title: Early-phase changes of extravascular lung water index as a prognostic indicator in acute respiratory distress syndrome patients.
abstract: BACKGROUND
  The features of early-phase acute respiratory distress syndrome (ARDS) are leakage of fluid into the extravascular space and impairment of its reabsorption, resulting in extravascular lung water (EVLW) accumulation. The current study aimed to identify how the initial EVLW values and their change were associated with mortality.
  
  
  METHODS
  This was a post hoc analysis of the PiCCO Pulmonary Edema Study, a multicenter prospective cohort study that included 23 institutions. Single-indicator transpulmonary thermodilution-derived EVLW index (EVLWi) and conventional prognostic factors were prospectively collected over 48 h after enrollment. Associations between 28-day mortality and each variable including initial (on day 0), mean, maximum, and Δ (subtracting day 2 from day 0) EVLWi were evaluated.
  
  
  RESULTS
  We evaluated 192 ARDS patients (median age, 69 years (quartile, 24 years); Sequential Organ Failure Assessment (SOFA) score on admission, 10 (5); all-cause 28-day mortality, 31%). Although no significant differences were found in initial, mean, or maximum EVLWi, Δ-EVLWi was significantly higher (i.e., more reduction in EVLWi) in survivors than in non-survivors (3.0 vs. -0.3 mL/kg, p = 0.006). Age, maximum, and Δ-SOFA scores and Δ-EVLW were the independent predictors for survival according to the Cox proportional hazard model. Patients with Δ-EVLWi > 2.8 had a significantly higher incidence of survival than those with Δ-EVLWi ≤ 2.8 (log-rank test, χ (2) = 7.08, p = 0.008).
  
  
  CONCLUSIONS
  Decrease in EVLWi during the first 48 h of ARDS may be associated with 28-day survival. Serial EVLWi measurements may be useful for understanding the pathophysiologic conditions in ARDS patients. A large multination confirmative trial is required.
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan ; Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8654, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Tagami
authors.affiliation: Intensive Care Unit, Nagasaki University Hospital, Nagasaki 852-8501, Japan.
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Nakamura
authors.affiliation: Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Miyagi 986-2242, Japan.
authors.forename: Shigeki
authors.initials: S
authors.lastname: Kushimoto
authors.affiliation: Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Fukushima 965-8611, Japan.
authors.forename: Ryoichi
authors.initials: R
authors.lastname: Tosa
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan.
authors.forename: Akihiro
authors.initials: A
authors.lastname: Watanabe
authors.affiliation: Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi 755-8505, Japan.
authors.forename: Tadashi
authors.initials: T
authors.lastname: Kaneko
authors.affiliation: Department of Emergency and Critical Care Medicine, Nara Medical University, Nara 634-8522, Japan.
authors.forename: Hidetada
authors.initials: H
authors.lastname: Fukushima
authors.affiliation: Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka 534-0021, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Rinka
authors.affiliation: Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Miyagi 986-2242, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Kudo
authors.affiliation: Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, Fukuoka 830-0011, Japan.
authors.forename: Hideaki
authors.initials: H
authors.lastname: Uzu
authors.affiliation: Department of Emergency and Critical Care Medicine, Fukuoka University Hospital, Fukuoka 814-0180, Japan.
authors.forename: Akira
authors.initials: A
authors.lastname: Murai
authors.affiliation: Department of Anesthesia and Intensive Care, Hiroshima City Hospital, Hiroshima 730-8518, Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Takatori
authors.affiliation: Advanced Emergency and Critical Care Center, Kansai Medical University Takii Hospital, Osaka 570-8507, Japan.
authors.forename: Hiroo
authors.initials: H
authors.lastname: Izumino
authors.affiliation: Department of Critical Care Medicine, Jikei University School of Medicine, Tokyo 105-8461, Japan.
authors.forename: Yoichi
authors.initials: Y
authors.lastname: Kase
authors.affiliation: Intensive Care Unit, Kobe City Medical Center General Hospital, Hyogo 650-0046, Japan.
authors.forename: Ryutarou
authors.initials: R
authors.lastname: Seo
authors.affiliation: Shock Trauma and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo 113-8519, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Takahashi
authors.affiliation: Department of Emergency and Critical Care Medicine, Kansai Medical University, Osaka 570-8506, Japan.
authors.forename: Yasuhide
authors.initials: Y
authors.lastname: Kitazawa
authors.affiliation: Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan.
authors.forename: Junko
authors.initials: J
authors.lastname: Yamaguchi
authors.affiliation: Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo 177-8521, Japan.
authors.forename: Manabu
authors.initials: M
authors.lastname: Sugita
authors.affiliation: Department of Intensive Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Kanagawa 230-8765, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Takahashi
authors.affiliation: Department of Emergency and Critical Care Medicine, Social Insurance Chukyo Hospital, Aichi 457-8510, Japan.
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Kuroki
authors.affiliation: Emergency and Critical Care Medicine, National Hospital Organization Disaster Medical Center, Tokyo 190-0014, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Kanemura
authors.affiliation: Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan.
authors.forename: Kenichiro
authors.initials: K
authors.lastname: Morisawa
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School, Chiba Hokusou Hospital, Chiba 270-1694, Japan.
authors.forename: Nobuyuki
authors.initials: N
authors.lastname: Saito
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School, Tama Nagayama Hospital, Tokyo 206-8512, Japan.
authors.forename: Takayuki
authors.initials: T
authors.lastname: Irahara
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Yokota
keywords: Acute lung injury; Hemodynamics; Pulmonary edema; Transpulmonary thermodilution; Vascular permeability