�[\���� Q4��perm. PE �YZ���%]�^(���" ~" 3¡�5_�[\� ¢?����C8�`�a[\�E�� ITBV, EVLW� IP"28C�£e+���� J�� perm. PE �,",-�����(L��sL��Q4��56�op���� PiCCO�� hemodynamic monitoring� ����,�"Yb�� 1� ���$M�¤8¤3�cd�6¥:� ef�� g/P� ���h¦�ij"�k��)lm§���� 2� ��",-����������EVLW�"��¨n���� 3�EVLW ��%��$%�o©�� ITBV ��¨n��A� ª«�-�'� p¬�'W�)\���®b� 1� #W�q�r¯��M"�¤8¤3st�6�� �¬°±� �u�v"²_³�HI���� 2� �¤8¤3h`´w³� 3� µ²x��¶ yz{��e¨n� �E��·�������"�!¸� ¹|"����¤8¤3�#W
�� �¤8¤3h`´w³�v}{��������A� ���u�.0������ 4�6�����¤8¤3�~�����
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1� �� 8 <X���.�������
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�PiCCO� ���������� ��� ��������� ���������� ��!���"#$� �%��!�2� �&'�()�*+,-.�� perm. PE "hydr. PE / ITBVI 0 PI ���123-4�56�/789:��3� perm. PE �;!1�� ITBV �<=">�?@AB�CDEF� �G-��&'�HI�JK-.�� LMN-.�?OPQ��M�RS�TU�HIV�WX/YZ-.�["�78U��4� ARDS�ALI"��&'�\]�^N">))_� `a�MN�bc 1 )�def-.�� ghperm. PE � 2)�*+,� direct injury type "indirect injury type�;!1� ITBV, EVLW, PI�i�9j�klU�YZ/.�� [:��m ALI�ARDS �n��MN�TU��o/pqm� HIrs�tu/vjw���56�/.��
� �
1� Connors AF, Jr. � Spero# T, Dawson NV,Thomas C, Harrell FE, Jr. � Wagner D, Des-biens N, Goldman L, Wu A W, Cali# RM,
Fulkerson W J Jr, Vidaillet H, Broste S, Bel-
lamy P, Lynn J and Knaus W A. The e#ectiv-
eness of right heart catheterization in the initial
care of critically ill patients. SUPPORT Inves-
tigators. Jama 1996; 276: 889�897.2� Richard C, Warszawski J, Anguel N, Deye N,Combes A, Barnoud D, Boulain T, Lefort Y,
Fartoukh M, Baud F, Boyer A, Brochard L
and Teboul JL. Early use of the pulmonary
artery catheter and outcomes in patients with
shock and acute respiratory distress syndrome:
a randomized controlled trial. Jama 2003; 290:
2713�2720.3� Sandham J D, Hull RD, Brant R F, Knox L,Pineo G F, Doig C J, Laporta D P, Viner S,
Passerini L, Devitt H, Kirby A and Jacka M .
A randomized, controlled trial of the use of
pulmonary-artery catheters in high-risk surgi-
cal patients. N Engl J Med 2003; 348: 5�14.4� xyVz{^|}~�� ARDS �+��+D�����. ALI�ARDS �I�����+��+D� 2005�10�01� 1�� 1�� �
5� Katzenelson R, Perel A, Berkenstadt H, Preis-man S, Kogan S, Sternik L and Segal E. Accu-
racy of transpulmonary thermodilution versus
gravimetric measurement of extravascular lung
water. Crit Care Med 2004; 32: 1550�1554.6� Marik P. Handbook of Evidence-Based Criti-cal Care. New York: Springer-Verlag; 2001:
123�139.7� Ashbaugh DG, Bigelow DB, Petty TL andLevine BE. Acute respiratory distress in adults.
Lancet 1967; 2: 319�323.8� Petty TL, Ashbaugh DG. The adult respiratorydistress syndrome. Clinical features, factors in-
fluencing prognosis and principles of manage-
ment. Chest 1971; 60: 233�239.9� Bernard GR, Artigas A, Brigham KL, Carlet J,Falke K, Hudson L, Lamy M, Legall JR, Mor-
ris A and Spragg R. The American-European
Consensus Conference on ARDS. Definitions,
mechanisms, relevant outcomes, and clinical
trial coordination. Am J Respr Crit Care Med
1994; 149: 818�824.10� Ware LB, Matthay MA. The acute respiratorydistress syndrome. N Engl J Med 2000; 342:
1334�1349.11� Lichtwarck-Ascho# M, Zeravik J and Pfei#er
UJ. Intrathoracic blood volume accurately re-
flects circulatory volume status in critically ill
patients with mechanical ventilation. Intensive
Care Med 1992; 18: 142�147.12� Manson N, Fraude A, Holst B, Saayman G
and Findlay G. The e#ect of continuous veno-
venous haemofiltration on PiCCO haemody-
namic parameters. Critical Care 2005; 9 Suppl
1: 65.
