Critical Care Medicine

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Critical Care Medicine:
doi: 10.1097/CCM.0b013e31828a2323
Clinical Investigations

End-Expiratory Occlusion Test Predicts Preload Responsiveness Independently of Positive End-Expiratory Pressure During Acute Respiratory Distress Syndrome

Silva, Serena MD1,2; Jozwiak, Mathieu MD1,2; Teboul, Jean-Louis MD, PhD1,2; Persichini, Romain MD1,2; Richard, Christian MD1,2; Monnet, Xavier MD, PhD1,2

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Abstract

Objective: A 15-second end-expiratory occlusion increases cardiac preload and allows detection of preload dependence. We tested whether the reliability of this test depends upon positive end-expiratory pressure.

Design: Prospective study.

Setting: Medical ICU.

Patients: Thirty-four patients presenting with acute circulatory failure and acute respiratory distress syndrome ventilated with a tidal volume of 6.7 mL/kg (interquartile range, 6.3–7.1).

Measurements: At positive end-expiratory pressure = 5 cm H2O, we measured the changes in cardiac index induced by end-expiratory occlusion and a passive leg raising test. Preload dependence was defined by a passive leg raising–induced increase in cardiac index greater than or equal to 10%. Positive end-expiratory pressure was increased to a plateau pressure of 30 cm H2O, and end-expiratory occlusion and passive leg raising were performed again.

Main Results: At positive end-expiratory pressure = 5 cm H2O, 29% of patients were passive leg raising responders. An end-expiratory occlusion–induced increase in cardiac index greater than or equal to 5% detected a passive leg raising–induced increase in cardiac index greater than or equal to 10% with a sensitivity of 90% (95% CI, 56–100) and a specificity of 88% (95% CI, 68–97). At higher positive end-expiratory pressure (15 cm H2O [interquartile range, 13–15]), the plateau pressure – positive end-expiratory pressure difference did not change (15 mm Hg [14–17] vs 15 mm Hg [13–18] before the positive end-expiratory pressure increase). Increasing positive end-expiratory pressure significantly reduced cardiac index in passive leg raising responders (–27% [interquartile range, –6 to –56]) but not in other patients. At high positive end-expiratory pressure, passive leg raising increased cardiac index to a larger extent than at positive end-expiratory pressure = 5 cm H2O (19% [interquartile range, 15–34] vs 16% [interquartile range, 13–23], respectively). The proportion of passive leg raising responders significantly increased (34 vs 29%, respectively), meaning preload dependence had increased. At higher positive end-expiratory pressure, an end-expiratory occlusion–induced increase in cardiac index greater than or equal to 6% detected a passive leg raising–induced increase in cardiac index greater than or equal to 10% with a sensitivity of 100% (95% CI, 75–100) and a specificity of 90% (95% CI, 70–99).

Conclusions: The end-expiratory occlusion test is reliable for detecting preload dependence whatever the positive end-expiratory pressure during acute respiratory distress syndrome.

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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