Review Article on Hemodynamic Monitoring in Critically Ill Patients

Page 1 of 10

Prediction of fluid responsiveness in spontaneously breathing

patients
Xavier Monnet1,2, Jean-Louis Teboul1,2
1
Hôpitaux Universitaires Paris-Saclay, Assistance Publique - Hôpitaux de Paris, Hôpital de Bicêtre, Service de Médecine Intensive-Réanimation, Le
Kremlin-Bicêtre, France; 2Inserm UMR S_999, Univ Paris-Saclay, Le Kremlin-Bicêtre, France
Contributions: (I) Conception and design: None; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV)
Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of
manuscript: All authors.
Correspondence to: Prof. Xavier Monnet. Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, 78 rue du Général Leclerc, Le Kremlin-
Bicêtre, F-94270 France. Email: [email protected].

Abstract: In patients with acute circulatory failure, the primary goal of volume expansion is to increase
cardiac output. However, this expected effect is inconstant, so that in many instances, fluid administration
does not result in any haemodynamic benefit. In such cases, fluid could only exert some deleterious effects.
It is now well demonstrated that excessive fluid administration is harmful, especially during acute respiratory
distress syndrome and in sepsis or septic shock. This is the reason why some tests and indices have been
developed in order to assess “fluid responsiveness” before deciding to perform volume expansion. While
preload markers have been used for many years for this purpose, they have been repeatedly shown to be
unreliable, which is mainly related to physiological issues. As alternatives, “dynamic” indices have been
introduced. These indices are based upon the changes in cardiac output or stroke volume resulting from
various changes in preload conditions, induced by heart-lung interactions, postural manoeuvres or by the
infusion of small amounts of fluids. The haemodynamic effects and the reliability of these “dynamic” indices
of fluid responsiveness are now well described. From their respective advantages and limitations, it is also
possible to describe their clinical interest and the clinical setting in which they are applicable.

Keywords: Volume expansion; passive leg raising (PLR); heart-lung interactions

Submitted Mar 03, 2020. Accepted for publication May 25, 2020.
doi: 10.21037/atm-2020-hdm-18
View this article at: http://dx.doi.org/10.21037/atm-2020-hdm-18

Introduction Therefore, before administering it, predicting whether or

not a bolus of fluid will increase cardiac output is a strategy
Fluid administration is the first therapeutic measure in
that reasonably reduces fluid administration and avoids the
the majority of cases of acute circulatory failure. It is
harmful effects of fluid when it has no beneficial effect.
intended to increase cardiac output and oxygen delivery (1). To detect preload dependence and predict fluid
However, apart from cases in which the absolute or relative responsiveness, several tests and indices have been
hypovolemia is very deep, such as during haemorrhage, developed over the past twenty years (4). They all consist
significant extracellular dehydration or septic shock in the of inducing or observing variations in cardiac preload, and
initial phase, the administration of fluid only leads to a measuring the resulting changes in cardiac output or stroke
significant increase in cardiac output in half of the cases (2). volume. The magnitude of these changes allows one to
In cases where preload dependence is absent, volume predict which changes will be induced by the fluid infusion.
expansion does not have a beneficial effect, but exerts What are the tests and indices that can be used in
deleterious effects which are today well demonstrated (3). patients who are not intubated, or intubated but who have

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(12):790 | http://dx.doi.org/10.21037/atm-2020-hdm-18
Page 2 of 10 Monnet and Teboul. Fluid responsiveness in spontaneous breathing

