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VOLUME 25 , ISSUE 6 ( June, 2021 ) > List of Articles

Original Article

Comparison of Changes in PPV Using a Tidal Volume Challenge with a Passive Leg Raising Test to Predict Fluid Responsiveness in Patients Ventilated Using Low Tidal Volume

Ahmed I Elsayed, Khaled AW Selim, Hanan E Zaghla, Hossam E Mowafy, Mohammed A Fakher

Keywords : Fluid responsiveness, Passive leg raising, Pulse pressure variation, Tidal volume challenge

Citation Information : Elsayed AI, Selim KA, Zaghla HE, Mowafy HE, Fakher MA. Comparison of Changes in PPV Using a Tidal Volume Challenge with a Passive Leg Raising Test to Predict Fluid Responsiveness in Patients Ventilated Using Low Tidal Volume. Indian J Crit Care Med 2021; 25 (6):685-690.

DOI: 10.5005/jp-journals-10071-23875

License: CC BY-NC 4.0

Published Online: 01-06-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Background: Tidal volume challenge pulse pressure variation (TVC-PPV) is considered one of the recent reliable dynamic indices of fluid responsiveness (FR); also, passive leg raising (PLR)-induced changes in cardiac output (CO) detected by echocardiography are considered a reliable reversible self-fluid challenge test; many patients share eligibility for both tests. Objectives: The study aimed to compare the sensitivity and specificity of both tests for the prediction of FR in mechanically ventilated patients with hemodynamic instability. Methods: We studied 46 patients. Hemodynamic parameters including PPV and CO (detected by velocity time integral (VTI) using echocardiography) recorded at tidal volume (VT) of 6 mL/kg/ideal body weight (IBW) in semi-recumbent position then recorded again after one-minute increase in TV from 6 to 8 mL/kg/IBW then recorded with PLR at TV of 6 mL/kg/IBW and finally with actual volume expansion in semi-recumbent position by 4 ml/kg bolus of crystalloid solution to define actual responders with increase of cardiac output of 15% or more. Results: Sixteen patients were responders, and thirty patients were nonresponders; responders had significant increase in PPV with TVC 6 to 8 ml/kg/IBW with best cutoff value of 3.5 with a sensitivity of 93.8% and a specificity of 93.9%. PLR test-induced changes in CO had a sensitivity of 93.9% and a specificity of 86.7% with statistically best cutoff value of 6.5% increase in CO, but sensitivity was 75% at cutoff value of 10% increase in CO. Other parameters like PPV, PPV changes with PLR test, and PPV changes with fluid expansion were less sensitive indicators. Conclusion: FR in patients with hemodynamic instability and mechanically ventilated with low tidal volume strategy can be efficiently predicted when PPV increases more than 3.5 with tidal volume challenge and when PLR induces 6.5% increase in CO monitored through VTI method by Doppler echocardiography, and both tests are equally reliable.

