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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 �

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�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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�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�/.��

� �

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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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