Concise Clinical Studies
Is Pulmonary Artery Catheterization Necessary for the
Diagnosis of Pulmonary Edema?1
Introduction
xulmonary edema is a common prob-
lem in critically ill patients. There are 2
distinct mechanisms for the genesis of
pulmonary edema (1), though both
may coexist in the same patient. Car-
diogenic pulmonary edema is charac-
terized by high microvascular driving
pressures, usually resulting from ele-
vated left atrial pressure caused by
heart failure. This form of pulmonary
edema is associated with a normal mi-
crovascular barrier. The second mech-
anism for pulmonary edema is caused
by increased permeability of the micro-
vascular barrier, resulting from loss of
integrity of the capillary endothelium
and/or alveolar epithelium. The result-
ing clinical syndrome is frequently as-
sociated with the adult respiratory dis-
tress syndrome. Although clinically
similar, the presence of cardiac pulmo-
nary edema requires a different thera-
peutic approach.
Pulmonary artery catheterization
(PAC), using the flow-directed, bal-
loon-tipped catheter, has gained accep-
tance in the monitoring of critically ill
patients. It is used diagnostically to dif-
ferentiate high pressure from permea-
bility pulmonary edema (2). Despite
widespread application of this tech-
nique, it is uncertain whether it contrib-
utes additional information over stan-
dard clinical and radiographic assess-
ment. In addition, such monitoring is
expensive and may lead to complica-
tions. Among these, heart block, ven-
tricular tachycardia (3-5), pulmonary
infarction (6), pulmonary artery rup-
ture (7), pulmonic valve injury (8), and
sepsis (3, 9) are the most dangerous.
The purpose of this study was to evalu-
ate PAC in the diagnosis of pulmonary
edema. Specifically, we sought to: (7)
prospectively determine if standard
clinical and radiographic examination
was sufficient to provide accurate diag-
nostic information concerning the
mechanisms of pulmonary edema, and
1006
SUMMARY The ability to differentiate cardiac from permeability edema on the basis of clinical
and radiographic criteria was studied in 70 ICU patients in whom subsequent pulmonary artery
catheterization (PAC) was performed. Our study demonstrated that the clinical assessment of
permeability pulmonary edema was correct in 17 of 20 patients (85%). In contrast, of the 50 pa-
tients initially suspected of having cardiac edema, only 31 (62%) were predicted correctly (p <
0.05). Complications relating to catheterization occurred in 25% of patients, with 3 deaths. We
conclude that the diagnosis of cardiogenic pulmonary edema, based on clinical criteria alone,
is often inaccurate in the intensive care setting. The failure of patients to respond to initial ther-
apy should mandate pulmonary artery catheterization, despite the attendant risks. Furthermore,
even though the clinical diagnosis is correct in 85% of patients with permeability pulmonary
edema, PAC data may be necessary for optimal management.
AM REV RESPIR DIS 1984; 129:1006-1009
(2) prospectively evaluate complica- an assessment of the accuracy of clinical
tions of PAC in these patients. criteria in predicting the mechanism of
edema formation. Previous work by
Methods McHugh and coworkers (10) indicates that
there is good correlation between radio-
Seventy consecutive patients with pulmo- graphic changes and pulmonary capillary
nary edema severe enough to require admis- wedge (PCW) pressure in cardiac edema.
sion to the Intensive Care Unit were studied The earliest changes are evident radiograph-
with PAC (57 came from the Emergency ically when the PCW pressure is greater
Room, and 13 from other units). Criteria than 18 mmHg. Cardiac and permeability
for admission included bilateral alveolar in- edema may, however, coexist (11), but it is
filtrates on chest roentgenogram, refractory unlikely for the pressure component of the
hypoxemia (Pao2 less than or equal to 50
edema to be significant when the wedge
mmHg on fraction of inspired 6 2 greater pressure is less than 18 mmHg.
than 0.5) and severe respiratory distress. Af- Pulmonary capillary wedge pressure was
ter examination by at least 2 of us immedi- measured at end expiration using a strip
ately prior to catheterization, patients were chart recording so that the influence of the
judged to have either cardiac or permeabil- respiratory cycle could be accounted for.