13� Bindels AJ, van der Hoeven JG and MeindersAE. Pulmonary artery wedge pressure and ex-
travascular lung water in patients with acute
cardiogenic pulmonary edema requiring me-
chanical ventilation. Am J Cardiol 1999; 84:
1158�1163.14� Sibbald WJ, Short AK, Warshawski FJ, Cun-ningham DG, Cheung H. Thermal dye meas-
urements of extravascular lung water in criti-
���� � �� j366
154
cally ill patients. Intravascular Starling forces
and extravascular lung water in the adult respi-
ratory distress syndrome. Chest 1985; 87: 585�592.
15� Takayama Y, Iwasaka T, Sugiura T, Sumi-moto T, Takeuchi M, Tsuji H, Takashima H,
Taniguchi H and Inada M. Increased extravas-
cular lung water in patients with low pulmo-
nary artery occlusion pressure after acute myo-
cardial infarction. Crit Care Med 1991; 19: 21�25.
16� ����� ������ �������� Swan-Ganz �������� ����2003; 27: 1209�1212�
17� Mitchell JP, Schuller D, Calandrino FS andSchuster DP. Improved outcome based on
fluid management in critically ill patients re-
quiring pulmonary artery catheterization. Am
Rev Respir Dis 1992; 145: 990�998.18� Halperin BD, Feeley TW,Mihm FG, Chiles C,
Guthaner DF and Blank NE. Evaluation of
the portable chest roentgenogram for quanti-
tating extravascular lung water in critically ill
adults. Chest 1985; 88: 649�652.19� Sakka SG, Klein M, Reinhart K and Meier-
Hellmann A. Prognostic value of extravascular
lung water in critically ill patients. Chest 2002;
122: 2080�2086.
��� !"#$%&'()*+,-. 367
155
Abstract
The Usefulness of Transpulmonary Thermodilution Method for
Hemodynamic Monitoring in Pulmonary Edema
Yosinari Fujinawa1, Yasuhiko Taira1, Kenichirou Morisawa1,
Hiroo Takahashi1, Masateru Takahashi1, Yoriko Egami1,
Yasuaki Koyama1, Hitoshi Ohashi1, Nobuhiko Shimozawa1,
Takashi Sakaino1, Eiichiro Hagiwara1, Tkahumi Wada1,
Yoshihiro Masui1, and Toshiya Kobayashi2
In recent years, the utility of hemodynamic monitoring by PiCCO systems �Pulsion Co. � Germany� forcritically ill patients has received attention.
Pulmonary edema �PE� is a common finding in many critically ill patients.The pathophysiological mechanism leading to PE is accumulation of fluid in the interstitial and alveolar
space in the lungs, termed extravascular lung water index �EVLWI�.The principles of PiCCO systems are pulse contour and single thermodilution methods. Especially,
single tehrmodilution method provides intrathoracic blood volume index: ITBVI and extravascular lung
water: EVLWI.
The purpose of this study was to investigate the utility of ITBVI and EVLWI as the parameters for
hemodynamic management for patients with pulmonary edema.
Eight patients with pulmonary edema received intensive care, including hemodynamic monitoring by
PiCCO systems, in our ICU were included. The eight patients were classified into group A: increased
permeability pulmonary edema, n�6 and group B: hydrostatic pulmonary edema, n�2.ITBVI, EVLWI and permeability index �PI� obtained by PiCCO were compared between group A and
group B.
ITBV values were indexed by the predicted body weight: ITBVI. EVLW values were indexed by the
predicted body surface: EVLWI. PI was shown as EVLW divided by ITBV. ITBVI was significantly higher
in hydrostatic PE �group B� than in increased permeability PE �group A�.There was no statisticallysignificant di#erence in EVLWI between group A and B. PI was significantly higher in group A than ingroup B.
ITBVI, EVLWI, and PI obtained by PiCCO can allow di#erentiation between increased permeabilityPE and hydrostatic PE. These parameters may play an important role for hemodynamic management in
critically ill patients.
Key Words
ALI�ARDS, pulmonary edema, ITBV �intrathoracic blood volume�,EVLW �extaravascular lung awter�, PI �permeability index�
1 Department of Emergemcy Clitical Care Medicine, St Marianna University School of Medicine2 Department of Cardiovascular Surgery, St Marianna University School of Medicine
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