FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 354:2213-2224 May 25, 2006 Number 21 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Supplementary Material Editorial by Shure, D. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background The balance between the benefits and the risks of pulmonary-artery catheters (PACs) has not been established.

Methods We evaluated the relationship of benefits and risks of PACs in 1000 patients with established acute lung injury in a randomized trial comparing hemodynamic management guided by a PAC with hemodynamic management guided by a central venous catheter (CVC) using an explicit management protocol. Mortality during the first 60 days before discharge home was the primary outcome.

Results The groups had similar baseline characteristics. The rates of death during the first 60 days before discharge home were similar in the PAC and CVC groups (27.4 percent and 26.3 percent, respectively; P=0.69; absolute difference, 1.1 percent; 95 percent confidence interval, –4.4 to 6.6 percent), as were the mean (±SE) numbers of both ventilator-free days (13.2±0.5 and 13.5±0.5; P=0.58) and days not spent in the intensive care unit (12.0±0.4 and 12.5±0.5; P=0.40) to day 28. PAC-guided therapy did not improve these measures for patients in shock at the time of enrollment. There were no significant differences between groups in lung or kidney function, rates of hypotension, ventilator settings, or use of dialysis or vasopressors. Approximately 90 percent of protocol instructions were followed in both groups, with a 1 percent rate of crossover from CVC- to PAC-guided therapy. Fluid balance was similar in the two groups, as was the proportion of instructions given for fluid and diuretics. Dobutamine use was uncommon. The PAC group had approximately twice as many catheter-related complications (predominantly arrhythmias).

Conclusions PAC-guided therapy did not improve survival or organ function but was associated with more complications than CVC-guided therapy. These results, when considered with those of previous studies, suggest that the PAC should not be routinely used for the management of acute lung injury. (ClinicalTrials.gov number, NCT00281268 [ClinicalTrials.gov] .)

Source Information

The members of the Writing Committee (Arthur P. Wheeler, M.D., and Gordon R. Bernard, M.D., Vanderbilt University, Nashville; B. Taylor Thompson, M.D., and David Schoenfeld, Ph.D., Massachusetts General Hospital, Boston; Herbert P. Wiedemann, M.D., Cleveland Clinic, Cleveland; Ben deBoisblanc, M.D., Louisiana State University Health Sciences Center, New Orleans; Alfred F. Connors, Jr., M.D., Case Western Reserve University at MetroHealth Medical Center, Cleveland; R. Duncan Hite, M.D., Wake Forest University Health Sciences, Winston-Salem, N.C.; and Andrea L. Harabin, Ph.D., National Institutes of Health, Heart, Lung, and Blood Institute, Bethesda, Md.) assume responsibility for the integrity of the article.

This article was published at www.nejm.org on May 21, 2006.

Address reprint requests to Dr. Wheeler at T-1217 MCN, Vanderbilt Medical Center, Nashville, TN 37232-2650, or at art.wheeler{at}vanderbilt.edu.

Full Text of this Article

Related Letters:

Catheters and the Treatment of Acute Lung Injury
Pastewski A. A., Kupfer Y., Tessler S., Daley M. R., Tornero-Campello G., Wheeler A. P., Wiedemann H. P., Schoenfeld D. A.
Extract | Full Text | PDF  
N Engl J Med 2006; 355:956-958, Aug 31, 2006. Correspondence

This article has been cited by other articles:

