Anaesth Crit Care Pain Med 34 (2015) 910

Editorial

Pulse pressure respiratory variation to predict uid responsiveness:

From an enthusiastic to a rational view
A R T I C L E I N F O

Keywords:
Physiologic MesH
Hypovolemia MesH
Arterial waveform
Heart-lung interactions

The concept of using respiratory variations of pulse pressure

(PPV) as a gauge for the volemic status has gained popularity in the
early 2000s [1,2]. PPV raised enthusiasm because the anesthetist or
the intensivist would, at last, handle a simple tool providing a
reliable answer to one of the most common questions asked when
caring for patients with circulatory failure: does my patient need
uids?. Indeed, meanwhile, several works underlined the poor
predictive ability of the classically used indices such as cardiac
lling pressures or dimensions [3]. PPV has been proposed to
bridge the gap between the deleterious effects of hypo- and
hypervolemia[3] and the lack of adequate tools for this purpose.
Thus, nearly 15 years after the publication of the rst studies
underscoring the promising ability of PPV for uid responsiveness
prediction [1,2], where are we now?
One can distinguish three main waves in the design of clinical
studies published to date, with slight overlap between these
waves.

A high respiratory rate, more specically a low heart rate-torespiratory rate ratio, was also associated with a poor performance
of PPV for the prediction of uid responsiveness [9].
Other clinical factors have been shown to aw the performance of PPV, or at least to alter its classic interpretation: acute
cor pulmonale [10], abdominal hypertension [11], low respiratory system compliance [12]. Of note, patients with low
respiratory system compliance often receive low tidal volumes
(as settled by the intensivist) because of presumed low lung
compliance, and low Vt is then often the cause for the poor
predictive ability of PPV observed in these patients [28]. Along
with low tidal volume, another major pathophysiological cause
for low respiratory change in pleural pressure is high chest wall
compliance [12].

1. Pathophysiological studies reporting an excellent

performance of PPV

During the last two decades, several trends in the care of the
critically ill and/or patients in the operating theatre have been
observed. First, the concept of protective ventilation has been
developed. It was rst encouraged for the ventilation of patients
suffering from ARDS [13], then for ICU patients with no lung injury
[14], then in the operating theatre [15]. All protective ventilation
strategies are associated with low tidal volumes (and the
frequently associated application of a high respiratory rate).
Therefore, protective ventilation impairs the predictive performance of PPV [46,9], as it exposes to false negative cases
[7,8,16]. Conicting data were reported when a low tidal volume
without high respiratory rate was applied [17].
Second, ICU patients with no inspiratory efforts are nowadays
infrequent. Indeed, limited use of sedation [18], invasive ventilation allowing inspiratory efforts (such as pressure support mode)
[19] and non-invasive ventilation (almost never in fully controlled
ventilation mode) [20] are encouraged. Even in the operating
theatre, general anaesthesia has been frequently replaced by
regional anaesthesia allowing a spontaneous breathing during the
surgical procedure [21].

In various settings, an impressive number of studies performed

under strictly regulated clinical conditions initiated an era of
enthusiasm about dynamic indices [2].
2. Pathophysiological studies exploring the limitations of PPV
The absence of both inspiratory efforts and arrhythmia are
obvious prerequisites for PPV use [3]. Indeed, the measured
variations of arterial pressure should only be related to regular (in
rate and magnitude) changes in the pleural pressure, not polluted
by any kind of arrhythmia.
Since tidal volume is the stimulus for respiratory uctuations of
the arterial pressure waveform, it was not surprising to observe the
publication of several studies showing that its magnitude impacts the
value of PPV. Hence, a low tidal volume [46] and its related low
change in airway driving pressure [7] (reecting low change in pleural
pressure [8]) were associated with a poor performance of PPV.

3. Large observational studies assessing the validity of

PPV in real life practice

http://dx.doi.org/10.1016/j.accpm.2015.02.002
2352-5568/ 2015 Published by Elsevier Masson SAS on behalf of the Societe francaise danesthesie et de reanimation (Sfar).

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10

Editorial / Anaesth Crit Care Pain Med 34 (2015) 910

Last, arrhythmia is a frequent condition in ICU patients [22] and

acute cor pulmonale and abdominal hypertension are not exceptional, especially in patients in circulatory failure, i.e., patients in
whom an index guiding uid management may be helpful.
For all these reasons, nowadays, very few patients satisfy all
criteria for valid use of PPV in the ICU, and in a lesser extent in the
operating theatre. Indeed, in a recent multicentric one-day
observational study in 26 French ICUs (311 patients), only 2% of
ICU patients (3% of those carrying an arterial line) satised all
validity criteria for PPV, as dened by the authors [23]. In the
current issue of Anaesthesia, Critical Care and Pain Medicine, Fischer
et al. reported a similar prevalence (1.3%) of patients in whom the
predictive performance of PPV was valid, i.e., not awed by clinical
factors. The study also took place in French ICUs (465 patients in
36 ICUs) with a one-day observational design. In addition, among
patients who received volume expansion during a half-day
observation period, PPV was used in 10% of patients [24]. This
last nding is consistent with what was also recently observed in
French ICUs: nearly 5% of uid boluses in the 4 rst days of shock
were associated with a measurement of PPV [25].
Hence, current knowledge in the eld of prediction of uid
responsiveness with PPV could be summarised as follows: PPV is a
reliable tool only if used in the right patients, i.e., in patients
satisfying all criteria for the valid use of this index including
regular cardiac rhythm, mechanical ventilation with no spontaneous breathing, sufcient ( 8 mL/kg) tidal volume (and sufcient
heart rate/respiratory rate ratio) and absence of acute cor
pulmonale. On the one hand, these specic patients are seldom
in the ICU setting (12%) as compared with the operating theatre
(39% of anaesthetised patients [26]). On the other hand, the use of
PPV is often tempting as PPV is nowadays automatically displayed
on several modern monitors. Therefore, it is important that
physicians acknowledge those monitors display misleading values
of PPV in most of the patients. This implies a sufcient knowledge
of PPV criteria of validity among anaesthetists and intensivists. In
the same issue of the Anaesthesia, Critical Care and Pain Medicine,
Fischer et al. reported that the knowledge of their pairs (n = 145)
about PPV criteria of validity was clearly insufcient [27].
Before the conduction of a fourth wave of studies such as studies
putting PPV to work into uid management algorithms, educational
efforts about the correct use of PPV should be encouraged.
Disclosure of interest
The authors declare that they have no conicts of interest
concerning this article.
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Karim Lakhala,*
Reanimation chirurgicale polyvalente,
service danesthesie-reanimation, hopital Laennec,
CHU, boulevard Jacques-Monod, 44093 Nantes cedex 1, France
a

Matthieu Biaisb,c
Emergency department, University hospital of Bordeaux,
33076 Bordeaux cedex, France
c
Inserm U1034, Cardiovascular Adaptation to Ischemia, National
Institute of Health and Medical Research, 33600 Pessac, France
b

*Corresponding author
E-mail address: lakhal_karim@yahoo.fr (K. Lakhal),
E-mail address: matthieu.biais@chu-bordeaux.fr (M. Biais)

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