ity pulmonary edema, based on the criteria Complications were assessed by one of us
outlined in table 1. For a patient to be in- prospectively during catheterization for 5 h
cluded in either group, 3 of 5 criteria had to thereafter, and then daily until the patient
be met. Patient characteristics are outlined was discharged or died. Arrhythmias were
in table 2. Examiners had access to what- assessed by visually monitoring the electro-
ever data base was available at the time of
cardiogram during insertion. The electro-
the admission. cardiogram was automatically recorded by a
Catheterization was performed using a computerized electrocardiographic moni-
triple lumen 7-French, balloon-tipped flow- toring system (Mennen Medical, Clarence,
directed, thermodilution catheter (Edwards NY) when the heart rate was below 60 or
Laboratories, Santa Ana, CA). The catheter above 110, and when there was an abnormal
was inserted via the subclavin vein in 15 pa- QRS configuration.
tients, and the internal jugular vein in the Clinical assessment was performed daily,
other 55. After balloon inflation, the cath- and included evaluation of maximal tem-
eter was advanced until the characteristic
wedge pressure contour was observed on the (Received in original form May 23, 1983 and in
monitor (Mennen Medical, Clarence, NY). revised form December 20, 1983)
No patient was receiving positive end-expi-
ratory pressure prior to catheterization. 1
Requests for reprints should be addressed to
All catheterizations were performed by Alan M. Fein, M.D., Department of Medicine,
one of us or a critical care fellow under our Pulmonary and Critical Care Division, Nassau
supervision. The measurements permitted Hospital, 259 First Street, Mineola, NY 11501.
CONCISE CLINICAL STUDIES 1007

TABLE 1 permeability pulmonary edema after

CRITERIA FOR DIFFERENTIATION OF CARDIAC FROM PAC. The PCW pressures ranged from
PERMEABILITY PULMONARY EDEMA 5 to 16 mmHg. The sensitivity of clini-
Cardiac Permeability cal evaluation (excluding PAC) was 17
of 36 (47%) for permeability and 31 of
Past history of significant cardiac disease No past history of cardiac
(ischemic, valvular, arrhythmia, or heart fail- disease 34 (91%) for cardiac edema. Specificity
ure of any origin) was 31 of 34 (91%) for permeability
Enlarged heart; apex beat greater than 2 x 2 Normal heart size and 17 of 36 (47%) for cardiac edema.
cm, cardiothoracic ratio greater than 60% by Thus, clinical evaluation was more sen-
physical examination or chest roentgenogram sitive but less specific for cardiac pul-
S3 gallop No S3 gallop monary edema, and less sensitive but
Jugular venous distention: height of oscillat- No jugular venous distention more specific for permeability edema.
ing top of distended portion jugular vein 4 cm Complications (table 4) occurred in 17
or greater above the sternal angle with the of 70 patients (25%) and were not sig-
patient at a 45° angle
nificantly different in either group. All
Peripheral edema No peripheral edema
3 deaths, however, occurred in the car-
diac group during the insertion of the
TABLE 2 PAC. Deaths in these cases resulted
PATIENT CHARACTERISTICS OF GROUPS ACCORDING TO DIAGNOSIS from sinus bradycardia and electrical-
BEFORE PULMONARY ARTERY CATHETERIZATION mechanical disassociation in 2 patients.
Cardiac Permeability In 1 patient 62 yr of age, pulmonary
artery rupture occurred (autopsy-con-
Age, X = 67 ± 7 Age, X = 56 ± 8
firmed). The patient did not have pul-
Sex, M/F = 33/17 Sex, M/F = 12/8
monary hypertension, nor was an
Mortality, 28/50 = 56% Mortality, 12/20 = 60% abrupt rise in the pressure tracing
Admitting diagnosis Admitting diagnosis noted.