• Mongardon, N., Dyson, A., Singer, M. (2009). Pharmacological optimization of tissue perfusion. Br J Anaesth 103: 82-88 [Abstract] [Full Text]  
• Kathirgamanathan, A., McCahon, R. A., Hardman, J. G. (2009). Indices of pulmonary oxygenation in pathological lung states: an investigation using high-fidelity, computational modelling. Br J Anaesth 0: aep140v1-aep140 [Abstract] [Full Text]  
• McAuley, D. F., Matthay, M. A. (2009). Clara Cell Protein CC16: A New Lung Epithelial Biomarker for Acute Lung Injury. Chest 135: 1408-1410 [Full Text]  
• Levitt, J. E., Bedi, H., Calfee, C. S., Gould, M. K., Matthay, M. A. (2009). Identification of Early Acute Lung Injury at Initial Evaluation in an Acute Care Setting Prior to the Onset of Respiratory Failure. Chest 135: 936-943 [Abstract] [Full Text]  
• Ricci, Z., Ronco, C. (2009). Kidney diseases beyond nephrology: intensive care. Nephrol Dial Transplant 24: 391-395 [Full Text]  
• Xu, D., Olivier, N. B., Mukkamala, R. (2009). Continuous cardiac output and left atrial pressure monitoring by long time interval analysis of the pulmonary artery pressure waveform: proof of concept in dogs. J. Appl. Physiol. 106: 651-661 [Abstract] [Full Text]  
• Quartin, A. A., Campos, M. A., Maldonado, D. A., Ashkin, D., Cely, C. M., Schein, R. M. H. (2009). Acute Lung Injury Outside of the ICU: Incidence in Respiratory Isolation on a General Ward. Chest 135: 261-268 [Abstract] [Full Text]  
• Phua, J., Badia, J. R., Adhikari, N. K. J., Friedrich, J. O., Fowler, R. A., Singh, J. M., Scales, D. C., Stather, D. R., Li, A., Jones, A., Gattas, D. J., Hallett, D., Tomlinson, G., Stewart, T. E., Ferguson, N. D. (2009). Has Mortality from Acute Respiratory Distress Syndrome Decreased over Time?: A Systematic Review. Am. J. Respir. Crit. Care Med. 179: 220-227 [Abstract] [Full Text]  
• Chatterjee, K. (2009). The Swan-Ganz Catheters: Past, Present, and Future: A Viewpoint. Circulation 119: 147-152 [Abstract] [Full Text]  
• Lameire, N., Van Biesen, W., Hoste, E., Vanholder, R. (2008). The prevention of acute kidney injury: an in-depth narrative review Part 1: volume resuscitation and avoidance of drug- and nephrotoxin-induced AKI. NDT Plus 1: 392-402 [Abstract] [Full Text]  
• Quartin, A. A., Schein, R. M.H., Cely, C. M. (2008). What Conclusions Should Be Drawn between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit?. ANN INTERN MED 149: 767-768 [Full Text]  
• Liu, K. D., Levitt, J., Zhuo, H., Kallet, R. H., Brady, S., Steingrub, J., Tidswell, M., Siegel, M. D., Soto, G., Peterson, M. W., Chesnutt, M. S., Phillips, C., Weinacker, A., Thompson, B. T., Eisner, M. D., Matthay, M. A. (2008). Randomized Clinical Trial of Activated Protein C for the Treatment of Acute Lung Injury. Am. J. Respir. Crit. Care Med. 178: 618-623 [Abstract] [Full Text]  
• McCahon, R. A., Columb, M. O., Mahajan, R. P., Hardman, J. G. (2008). Validation and application of a high-fidelity, computational model of acute respiratory distress syndrome to the examination of the indices of oxygenation at constant lung-state. Br J Anaesth 101: 358-365 [Abstract] [Full Text]  
• Marik, P. E., Baram, M., Vahid, B. (2008). Does Central Venous Pressure Predict Fluid Responsiveness?: A Systematic Review of the Literature and the Tale of Seven Mares. Chest 134: 172-178 [Abstract] [Full Text]  
• Crowley, S. T., Chertow, G. M., Vitale, J., O'Connor, T., Zhang, J., Schein, R. M.H., Choudhury, D., Finkel, K., Vijayan, A., Paganini, E., Palevsky, P. M., for the VA/NIH Acute Renal Failure Trial Network S, (2008). Lessons for Successful Study Enrollment from the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network Study. CJASN 3: 955-961 [Abstract] [Full Text]  