  1. Micek ST, McEvoy C, McKenzie M, Hampton N, Doherty JA, Kollef MH. Fluid balance and cardiac function in septic shock as predictors of hospital mortality. Crit Care 2013;17(5):R246. DOI: 10.1186/cc13072.
  2. Messmer AS, Zingg C, Müller M, Gerber JL, Schefold JC, Pfortmueller CA. Fluid overload and mortality in adult critical care patients-a systematic review and meta-analysis of observational studies. Crit Care Med 2020;48(12):1862–1870. DOI: 10.1097/CCM.0000000000004617.
  3. Jozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, et al. Extravascular lung water is an independent prognostic factor in patients with acute respiratory distress syndrome. Crit Care Med 2013;41(2):472–480. DOI: 10.1097/CCM.0b013e31826ab377.
  4. Boyd JH, Forbes J, Nakada T, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39(2):259–265. DOI: 10.1097/CCM.0b013e3181feeb15.
  5. Michard F, Teboul J-L. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest 2002;121(6):2000–2008. DOI: 10.1378/chest.121.6.2000.
  6. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med 2009;37(9):2642–2647. DOI: 10.1097/CCM.0b013e3181a590da.
  7. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013;41(7):1774–1781. DOI: 10.1097/CCM.0b013e31828a25fd.
  8. Monnet X, Marik PE, Teboul JL. Prediction of fluid responsiveness: an update. Ann Intensive Care 2016;6(1):1–11.
  9. Hasanin A. Fluid responsiveness in acute circulatory failure. J Intensive Care 2015;3(1):50. DOI: 10.1186/s40560-015-0117-0.
  10. De Backer D, Heenen S, Piagnerelli M, Koch M, Vincent J-L. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med 2005;31(4):517–523. DOI: 10.1007/s00134-005-2586-4.
  11. Myatra SN, Monnet X, Teboul JL. Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation. Crit Care 2017;21(1):60. DOI: 10.1186/s13054-017-1637-x.
  12. Alvarado-Sánchez JI. The passive leg raising test (PLR). Colomb J Anesthesiol 2015;43(3):214–218. DOI: 10.1016/j.rcae.2015.03.005.
  13. Cherpanath TGV, Hirsch A, Geerts BF, Lagrand WK, Leeflang MM, Schultz MJ, et al. Predicting fluid responsiveness by passive leg raising: a systematic review and meta-analysis of 23 clinical trials. Crit Care Med 2016;44(5):981–991. DOI: 10.1097/CCM.0000000000001556.
  14. Monnet X, Marik P, Teboul J-L. Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis. Intensive Care Med 2016;42(12):1935–1947. DOI: 10.1007/s00134-015-4134-1.
  15. Thiel SW, Kollef MH, Isakow W. Non-invasive stroke volume measurement and passive leg raising predict volume responsiveness in medical ICU patients: an observational cohort study. Crit Care 2009;13(4):R111. DOI: 10.1186/cc7955.
  16. Lafanechère A, Pène F, Goulenok C, Delahaye A, Mallet V, Choukroun G, et al. Changes in aortic blood flow induced by passive leg raising predict fluid responsiveness in critically ill patients. Crit Care 2006;10(5):1–8. DOI: 10.1186/cc5044.
  17. Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul J-L. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity. Intensive Care Med 2007;33(7):1125–1132. DOI: 10.1007/s00134-007-0646-7.
  18. Vincent J-L and De Backer D. Circulatory shock. N Engl J Med 2013;369(18):1726–1734. DOI: 10.1056/NEJMra1208943.
  19. Tan C, Rubenson D, Srivastava A, Mohan R, Smith MR, Billick K, et al. Left ventricular outflow tract velocity time integral outperforms ejection fraction and Doppler-derived cardiac output for predicting outcomes in a select advanced heart failure cohort. Cardiovasc Ultrasound 2017;15(1):18. DOI: 10.1186/s12947-017-0109-4.
  20. MacFarland, Thomas W., and Jan M. Yates. “Mann–whitney u test.” Introduction to nonparametric statistics for the biological sciences using R. Springer, Cham, 2016. 103-132. DOI:
  21. Bewick V, Cheek L, Ball J. Statistics review 8: Qualitativedata – tests of association. Crit Care 2004;8:46-53. DOI:
  22. Min JJ, Gil NS, Lee JH, Ryu DK, Kim CS, Lee SM. Predictor of fluid responsiveness in the ‘grey zone’: augmented pulse pressure variation through a temporary increase in tidal volume. Br J Anaesth 2017;119(1):50–56. DOI: 10.1093/bja/aex074.
  23. Charron C, Fessenmeyer C, Cosson C, Mazoit J-X, Hebert J-L, Benhamou D, et al. The influence of tidal volume on the dynamic variables of fluid responsiveness in critically ill patients. Anesth Analg 2006;102(5):1511–1517. DOI: 10.1213/01.ane.0000209015.21418.f4.
  24. Messina A, Montagnini C, Cammarota G, De Rosa S, Giuliani F, Muratore L, et al. Tidal volume challenge to predict fluid responsiveness in the operating room. Eur J Anaesthesiol 2019;36(8):583–591. DOI: 10.1097/EJA.0000000000000998.
  25. Jun, J-H, Chung RK, Baik HJ, Chung MH, Hyeon J-S, Lee Y-G, et al. The tidal volume challenge improves the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation. BMC Anesthesiol 2019;19(1):142.DOI: 10.1186/s12871-019-0807-6.
  26. Teboul, J-L., and X. Monnet. “Meaning of pulse pressure variation during ARDS.” Annual Update in Intensive Care and Emergency Medicine 2011. Springer, Berlin, Heidelberg, 2011. 322-331. Doi:
  27. García MIM. Effects of fluid administration on arterial load in septic shock patients. Intensive Care Med. 2015;41(7):1247–1255. DOI: 10.1007/s00134-015-3898-7.
  28. Cherpanath TGV, Smeding L, Lagrand WK, Hirsch A, Schultz MJ, Groeneveld JAB. Pulse pressure variation does not reflect stroke volume variation in mechanically ventilated rats with lipopolysaccharide‐induced pneumonia. Clin Exp Pharmacol Physiol 2014;41(1):98–104. DOI: 10.1111/1440-1681.12187.
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