Ischemic heart disease 36 Sepsis 7
included: acute myocardial infarc- Discussion
tion, 4; crescendo angina, 15;
ischemic cardiomyopathy, 17
The use of the flow-directed, balloon-
Bacterial pneumonia 4 Viral pneumonia 6
tipped, pulmonary artery catheter has
Pulmonary embolus 3 Bacterial pneumonia 2
contributed to the diagnosis and ther-
Valvular heart disease 3 Drug overdose 2
apy of critically ill patients. Pulmonary
Idiopathic cardiomyopathy 2 Aspiration 1
artery catheterization has been of value
Sepsis 1 Pancreatitis 1
in the management of low cardiac out-
Renal failure 1 Transfusion reaction 1
put syndromes, myocardial infarction,
and respiratory failure (2, 13). Despite
Total 50 20
this, questions have been raised about
whether this procedure adds additional
information to standard clinical diag-
perature, blood culture results, and chest previous 8 h prior to catheterization. In nostic assessment. Our data clearly
roentgenogram. Bacteremia was attributed the 19 patients with PCW pressures less
to the catheter only when more than 2 cul- show that clinical evaluation is very
than 18, seven were treated with di-
tures yielded a potential pathogen and when sensitive but not specific for cardio-
uretics before the study. These results
this organism also grew from the cultured genic edema in the intensive care unit.
suggest that the ability to make the
catheter tip. Complications were included When 2 skilled and experienced physi-
only if they required medical intervention. clinical diagnosis of cardiac pulmonary
cians evaluated patients suspected of
edema is more difficult than that of
Statistics permeability edema. In the 3 patients
Differences between groups were analyzed incorrectly diagnosed initially as per- TABLE 4
using differences between proportions (12). meability pulmonary edema, PCW
COMPLICATIONS IN PATIENTS UNDERGOING
pressure was elevated in all and ranged PULMONARY ARTERY CATHETERIZATION
Results from 22 to 32 mmHg. Of the patients
initially thought to have cardiac edema, PPE CPE
We found that PAC substantiated the
clinical impression in the vast majority 19 were subsequently found to have Complications (n) (%) (n) (%)
of patients initially thought to have Local bleeding 4 20 3 3
permeability pulmonary edema (table Ventricular tachycardia 0 2 4
TABLE 3
3), none of whom had been given Bradyarrhythmia 0 1 2
INITIAL AND FINAL DIAGNOSES IN PATIENTS Electrical-mechanical
diuretics prior to catheterization. In
WITH CARDIAC (CPE) AND PERMEABILITY dissociation 0 1 2
this case, 17 of 20 (85%) were correctly PULMONARY EDEMA (PPE) Pulmonary artery rupture 0 1 2
predicted. In contrast, the 50 patients Permanent wedge 1 5 1 2
Final Diagnoses
initially thought to have cardiac edema, Local infection 1 5 0
only 31 (62%) were predicted correctly Initial Diagnosis PPE CPE Sepsis 0 2 4
clinically (p < 0.05). Twenty of these 31 PPE, 20 17 3
Total 6/20 30 11/50 22
patients had PCW pressures greater Definition of abbreviations: PPE = permeability pulmo-
CPE, 50 19 31
than 18, despite diuretic therapy in the nary edema; CPE = cardiogenic pulmonary edema.
1008
having cardiogenic edema, they were
correct in 31 of 50 patients, or 62% of
the time.
Patients have been described with
clinical evidence of heart failure who
have normal pressures when catheter-
ized after diuretic therapy (14). Al-
though this may have occurred in some
of our patients, it is unlikely to have
been a major consideration. Of the 19
patients in the high pressure pulmonary
edema group later reclassified, only 7
received diuretic therapy prior to PAC.
Of these seven, 6 continued to demon-
strate radiographic evidence of severe
pulmonary edema, despite PCW pres-
sures below 18 mmHg over 24 to 72 h
of observation. Four patients had mul-
tiple positive blood cultures, and 2 had
severe viral pneumonia confirmed by
culture. Thus, despite their diuretic
therapy, it is likely that the mechanism
of their pulmonary edema was in-
creased permeability.
There are several reasons for the dif-
ficulty associated with the clinical diag-
nosis of cardiogenic pulmonary edema.
First, in the setting of underlying heart
disease, as was the case in 41 of 50 of
these patients, physicians may lean to-
ward a cardiac origin for pulmonary
edema. Second, the physical findings
associated with heart failure, such as
bilateral rales, jugular venous disten-
tion, and edema, are nonspecific, and
they can be found in critically ill pa-
tients without left ventricular failure.
The S3 gallop, often considered diag-
nostic of heart failure, was heard in
only 10 of 31 patients with cardiogenic
pulmonary edema confirmed by PAC.
Background noise in the Intensive Care
Unit may make accurate characteriza-
tion of auscultatory findings extremely
difficult.