• Eisner, M. D., Schermerhorn, M. L., O'Malley, A. J., Landon, B. E. (2008). Endovascular vs. Open Repair of Abdominal Aortic Aneurysms. NEJM 358: 2644-2645 [Full Text]  
• Checkley, W., Brower, R., Korpak, A., Thompson, B. T., for the Acute Respiratory Distress Syndrome Networ, (2008). Effects of a Clinical Trial on Mechanical Ventilation Practices in Patients with Acute Lung Injury. Am. J. Respir. Crit. Care Med. 177: 1215-1222 [Abstract] [Full Text]  
• Effros, R. M., Pornsuriyasak, P., Porszasz, J., Casaburi, R. (2008). Indicator dilution measurements of extravascular lung water: basic assumptions and observations. Am. J. Physiol. Lung Cell. Mol. Physiol. 294: L1023-L1031 [Abstract] [Full Text]  
• Zambon, M., Vincent, J.-L. (2008). Mortality Rates for Patients With Acute Lung Injury/ARDS Have Decreased Over Time. Chest 133: 1120-1127 [Abstract] [Full Text]  
• Leff, B., Finucane, T. E. (2008). Gizmo Idolatry. JAMA 299: 1830-1832 [Full Text]  
• Matthay, M. A. (2008). Treatment of Acute Lung Injury: Clinical and Experimental Studies. Proc Am Thorac Soc 5: 297-299 [Abstract] [Full Text]  
• Liu, K. D., Matthay, M. A. (2008). Advances in Critical Care for the Nephrologist: Acute Lung Injury/ARDS. CJASN 3: 578-586 [Abstract] [Full Text]  
• Ronco, C., Kellum, J. A., Bellomo, R., House, A. A. (2008). Potential Interventions in Sepsis-Related Acute Kidney Injury. CJASN 3: 531-544 [Abstract] [Full Text]  
• Davison, D., Junker, C. (2008). Advances in Critical Care for the Nephrologist: Hemodynamic Monitoring and Volume Management. CJASN 3: 554-561 [Abstract] [Full Text]  
• Durairaj, L., Schmidt, G. A. (2008). Fluid Therapy in Resuscitated Sepsis: Less Is More. Chest 133: 252-263 [Abstract] [Full Text]  
• Schuster, K. M., Alouidor, R., Barquist, E. S. (2008). Nonventilatory Interventions in the Acute Respiratory Distress Syndrome. J Intensive Care Med 23: 19-32 [Abstract]  
• Chiche, L., Forel, J.-M., Papazian, L., Asakura, Y., Komatsu, T., Busch, T., Bercker, S., Kaisers, U., Malhotra, A. (2007). Low-Tidal-Volume Ventilation. NEJM 357: 2518-2520 [Full Text]  
• Wheeler, A. P. (2007). Recent Developments in the Diagnosis and Management of Severe Sepsis. Chest 132: 1967-1976 [Abstract] [Full Text]  
• Pinsky, M. R. (2007). Hemodynamic Evaluation and Monitoring in the ICU. Chest 132: 2020-2029 [Abstract] [Full Text]  
• Mackenzie, I., Lever, A. (2007). Management of sepsis. BMJ 335: 929-932 [Full Text]  
• Osborne, M. (2007). Update in Critical Care. ANN INTERN MED 147: 412-416 [Full Text]  
• Ware, L. B. (2007). Clinical Year in Review III: Asthma, Lung Transplantation, Cystic Fibrosis, Acute Respiratory Distress Syndrome. Proc Am Thorac Soc 4: 489-493 [Full Text]  
• Leibowitz, A. B., Oropello, J. M. (2007). The Pulmonary Artery Catheter in Anesthesia Practice in 2007: An Historical Overview With Emphasis on the Past 6 Years. SEMIN CARDIOTHORAC VASC ANESTH 11: 162-176 [Abstract]  
• Cepkova, M., Kapur, V., Ren, X., Quinn, T., Zhuo, H., Foster, E., Liu, K. D., Matthay, M. A. (2007). Pulmonary Dead Space Fraction and Pulmonary Artery Systolic Pressure as Early Predictors of Clinical Outcome in Acute Lung Injury. Chest 132: 836-842 [Abstract] [Full Text]  
• Sakka, S. G., Kozieras, J., Thuemer, O., van Hout, N. (2007). Measurement of cardiac output: a comparison between transpulmonary thermodilution and uncalibrated pulse contour analysis. Br J Anaesth 99: 337-342 [Abstract] [Full Text]  
