Fluid Therapy in Pulmonary Diseases

Dr Parthiv MEHTACentral United Hospital, Ahmedabad

There are some 300 million alveoli in two adult lungs, to provide a surface area of some 160 m2 (equal to that of a tennis court and 80 times the area of our skin!). Exposure to environment 24X7X365!

Lung … Structure…

Lungs and body structure..

I’m Thin, My Lungs are Happy..

I’m Moderate…Lungs feel OK..

Oh dear…I’m Compressed..

See the Difference…

Pulmonary Diseases..Injury…

• Acute

• Chronic

Cascade of Events in Pulmonary Diseases / Lung Injury

X

Cascade of Events in Pulmonary Diseases

• Patients demonstrate varying degrees of

– Shunt physiology,

– Dead Space Ventilation, and

– Pulmonary Hypertension.

Acute Pulmonary Disease

Acute Lung Injury (ALI) can be defined as a “rapid alteration of the alveolar wall leading to impairment of the gas exchange apparatus following exposure to noxious environmental or endogenous agents.”

Infection: Viral/ Bacterial or Inhalation Injury

Lung… Injury…ACUTE.. ALI

Clinicians from nearly all disciplines regularly come across this problem.

Chronic Pulmonary Diseases

Chronic - Hypoxic• Airway Diseases

– COPD:• Severe• Chronic – Hypoxia

• Parenchymal Diseases– Inflammatory :

• Interstitial Inflammatory Diseases– Infective:

• Anatomical Parenchymal Loss

• Obesity Hypo-Ventilation– O.S.A.

• Chronic Pulmonary Thromboembolism

What do

they have

Common?

How much of Fluids…• Euvolemic patients with adequate tissue

perfusion:– should be given sufficient isotonic fluid to balance

insensible losses.

– If severe pulmonary compromise is present, cessation of all fluid therapy may be considered if the patient is able to match its losses by voluntary intake.

Clin North Am. 2008 May;38(3):719-25, Fluid therapy in patients with pulmonary disease. Adamantos S, Hughes D. PMID: 18402892 [PubMed - indexed for MEDLINE]

How much of Fluids…• In hypovolemic or hypotensive patients: – Small boluses of isotonic crystalloids or colloids

should be given to restore perfusion.

– If perfusion is not restored by adequate volume resuscitation, Vasopressors or Positive Inotropes should be administered to prevent fluid overload and deterioration in pulmonary function.

Clin North Am. 2008 May;38(3):719-25, Fluid therapy in patients with pulmonary disease. Adamantos S, Hughes D. PMID: 18402892 [PubMed - indexed for MEDLINE]

Which Fluid?

• Crystalloids….

• Colloids…

Which Fluid?Post Traumatic Lung Diseases

• Use of colloid-containing solutions has been

advocated in an attempt to maintain

intravascular colloid osmotic pressure,

minimize pulmonary oedema and draw fluid

out of areas of contused lung.Injury. 1986 Sep;17(5):295-300.Controversies in the fluid management of post-traumatic lung disease. Wisner DH, Sturm JA. PMID: 3770929 [PubMed - indexed for MEDLINE]

Which Fluid?Post Traumatic Lung Diseases

• Studies in human patients of the rate of extravasation of labelled albumin from the pulmonary intravascular space indicate that – Increased permeability of pulmonary capillaries occurs early after

injury and remains elevated in many severely injured patients. – Low plasma colloid osmotic pressures do not correlate with increases

in extra-vascular lung water. • A shift to the use of vigorous crystalloid resuscitation of injured

patients resulted in decreases in both mortality rate (35% to 28%) and the rate of dialysis-dependent renal failure (6 % to 2%) in a study period of 3 years.

• Current evidence supports the use of crystalloid solutions together with blood for resuscitation after injury.