In the permeability pulmonary
edema group, the clinical assessment
was correct in 17 of 20 patients, or 85%
of the time. Thus, clinical evaluation is
very specific but not sensitive in the
diagnosis of PPE. This accuracy prob-
ably is a reflection of the importance of
the underlying illness. In none of the
patients was underlying heart disease
or an S3 gallop noted, and no patient
received diuretic therapy. However, 3 of
20 (15%) of this group had increased
PCW pressures when evaluated by
PAC. These findings concur with those
of Unger and associates (11), who
found left ventricular failure in 29% of
a group of patients with adult respira-
tory distress syndrome. Thus, the
added information gained in 3 patients
must be balanced against the monetary
expense, physician and nurse time, dis-
comfort, and morbidity suffered by the
17 patients who did not derive any
benefit from this procedure. However,
it is important to stress that PAC pro-
vides management as well as diagnostic
information. Although it was demon-
strated that clinical assessment is usual-
ly specific for the diagnosis of perme-
ability pulmonary edema, PAC may be
necessary in such patients to monitor
fluid balance and optimize cardiac out-
put, once positive and expiratory pres-
sure is instituted (15).
Despite its role in the differential di-
agnosis of patients with pulmonary
edema, PAC remains a procedure with
significant morbidity and mortality. As
in previous studies, arrhythmias were
frequently encountered. The incidence
of ventricular tachycardia in our group
was low compared with the 53% re-
ported by Sprung and coworkers (4)
and the 22% reported by Elliott and as-
sociates (3). Complications in our
study were only included when antiar-
rhythmic therapy was required. Prema-
ture ventricular contractions are usual-
ly seen during insertion of the catheter,
and usually stop spontaneously as the
tip passes through the right ventricle.
Sepsis was infrequent, occurring in
only 3 patients, all of whom had the
catheter in place more than 72 h. Three
deaths directly attributable to PAC oc-
curred, all in patients with confirmed
cardiogenic pulmonary edema. Our
4% catheterization-related mortality is
somewhat higher than the 0% reported
by Elliott and associates (3) and the 2%
reported by Sprung and coworkers (4).
While the mortality in PAC is high, it
must be considered against the back-
ground of severely ill patients, with a
56% overall mortality, and the possibil-
ity that it might have been even higher
had the procedure not been performed.
The detrimental effects of misdiag-
nosis and subsequent mistreatment
cannot be specifically detailed, as all
patients had PAC. However, the man-
agement of all 22 patients found to
have been misclassified at the time of
PAC was altered. Those in whom a
diagnosis of heart failure was initially
entertained would have continued to
receive treatment for cardiac failure,
including unnecessary diuretic and
inotropic therapy. Diuretic therapy in
patients already normovolemic or hypo-
volemic may cause profound reduction
in cardiac output, leading to shock (14).
In addition, it is likely that there would
CONCISE CLINICAL STUDIES
have been a delay in the appropriate di-
agnostic and therapeutic interventions.
Specific cultures looking for the origin
of their adult respiratory distress syn-
drome and treatment with positive ex-
piratory pressure and, in some in-
stances, corticosteroids, would have
been withheld. Those found to have
high PCW pressures at PAC would not
have received appropriate inotropic or
diuretic therapy.
Our data concur with those of Con-
nors and coworkers (16), who reported
62 PAC procedures in a heterogenous
group of critically ill patients without
evidence of recent myocardial infarc-
tion. Physicians in their study were able
to estimate PCW pressure only 42% of
the time. In 30 of their 62 cases, infor-
mation obtained by PAC resulted in a
significant change in the management
of their patients.
In summary, we find that the diag-
nosis of pulmonary edema, based on
clinical criteria alone, is often inac-
curate in the intensive care setting. We
suggest that when this diagnosis is con-
sidered, and the patient fails to respond
to initial therapy, PAC should be un-
dertaken promptly, despite the associ-
ated morbidity and mortality.
ALAN M. FEIN
STEVEN K. GOLDBERG
MICHAEL D. WALKENSTEIN
BRUCE DERSHAW
LEONARD BRAITMAN
MICHAEL L. LIPPMANN
Department of Medicine
Pulmonary and Critical Care Divisions
Albert Einstein Medical Center,
Northern Division, and the
Department of General Internal
Medicine
Temple University Health Sciences
Center
Philadelphia, Pennsylvania
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