some spontaneous breathing activity? How should these other “static” markers of cardiac preload that the decision
tests be performed in practice? What are their limitations was made whether or not to give boluses. However, it
and the conditions under which they can be used? What is has been clearly demonstrated in a considerable number
the overall strategy in which they should be implemented? of studies that this strategy does not work (8). Perhaps
These are the questions we will answer in this review, based outside of extreme values, a given level of cardiac preload
on the most recent data in the literature. does not predict the response to volume expansion. It is
clear from a figure on which are superimposed curves of
cardiac function with different slopes, that a given value
What is the concept of fluid responsiveness
on the abscissa axis does not determine the slope of the
prediction?
curve and therefore the degree of preload dependence. In
Fluid administration in patients with acute circulatory this spontaneously breathing population, to which we are
failure is intended to increase the mean systemic pressure, interested in this review, another reason is that barometric
which is the upstream pressure of systemic venous return, to markers are difficult to measure in the event of irregular and
increase cardiac preload, and therefore to improve cardiac rapid breathing. On a CVP or pulmonary artery occlusion
output (5). However, in the early 1980s, it appeared that the pressure curve, it can be difficult to distinguish expiration,
increase in stroke volume and cardiac output only occurs during which the intravascular pressure should be measured
in half of the patients who receive a fluid bolus (6). The to overcome the influence of intrathoracic pressure.
explanation is probably physiological. The Frank-Starling Despite physiological reality and the large number of
relationship between cardiac preload and stroke volume is studies that have demonstrated it, it is very surprising to
curvilinear, and the response to volume expansion can only find that CVP still guides many intensivists in their decision
occur in a state of preload dependence, i.e., if the slope of to administer fluid or not (9). In this regard, it must be said
the relationship is sufficiently steep (4). However, this slope, that this strategy has been recommended for septic patients
which is determined by the contractile function of the two for many years by the Surviving Sepsis Campaign (10,11).
ventricles, varies from patient to patient, and it is impossible In contrast to this “static” method, the “dynamic”
to determine it from basic clinical data. This is the first part approach for detecting dependence preload is based on the
of the problem. observation of changes in stroke volume or cardiac output
The second part, highlighted a little later (7), is that the which result from changes in cardiac preload, observed
administration of fluid in critical patients is deleterious. spontaneously or induced by specific tests. Some of these
Fluids have a multitude of deleterious effects, particularly tests and indices cannot be used in spontaneously breathing
in intensive care patients with sepsis, lung damage, kidney patients. The respiratory variation of arterial pulse pressure
failure or abdominal problems (3). The fluid balance is even is very reliable, but can be used only in case of regular
a factor which is linked to the mortality of these patients mechanical ventilation with no spontaneous cycle (12).
independently of the other gravity factors (7). Therefore, This is also the case of the variation of the diameter of the
it appears that administering fluid to a patient who is not inferior or superior venae cavae, which is in anyway a less
“responder” to fluid is not only ineffective, but harmful.
reliable index of preload responsiveness (13). Nevertheless,
Like any drug with inconsistent efficacy and significant
in spontaneously breathing patients, a study has suggested
side effects, it appears necessary to administer fluid only if
that the changes in inferior vena cava diameter induced by
one is almost certain that it will be effective. The concept
a standardised deep inspiration predict fluid responsiveness
of prediction of response to volume expansion is based on
reliably (14).
the idea that fluid should only be administered in critically
ill patients in a state of dependence preload. This should
reduce the fluid balance, and ultimately improve the Fluid challenge
prognosis for these patients.
What is it?

The easiest way to test dependence preload a priori is to

The static approach must be abandoned!
administer fluid and measure the increase in cardiac output
For years, it was on central venous pressure (CVP) and it induces. This “fluid challenge” method has been used de

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(12):790 | http://dx.doi.org/10.21037/atm-2020-hdm-18
Annals of Translational Medicine, Vol 8, No 12 June 2020 Page 3 of 10

facto for many years. course, the test assumes that changes in cardiac output can
be measured despite their small amplitude.

