Clinical trial NCT01605214: Measurement of Extravascular Lung Water to Detect and Predict Primary Graft Dysfunction Following Lung Transplant
Official title: Measurement of Extravascular Lung Water to Detect and Predict Primary Graft Dysfunction Following Lung Transplant
Study type: OBSERVATIONAL
Overall status: UNKNOWN
Conditions: Primary Graft Dysfunction
Keywords: Extravascular Lung Water
Transpulmonary Thermodilution
Primary Graft Dysfunction
Ischemia Reperfusion Injury
Lead sponsor: University Health Network, Toronto
Sponsor class: OTHER
Collaborators: name: Toronto General Hospital
First posted: 2012-05-24
Enrollment: 60
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: All patients undergoing bilateral lung transplant for any indication will be considered to be enrolled in this study.

Brief summary: Primary graft dysfunction (PGD) is the most common cause of early morbidity and mortality following lung transplant and is characterized by acute lung injury and capillary leak leading to an increase in extravascular lung water index (ELWI) and impaired graft function. PGD has many features in common with acute respiratory distress syndrome (ARDS). PGD may be life-threatening and can also lead to impaired long term lung function. In ARDS, a restrictive fluid strategy has been associated with an improvement in lung function and outcomes. Accurate methods of evaluating, quantifying and guiding the hemodynamic / fluid management and limiting the extent of ELWI that accumulates in the setting of PGD are lacking. Using transpulmonary thermodilution to estimate ELWI and the pulmonary permeability index (PPI) represents a novel approach to fluid management, which has been used in patients with ARDS, but to date not in the transplant setting. To determine if these measurements may better guide the management of lung transplant patients, the investigators first wish to establish whether these methods are able to predict the onset of clinical pulmonary edema earlier, whether they correlated with traditional markers of PGD, and whether they may be useful for predicting outcomes.

AIM 1: The investigators will evaluate the correlation between ELWI and current surrogates of pulmonary edema in lung transplant patients with and without Primary Graft Dysfunction (PGD)

AIM 2: The investigators will correlate the use of ELWI and PPI to determine the presence and severity of PGD.

AIM 3: a) The investigators will determine whether early measurements of ELWI and PPI can predict the onset of PGD.

b) Across different strata of PGD, the investigators will determine whether ELWI and PPI have a differential effect on duration of mechanical ventilation.

The results of the study will be used for the following:

1. Provide the rationale for routine monitoring of ELWI to detect PGD if found to be more discriminatory and have a stronger association with outcome compared to the current gold standard.
2. Provide the means of early identification of those as risk of developing PGD in order to guide management decisions or future therapeutic interventions aimed at preventing or treating PGD.
3. Provide the requisite groundwork for a clinical trial comparing the effects of an ELWI-driven protocol versus usual care on ICU outcomes in lung transplant recipients.


Eligibility criteria: Inclusion Criteria:

* All consecutive bilateral lung transplant recipients

Exclusion Criteria:

* Immediate need for extracorporeal life support following transplant (those requiring ECLS four hours after intensive care admission can be included as the investigators would have obtained some ELWI measurements)
* Contraindications to femoral artery catheterization (eg, abdominal aortic aneurysm)