Injury. 1986 Sep;17(5):295-300.Controversies in the fluid management of post-traumatic lung disease. Wisner DH, Sturm JA. PMID: 3770929 [PubMed - indexed for MEDLINE]

Crystalloid v/s Colloids…Crystalloid or colloid fluid loading and pulmonary permeability, edema, and injury in septic and non-septic critically ill patients with hypovolemia. (Crit Care Med. 2009)

Prospective randomized clinical trial on the effect of fluids in 24 septic and 24 nonseptic mechanically ventilated patients with clinical hypovolemia.

OBJECTIVE: • To compare crystalloid and colloid fluids in their effect on pulmonary edema in hypovolemic

septic and nonseptic patients with or at risk for acute lung injury/acute respiratory distress syndrome.

HYPOTHESIS:1) crystalloid loading results in more edema formation than colloid loading and 2) the differences among the types of fluid decreases at high permeability.

INTERVENTIONS: • Patients were assigned to NS 0.9%, Gelatin 4%, Hydroxyethyl starch 6%, or Albumin 5% loading

for 90 minutes according to changes in filling pressures.

Crystalloid v/s Colloids…RESULTS: • 23 septic and 10 nonseptic patients had ALI/ARDS (p < 0.001). • Septic patients had greater pulmonary capillary permeability, edema, and

severity of lung injury than nonseptic patients (p < 0.01), as measured by the pulmonary leak index (PLI) for Gallium-labelled transferrin, extravascular lung water (EVLW), and lung injury score (LIS), respectively.

• Colloids increased plasma volume, cardiac index, and central venous pressure (CVP) more than crystalloids (p < 0.05).

• Colloid osmotic pressure (COP) increased in colloid and decreased in crystalloid groups (p < 0.001).

• Irrespective of fluid type or underlying disease, the pulmonary leak index increased by median 5% (p < 0.05).

• Regardless of fluid type or underlying disease, EVLW and LIS did not change during fluid loading and EVLW related to COP-CVP (rs = -.40, p < 0.01).

Crystalloid v/s Colloids…CONCLUSIONS: • Pulmonary edema and LIS are not affected by the

type of fluid loading in the steep part of the cardiac function curve in both septic and nonseptic patients.

• Pulmonary capillary permeability may be a smaller determinant of pulmonary edema than COP and CVP.

• Safety factors may have prevented edema during a small filtration pressure-induced rise in pulmonary protein and thus fluid transport.

Crystalloid v/s Colloids…

Crystalloid v/s Colloids…Albumin versus crystalloid solutions in patients with the ARDS: a systematic review and meta-analysis.

To determine the effects of colloid therapy compared to crystalloids on mortality and oxygenation in adults with ARDS who need fluid therapy.

RESULTS: • Qualitative and quantitative analysis of 206 patients who received either albumin or saline. • Overall risk of bias was unclear to high in the identified trials. • Calculated pooled risk of death was not statistically significant (albumin 34.0% versus saline

38.5%, • PaO2/FiO2 (mmHg) improved in the first 48 hours after therapy start and remained stable

after 7 days.CONCLUSIONS: • Colloid therapy with albumin improved oxygenation but did not affect mortality.

Crit Care. 2014 Jan 9;18(1):R10. doi: 10.1186/cc13187. PMID: 24405693 [PubMed - indexed forMEDLINE] PMCID: PMC4056106 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056106/

Chronic Hypoxic Lung

Chronic Hypoxic Diseases

• Poor Pulmonary reserve for fluids– Need:• X-ray / USG Thorax• 2D Echo – RVSP • Central Venous Access• Strict Fluid balance

– Include every form of fluid (In/out)• Co-morbidities: CKD/CCF/CLD

Need to be careful on using Dextrose..

Chronic Hypoxic Diseases

• Problem cases:–COPD / ILD with• Uraemia• Prolonged Hypotension• Hypoproteinaemia• Hypernatremia• Hypokalaemia

Need to have a Good Nephrologist as FRIEND..

Fluid Therapy in Pulmonary Diseases

• Wet lungs are a higher risk for HAP/VAP

• Colloids better to improve oxygenation – may

not help improve mortality

• Keeping good track of cumulative

fluid balance helps

Fluid Therapy in Pulmonary Diseases

• Be Careful and Conservative…

Thank You…..