How to do it in practice?
How to do it in practice?
The “classic” fluid challenge consists of the administration
of 300 to 500 mL of fluid over 30 minutes. The The first study which tested the validity of a “mini
crystalloid and colloid solutions may be suitable (15), fluid challenge” reported the injection of 100 mL of
but the recommendation not to use colloid should be hydroxyethyl starch over a few minutes, the effects of which
reminded here in patients with septic shock (16). The were measured by changes in velocity-time integral (VTI)
effectiveness of the fluid challenge must be evaluated in transthoracic echocardiography (21).
above all on the reversion of the criterion which In the studies that followed, volumes of 50 to 150
initiated it: drop in diuresis, skin mottling, increase in mL were tested, with colloids and crystalloids (22,23).
lactate, etc. (15). However, the effects on cardiac output However, some studies using lower volumes have shown
should be estimated on a direct measurement of cardiac less reliability (24).
output as they are poorly reflected by simultaneous
changes in blood pressure or in heart rate (17).
What are the limitations?
This is the case even when the arterial pulse pressure,
physiological reflection of the stroke volume, is considered The first limitation of the mini fluid challenge is that, even
(18,19). if its volume is less than that of the classic fluid challenge,
Finally, it is recommended by the proponents of the it persists that repeating it several times in a few hours
method to set safety limits, in particular to avoid fluid in a patient can only lead to an increase in the total fluid
overload. A CVP limit of 15 mmHg can be used (15). balance.
The second limitation is related to the technique used to
measure changes in cardiac output. Indeed, small volumes
What are the limitations?
of fluid can only induce small changes in cardiac preload,
The most obvious limitation of the fluid challenge is that it which can only induce small increases in cardiac output
is not a “test”, but the treatment itself. In the event of fluid even in the case of preload responsiveness. The threshold
unresponsiveness, it is impossible to withdraw from the reported to define the positivity of the test is also low (21).
patient the fluid which has been administered but which is This implies that the technique that measures cardiac
ineffective. Inherently, managing the fluid therapy with the output must be very precise. From this point of view, it
fluid challenge induces fluid overload. This is particularly should be remembered that the smallest significant change
the case if the test must be repeated several times, which in VTI that ultrasound can measure is only 10% (25).
may occur in the first hours of acute circulatory failure in In comparison, the pulse contour analysis can detect
many patients. changes in cardiac output as low as 1.3% (26), and may be
more suitable for the mini-fluid challenge (24). It has been
demonstrated that the decrease in pulse pressure variation
Mini-fluid challenge
induced by a mini fluid challenge could detect preload
What is it? responsiveness, but the study was performed in deeply
sedated patients (27). Whether the method is possible in
The principle is based on the very limitation of the
spontaneously breathing patients should be investigated.
“standard” fluid challenge. The idea is to administer not
300–500 mL of fluid, but only a few tens of millilitres of
colloid or crystalloid. The response of cardiac output to this End-expiratory occlusion test
low volume is used to predict the effects of more important
What is it?
volumes of fluid. The test is based on the hypotheses that
a small volume of fluid can significantly increase cardiac This test is based on the haemodynamic effects of
preload and that this increase in preload is sufficient to mechanical ventilation and can only be used in intubated
test the preload dependence of the two ventricles (20). Of patients. However, unlike the variations induced in pulse

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(12):790 | http://dx.doi.org/10.21037/atm-2020-hdm-18
Page 4 of 10 Monnet and Teboul. Fluid responsiveness in spontaneous breathing

pressure, stroke volume or diameter of the venae cavae, ultrasonic techniques may be less reliable for this test
it can be used in patients who have slight spontaneous because they lack precision. From this point of view, our
respiratory activity. group has shown that, to be used with echocardiography,
Under positive pressure ventilation, each insufflation the 15-second EEXPO test must be associated with
of the ventilator increases the intrathoracic pressure, and a 15-second end-inspiratory occlusion (EIXPO) test,
this increase is transmitted to the right atrium through separated from the first by a few seconds, the while the
its thin and compliant free wall. This cyclically causes a patient’s condition stabilises again (30). In the case of
drop in the pressure gradient of systemic venous return preload-dependence, the subaortic VTI increases during
(mean systemic pressure - right atrial pressure) and a drop the EEXPO and decreases during the EIXPO pause in a
in cardiac preload. Thus, stopping ventilation et end- greater manner than in the case of preload-independence
expiration stops the cyclic impediment in systemic venous (Figure 1). If the effect (in absolute value) of these two
return (28). During the expiratory pause, the right cardiac manoeuvres is added, the test detects preload dependence
preload increases. The increase in preload is transmitted with a positivity threshold of 15%. If, on the other hand,
from the right to the left side. If, in response, stroke volume only the changes in VTI are considered during the
and cardiac output increase, the two ventricles are preload EEXPO pause, the sensitivity and specificity are correct,
dependent (28). but the diagnostic threshold is only 4%, which is too low
Since the first study published in 2009 (29), a substantial compared to the accuracy of the echocardiography (30).
number of other publications have come to support the Similar results have been demonstrated with oesophageal
validity of the end-expiratory (EEXPO) test. Several Doppler, which suffers from the same lack of precision as
of them have been included in recent meta-analyses, echocardiography (31).
concluding that the test is valid (23). The threshold for
increase in cardiac output that defines positivity is 5%.
What are the limitations?

