We prospectively evaluated a protocol that included extravascular thermal volume (ETV) as a measure of extravascular lung water (EVLW) instead of pulmonary artery wedge pressure (Ppaw) measurements to guide the hemodynamic management of 48 critically ill patients. Patients were randomized to either a protocol management (PM), or to a routine management (RM) group. In the RM group, EVLW measurements were unknown to the primary care physicians. The 2 groups were similar with respect to age, gender, and severity of illness. In patients with initially high EVLW, EVLW fell to a greater extent in PM than in RM patients (18 +/- 5 versus 4 +/- 8% decrease, p less than 0.05). This difference was even greater in patients with heart failure. No adverse effects on oxygenation or renal function occurred in following the protocol. Mortality for the groups as a whole was similar, but was significantly better (p less than 0.05) for PM patients with initially high EVLW and normal Ppaw (predominantly patients with sepsis or the adult respiratory distress syndrome). For both groups, patients with an initial EVLW greater than 14 ml/kg had a significantly greater mortality than did those with a lesser amount of EVLW: 13 of 15 (87%) versus 13 of 32 (41%), p less than 0.05. We conclude that management based on a protocol using EVLW measurements is safe, may hasten the resolution of pulmonary edema, and may lead to improved outcome in some critically ill patients.

The computed tomographic (CT) scans of 80 patients with bronchogenic carcinoma classified as indeterminate for direct mediastinal invasion were retrospectively reviewed after the patients had undergone thoracotomy. Forty-eight (60%) of the masses were resectable, without invasion of the mediastinum, 18 (22%) focally invaded the mediastinum but were technically resectable, and 14 (18%) invaded the mediastinum and were not technically resectable. Although in most circumstances in this relatively small subset of patients CT was not helpful in differentiating masses with and without mediastinal invasion, CT was able to separate a large group of masses that were likely to be technically resectable. Thirty-six (97%) of 37 masses with one or more of these CT findings were considered technically resectable: contact of 3 cm or less with mediastinum, less than 90 degrees of contact with aorta, and mediastinal fat between mass and mediastinal structures. Of these 36 masses, 28 were resectable without mediastinal invasion, and eight were resectable with focal limited mediastinal invasion.

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We evaluated pulmonary vascular permeability with positron emission tomography (PET) in 16 patients with interstitial lung disease (ILD) by measuring the pulmonary transcapillary escape rate (PTCER) for transferrin labeled with gallium-68. In patients with active ILD, defined by lung biopsy or clinical criteria, mean PTCER was significantly greater than in normal subjects (118 +/- 46 versus 21 +/- 11 x 10(-4) min-1, respectively, p less than 0.05). Mean PTCER in patients with inactive ILD, in contrast, was not different from that in normal subjects (32 +/- 10 x 10(-4) min-1, p = NS). Thus, these data suggest that PET measurements of PTCER might serve as an index of disease activity in patients with ILD.

The natural history of change in pulmonary vascular permeability (PVP) during the adult respiratory distress syndrome (ARDS) is unknown. Therefore, we evaluated PVP by measuring the pulmonary transcapillary escape rate (PTCER) for transferrin with positron emission tomography (PET) in 15 ARDS patients, including 5 patients studied within 4 days of onset and 13 patients studied at least 7 days after onset. In 3 patients, studies were performed at both early and late stages. These results were compared to 12 non-smoking adult volunteers. Regional PTCER and extravascular lung density (EVD) were determined from a 1-h PET scan after intravenous injection of gallium-68 citrate, which binds rapidly to native transferrin. Oxygenation, radiologic score, as well as outcome were recorded for each patient. Mean PTCER was highest during the early phase of ARDS (560 +/- 275 x 10(-4) min-1) although PTCER in the late ARDS patients was also significantly higher than in normals (319 +/- 187 vs 58 +/- 33 x 10(-4) min-1; p less than .01). EVD was similar in both early and late ARDS groups (.39 +/- .08 and .37 +/- .13 g/ml lung, respectively) and markedly higher than in normals (.22 +/- .05 g/ml lung, p less than 0.01). PTCER decreased in each of the 3 serial studies. The correlation between PTCER and EVD was poor, as were correlations for either PTCER or EVD versus changes in oxygenation, radiologic score, survival, or duration of ventilator dependency. In the late ARDS patients, PTCER was usually elevated even if EVD had returned to normal.(ABSTRACT TRUNCATED AT 250 WORDS)