Assessing volume responsiveness
in spontaneously breathing patients
Dr Xavier MONNET
Medical Intensive Care Unit
Bicêtre Hospital
FRANCE
Conflicts of interest
Lilly
Arrow
Deltex Medical
Pulsion Medical Systems
Prediction of fluid responsiveness Concept
Stroke
volume
When we administer fluid, we expect an
increase in SV
b'
a'
b'
All patients do not « respond » to fluid
administration
a'
A
B
VE
A
B
VE
Ventricular preload
Prediction of fluid responsiveness Concept
2 situations must be distinguished
initial phase of septic shock
hypovolemic shock
a positive « response » to fluid is certain
fluid must be administered immediately
septic shock after the initial phase
previous fluid administration
lung injury
fluid responsiveness is not certain
Prediction of fluid responsiveness Concept
Stroke
volume
b'
a'
deleterious effects
 lung edema
gas exchange alteration
b'
in case of ARDS
 interstitial edema
a'
alteration in tissue oxygenation
How to predict fluid responsiveness

A
B
A
B
Ventricular preload
?
Prediction of fluid responsiveness CVP
Prediction of fluid responsiveness CVP

CVP does not enable predicting
fluid responsiveness
?
Prediction of fluid responsiveness CVP
Stroke
volume
impaired ventricular function
b'
a'
effects
on SV
impaired ventricular function
b
a
"fluid challenge"
CVP
 preload
Ventricular preload
Prediction of fluid responsiveness respiratory variation of stroke volume
A
B
Prediction of fluid responsiveness pulse pressure variation
Respiratory variation of stroke volume limitations
The respiratory variation of hemodynamic
signals cannot be used in case of
cardiac arrhythmias
low Vt
Respiratory variation of stroke volume limitations
PPmin
PPmax
PPmax
PPmin
Respiratory variation of stroke volume limitations
mmHg
110
90
70
50
PPmax
PPmin
Respiratory variation of stroke volume limitations
The respiratory variation of hemodynamic
signals cannot be used in case of
cardiac arrhythmias
low Vt
spontaneous breathing
Respiratory variation of stroke volume limitations
100
PPV for predicting a 15% increase in cardiac index
31 patients with spontaneous breathing activity
sensitivity
80
60
40

20
PPV cannot be used in case of
spontaneous breathing activity
PPV
0
0
20
40
60
100 - specificity
80
100
Respiratory variation of stroke volume limitations
PPV for predicting a 15% increase in cardiac index
21 patients with spontaneous breathing activity
Respiratory variation of stroke volume limitations
PPV for predicting a 15% increase in cardiac index
32 patients with SB
Respiratory variation of stroke volume limitations
The respiratory variation of hemodynamic
signals cannot be used in case of
cardiac arrhythmias
low Vt
spontaneous breathing
frequent in the ICU
How to predict fluid
responsiveness ?
cardiac arrhythmias, low Vt, spontaneous breathing ?
no
respiratory variation
yes
?
Passive leg raising hemodynamic effects
45°

Blood shift toward the
intrathoracic compartment
Passive leg raising hemodynamic effects
CVP
PAOP
Passive leg raising is enough
for increasing
right cardiac preload
left cardiac preload
base
PLR
base
base
PLR
base
Passive leg raising hemodynamic effects
CVP
PAOP
PLR acts like a
″self volume challenge ″
base
PLR
base
base
PLR
base
Passive leg raising prediction of fluid responsiveness ?
76 ICU patients with acute circulatory failure
Aortic blood flow
(% change from baseline)
70
esophageal Doppler monitoring
non responders
responders
60
50
40
30
20
10
0
During
PLR
After
fluid infusion
After
fluid infusion
Monnet et al., Crit Care Med, 2006
Passive leg raising prediction of fluid responsiveness ?
ABF
Volume expansion
PLR
Passive leg raising prediction of fluid responsiveness ?
76 ICU patients with acute circulatory failure
Aortic blood flow
(% change from baseline)
70
esophageal Doppler monitoring
non responders
responders
60
50
40
30
20
10
0
During
PLR
After
fluid infusion
During
PLR
After
fluid infusion
Monnet et al., Crit Care Med, 2006
Passive leg raising prediction of fluid responsiveness ?
%
PLR-induced changes in ABF
80

prediction of fluid responsiveness
60
40
*
Cut-off 10%
20
Se = 97 %
Sp = 94 %
0
-20
-40
The PLR test allows a reliable
NR
R
Passive leg raising prediction of fluid responsiveness ?
100

sensitivity
80
The PLR test remains reliable in case of SB
60
31 patients with spontaneous
triggering of the ventilator
40
PLR effects on ABF
20
PPV
0
0
20
40
60
100 - specificity
80
100
How to predict fluid
responsiveness ?
cardiac arrhythmias, low Vt, spontaneous breathing ?
no
yes
respiratory variation indices
PLR
PLR
Passive leg raising

Which monitoring tool for assessing PLR effects
?
Passive leg raising which monitoring tool ?
EDM
10 %
increase in ABF
10 %
increase in ABF
echo
12 %
increase in aoVTI
12 %
increase in aoVTI
PiCCO
Passive leg raising which monitoring tool ?
EDM
10 %
increase in ABF
10 %
increase in ABF
12 %
echo
increase in aoVTI
12 %
increase in aoVTI
10 %
PiCCO
increase in PCCI

Which method for performing PLR
?
PLR test method
importance of the postural change
45°
semi-recumbent position
45°
PLR position
45°
recumbent position
PLR position
PLR test importance of the postural change
35 patients
All responders to PLR
% change in cardiac
index from baseline
37.5
25
12.5
0
PLR test importance of the postural change
PLR test importance of the postural change
35 patients
(all responders to fluid administration)
35 responders
20 responders
15
non responders
(not correctly classified)
PLR test limitations
PLR-induced
changes in PP
80
false negative cases
60
40
*
20

0
-20
-40
PLR test effects cannot be assessed
by arterial pressure changes
NR
R
PLR test limitations

cannot be assessed with arterial pressure

cannot be used in the OR
How to predict fluid
responsiveness ?
cardiac arrhythmias, low Vt, spontaneous breathing ?
no
yes
respiratory variation indices
PLR
?
PLR
?
Vasalva maneuver ?
30 patients without MV
Prediction of a 15% increase in SV with fluid
Vasalva maneuver ?
Vasalva maneuver ?
Vasalva maneuver ?
9 pigs with SB
Prediction of a 15% increase in SV with fluid
Breathing against an I and/or E 7.5 cmH2O resistance
OAP de sevrage de la ventilation mécanique
mécanismes
Mise en VS
 pression intrathoracique
 pression
intrathoracique
 postcharge
cardiaque
gauche
 retour veineux
systémique
 pression
transmurale VG
 précharge VG
 postcharge VG
 travail
cardiaque
 POD
OAP
 retour
veineux
systémique
Tele-expiratory occlusion
A
B
tele-expiratory occlusion
Tele-expiratory occlusion test
34 patients with SB or cardiac arrhythmias
Tele-expiratory occlusion test
34 patients with SB or cardiac arrhythmias
Tele-expiratory occlusion test
Effects of end-expiratory pause
Effects of end-expiratory pause
on cardiac index
on pulse pressure
50
50
40
40
30
30
20
20
10
0
-10
increase  5%
Se = 91%
Sp = 100 %
10
0
-10
increase  5%
Se = 87 %
Sp = 100 %
How to predict fluid
responsiveness ?
cardiac arrhythmias, low Vt, spontaneous breathing ?
no
yes
respiratory variation indices
PLR
PLR
TEO
TEO