Primary outcomes:
measure: AIM 1: The presence of pulmonary edema on chest X ray (CXR) at 24 hours determined by blinded CXR reviewers
timeFrame: 24 hours following lung transplant
measure: AIM 2: The presence of primary graft dysfunction at 24 hours determined by CXR evidence of bilateral airspace disease and Pa02/FiO2 ratio threshold by reviewers blinded to the extravascular lung water and pulmonary permeability measurements at 24
timeFrame: 24 hours
measure: AIM 3: The presence of primary graft dysfunction at 24 hours determined by CXR and Pa02/FiO2 ratio by reviewers blinded to early (time 0) extravascular lung water and pulmonary permeability measurements
timeFrame: Time 0 extravascular lung water and pulmonary permeability measurements and primary graft dysfunction at 24 hours
Secondary outcomes:
measure: AIM 1: The presence of pulmonary edema on chest X ray at 48 and 72 hours evaluated by CXR reviewers blinded to the extravascular lung water measurements measured at 48 and 72 hours
timeFrame: 48 and 72 hours following lung transplant
measure: AIM 2: The presence of late primary graft dysfunction determined by CXR and PaO2/FiO2 ratio evaluated by reviewers blinded to the extravascular lung water and pulmonary permeability measurements evaluated at 48 and 72 hours
timeFrame: 48 and 72 hours following lung transplant
measure: AIM 3: The presence of late primary graft dysfunction (48 and 72 hours) determined by CXR and PaO2/FiO2 ratio evaluated by reviewers blinded to the extravascular lung water and pulmonary permeability measurements at time 0
timeFrame: Extravascular lung water and pulmonary permeability measurements at time 0 hours, primary graft dysfunction determination at 48 or 72 hours
measure: AIM 3: The presence of any primary graft dysfunction determined by CXR and PaO2/FiO2 ratio (24, 48 or 72 hours) evaluated by reviewers blinded to the early extravascular lung water and pulmonary permeability measurements (6 hours and 12 hours)
timeFrame: Extravascular lung water and pulmonary permeability measurements at 6 hours and 12 hours, any primary graft dysfunction determined at 24, 48 or 72 hours
measure: AIM 3: Duration of mechanical ventilation
timeFrame: Extravascular lung water and pulmonary permeability measurements at 24 hours, Hospital admission following lung transplant
Other outcomes:
Locations:
city: Toronto
country: Canada
facility: Toronto General Hospital
state: Ontario
Study officials:
affiliation: University Health Network, Toronto
name: John Granton, MD, FRCPC
role: PRINCIPAL_INVESTIGATOR
References:
citation: Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul JL. Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS. Intensive Care Med. 2007 Mar;33(3):448-53. doi: 10.1007/s00134-006-0498-6. Epub 2007 Jan 13.
citation: Sakka SG, Ruhl CC, Pfeiffer UJ, Beale R, McLuckie A, Reinhart K, Meier-Hellmann A. Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med. 2000 Feb;26(2):180-7. doi: 10.1007/s001340050043.
citation: Chung FT, Lin HC, Kuo CH, Yu CT, Chou CL, Lee KY, Kuo HP, Lin SM. Extravascular lung water correlates multiorgan dysfunction syndrome and mortality in sepsis. PLoS One. 2010 Dec 16;5(12):e15265. doi: 10.1371/journal.pone.0015265.
citation: Della Rocca G, Costa GM, Coccia C, Pompei L, Di Marco P, Pietropaoli P. Preload index: pulmonary artery occlusion pressure versus intrathoracic blood volume monitoring during lung transplantation. Anesth Analg. 2002 Oct;95(4):835-43, table of contents. doi: 10.1097/00000539-200210000-00009.
citation: Michard F, Alaya S, Zarka V, Bahloul M, Richard C, Teboul JL. Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock. Chest. 2003 Nov;124(5):1900-8. doi: 10.1378/chest.124.5.1900.
citation: Sakka SG, Klein M, Reinhart K, Meier-Hellmann A. Prognostic value of extravascular lung water in critically ill patients. Chest. 2002 Dec;122(6):2080-6. doi: 10.1378/chest.122.6.2080.
citation: Hillinger S, Hoerstrup SP, Zollinger A, Weder W, Schmid RA, Stammberger U. A new model for the assessment of lung allograft ischemia/reperfusion injury. J Invest Surg. 2000 Jan-Feb;13(1):59-65. doi: 10.1080/089419300272267.
citation: Rocca GD, Coccia C, Costa GM, Pompei L, Di Marco P, Pierconti F, Cappa M, Venuta F, Pietropaoli P. Is very early extubation after lung transplantation feasible? J Cardiothorac Vasc Anesth. 2003 Feb;17(1):29-35. doi: 10.1053/jcan.2003.6.