How to do it in practice? Some studies have suggested that the EEXPO test was less
reliable in patients with a tidal volume of 6 mL/kg rather
In a patient under mechanical ventilation, a first value of the than 8 mL/kg (32,33). However, this result was not found
cardiac output is measured. The patient’s condition must in all the studies that demonstrated the reliability of the test
be stable enough for this value to be considered a reliable when they included a large number of ventilated patients
reference. Ventilation is stopped at the end of expiration, with low tidal volume. It seems that the level of positive
with the same procedure as that usually used to measure end-expiratory pressure does not influence the reliability of
intrinsic positive end-expiratory pressure. Importantly, the the EEXPO test (33,34).
hold should be at least 15 seconds (Figure 1). The reason is Of course, the test cannot be used in patients who are
that devices that measure cardiac output continuously do unable to support a breathing pause as long as 15 seconds,
so on a moving average of several seconds, tending to delay that is, if the patients have too much spontaneous breathing
the on-screen appearance of the maximum value reached activity. Also, as stated above, the test requires direct
by cardiac output. This maximum value of cardiac output
measurement of cardiac output. Indeed, if the changes in
measured at the end of the 15 seconds is noted, and the
arterial pulse pressure can detect the changes in cardiac
percentage of change compared to the pre-pause value is
output in this circumstance, these changes cannot be easily
calculated (28).
assessed on the bedside monitors.
The technique for measuring cardiac output must meet
two criteria (28). The first is that it must be able to detect
rapid changes in cardiac output occurring in real time. Passive leg raising (PLR)
The second criterion is that the technique must be precise
What is it?
enough to measure changes in cardiac output of only a few
percent. When transferring a patient from the semi-recumbent
Pulse contour analysis, which is a very precise technique, position at 30–45°, to a position in which the trunk is
is perfectly suited for the test, and has been used in several horizontal and the lower limbs raised at 30–45°, a portion
studies. On the contrary, cardiac echography and other of the venous blood stagnating in the lower limbs and in

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Annals of Translational Medicine, Vol 8, No 12 June 2020 Page 5 of 10

EEXPO must The EIXPO must

Perform EEXPO like be at least Can be inspiratory also be at least
when measuring 15’’ long efforts if they do not 15’’ long
intrinsic PEEP interrupt EEXPO

Baseline EEXPO Baseline EIXPO Baseline Fluid infusion

Measure CO value
during a period of
stability Check patient’s
stability before * if a less precise technique is used to measure
Use a precise
infusing fluid CO (e.g., echo, oeso Doppler)
and real time CO
monitoring

Figure 1 Rules for performing the end-expiratory occlusion test. EEXPO, end-expiratory occlusion; EIXPO, end-inspiratory occlusion;
CO, cardiac output.