• Leaver, S. K, Evans, T. W (2007). Acute respiratory distress syndrome. BMJ 335: 389-394 [Full Text]  
• Wiener, R. S., Welch, H. G. (2007). Trends in the Use of the Pulmonary Artery Catheter in the United States, 1993-2004. JAMA 298: 423-429 [Abstract] [Full Text]  
• Angus, D. C. (2007). Caring for the Critically Ill Patient: Challenges and Opportunities. JAMA 298: 456-458 [Full Text]  
• Rubenfeld, G. D., McNamara-Aslin, E., Rubinson, L. (2007). The Pulmonary Artery Catheter, 1967 2007: Rest in Peace?. JAMA 298: 458-461 [Full Text]  
• Brennan, J. M., Blair, J. E. A., Hampole, C., Goonewardena, S., Vasaiwala, S., Shah, D., Spencer, K. T., Schmidt, G. A. (2007). Radial Artery Pulse Pressure Variation Correlates With Brachial Artery Peak Velocity Variation in Ventilated Subjects When Measured by Internal Medicine Residents Using Hand-Carried Ultrasound Devices. Chest 131: 1301-1307 [Abstract] [Full Text]  
• Karmpaliotis, D., Kirtane, A. J., Ruisi, C. P., Polonsky, T., Malhotra, A., Talmor, D., Kosmidou, I., Jarolim, P., de Lemos, J. A., Sabatine, M. S., Gibson, C. M., Morrow, D. (2007). Diagnostic and Prognostic Utility of Brain Natriuretic Peptide in Subjects Admitted to the ICU With Hypoxic Respiratory Failure Due to Noncardiogenic and Cardiogenic Pulmonary Edema. Chest 131: 964-971 [Abstract] [Full Text]  
• Milbrandt, E. B., Ishizaka, A., Angus, D. C. (2007). Update in Critical Care 2006. Am. J. Respir. Crit. Care Med. 175: 638-648 [Full Text]  
• Calfee, C. S., Matthay, M. A. (2007). Nonventilatory Treatments for Acute Lung Injury and ARDS. Chest 131: 913-920 [Abstract] [Full Text]  
• Himmelfarb, J. (2007). Continuous Renal Replacement Therapy in the Treatment of Acute Renal Failure: Critical Assessment Is Required. CJASN 2: 385-389 [Abstract] [Full Text]  
• Isakow, W., Schuster, D. P. (2006). Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives to the pulmonary artery catheter. Am. J. Physiol. Lung Cell. Mol. Physiol. 291: L1118-L1131 [Abstract] [Full Text]  
• Finfer, S., Delaney, A. (2006). Pulmonary artery catheters. BMJ 333: 930-931 [Full Text]  
• Moss, M. (2006). Clinical Year in Review III: Critical Care, Mechanical Ventilation, Sleep Medicine, and Lung Cancer. Proc Am Thorac Soc 3: 645-649 [Full Text]  
• Otero, R. M., Nguyen, H. B., Huang, D. T., Gaieski, D. F., Goyal, M., Gunnerson, K. J., Trzeciak, S., Sherwin, R., Holthaus, C. V., Osborn, T., Rivers, E. P. (2006). Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings.. Chest 130: 1579-1595 [Abstract] [Full Text]  
• Blank, A. (2006). A piece of my mind. Swan's way.. JAMA 296: 1041-1042 [Full Text]  
• Yen, J T C (2006). No benefit from using pulmonary artery catheters to guide treatment of acute lung injury. Thorax 61: 804-804 [Full Text]  
• Pastewski, A. A., Kupfer, Y., Tessler, S., Daley, M. R., Tornero-Campello, G., Wheeler, A. P., Wiedemann, H. P., Schoenfeld, D. A. (2006). Catheters and the treatment of acute lung injury.. NEJM 355: 956-957 [Full Text]  
• (2006). Another Nail in the Coffin for Pulmonary-Artery Catheters. JWatch Emergency Med. 2006: 1-1 [Full Text]  
• The National Heart, Lung, and Blood Institute Acut, (2006). Comparison of Two Fluid-Management Strategies in Acute Lung Injury. NEJM 354: 2564-2575 [Abstract] [Full Text]  
• Tonks, A. (2006). What's new in the other general journals.. BMJ 332: 1327-1327 [Full Text]  
• (2006). Once Again, No Benefit from Pulmonary Artery Catheters. JWatch General 2006: 1-1 [Full Text]  
• Shure, D. (2006). Pulmonary-Artery Catheters -- Peace at Last?. NEJM 354: 2273-2274 [Full Text]