the vast splanchnic territory is transferred to the heart from the horizontal position, the test does not mobilize
chambers (35). The resulting increase in cardiac preload the vast reservoir of splanchnic venous blood, making the
mimics the effects of a fluid challenge. PLR has in fact test less sensitive than when it begins with the trunk tilted
been shown to cause a significant increase in mean systemic at 30–45° (39). Rather than performing the test by lifting
filling pressure (5). Unlike a fluid challenge, however, the manually lower limbs holding the heels of the patient, it
PLR test has the major advantage of being reversible when is better to use the automatic movements of the electric
the patient is returned to the semi-recumbent position (36). bed (38). This prevents possible pain from creating false
Compared to tests using heart-lung interactions, the PLR positives. The maximum value of cardiac output or stroke
test has the advantage that it can be used also in patients volume, which generally appears in less than a minute, is
without mechanical ventilation or ventilated but with noted and the percentage increase compared to the value
spontaneous breathing cycles. measured before the test is calculated. After the test, it must
A now large number of studies have shown that the test be checked that the cardiac output or stroke volume return
is reliable. The threshold for increasing cardiac output to its baseline value when the patient has been returned
used for positivity is 10% (35,37). The last version of the to the semi-recumbent position. This makes sure that the
Surviving Sepsis Campaign recommends to use PLR for baseline value considered was indeed stable (38).
guiding fluid therapy in patients with septic shock (16). Above all, the test must be performed by measuring
cardiac output or stroke volume directly (38). When its
effects are measured on blood pressure, the test is less
How to do it in practice?
reliable, with a significant proportion of false negatives.
A first measurement of cardiac output, stroke volume, or This has been reported by several studies (35).
their surrogate is collected at the base, making sure that the The technique used to measure cardiac output must
value considered is fairly stable. Simple rules must then be be able to measure changes that occur over a short period
followed for the test to be reliable (Figure 2). First, it must of time. Indeed, the effects may decrease after reaching
be started from the semi-recumbent position (38). Started the maximum value, in certain particularly vasodilated

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Page 6 of 10 Monnet and Teboul. Fluid responsiveness in spontaneous breathing

5
3
Re-assess CO in the semi-
Assess PLR effects by directly recumbent position
measuring CO (should return to baseline)
(not with blood pressure only)

2 Volume
Use the bed adjustment expansion
and avoid touching the patient
(pain, awakening)

1 4
Check that the trunk Use a real-time
is at 45° measurement of CO

Figure 2 Rules for performing the passive leg raising test. CO, cardiac output.

patients and in whom capillary leakage is significant. The assessment of the haemodynamic status through
Thus, pulmonary or transpulmonary thermodilution is clinical examination is gaining more and more interest
not appropriate because of the time required to repeat (45,46). One study reported that the test could be
cold boluses injection. The pulse wave contour analysis performed by measuring cardiac output from capillary refill
is particularly simple to use. With echocardiography, the time instead (47). However, to ensure the reproducibility
changes in VTI are proportional to those in cardiac output, of the measurement, the capillary refill time was measured
without the need to measure the area of the left ventricle according to a standardised method which cannot be used
outflow tract. in current practice (47). Automating the method may make
Bioreactance can be used when the last version of the the test easier.
system is used, because it is more reactive to changes in Recently, our group reported that changes in the
cardiac output than the previous one (40). There is some plethysmography perfusion index (ratio between the
doubt that the effects of the test can be detected via changes pulsatile portion and the non-pulsatile portion of the signal)
in carotid or femoral flow measured by arterial Doppler, are able to track changes in cardiac output during the PLR
because positive and negative results are found in the test, so that the changes in this index induced by the PLR
literature (41-43). are capable of detecting the preload-dependence (48).
Capnography, which can detect changes in cardiac output These results undoubtedly need to be confirmed. Also, t
using those of carbon dioxide at the end of expiration, is an perfusion index signal was unstable in some patients, but it
interesting technique because it is not invasive. However, is an interesting opportunity (48).
in this case the ventilation must be perfectly stable (44), so
that changes in carbon dioxide in exhaled gas are only due
Limitations
to changes in cardiac output. The method is not suitable for
patients with spontaneous ventilation, to whom this review First of all, as we have seen, performing the PLR test
is devoted. requires a direct measurement of cardiac output, which

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Annals of Translational Medicine, Vol 8, No 12 June 2020 Page 7 of 10

is the main limitation in practice (38). Then, the test is fluid is often a therapeutic objective, and the question
contraindicated in case of intracranial hypertension. Intra- that arises in this context is to know what volume should
abdominal hypertension compresses the splanchnic territory, be removed without causing hemodynamic impairment.
probably hinders blood transfer from the lower limbs to the Testing preload responsiveness allows one to undertake
thorax and certainly reduces the splanchnic blood volume depletion only in the case where it is certain that the decrease
that can be mobilised by the manoeuvre. Indeed, intra- in preload will not reduce the cardiac output. At the time of
abdominal hypertension seems to be a condition in which weaning from mechanical ventilation, the PLR test has been
false negatives appear on the PLR test (49). shown to reliably predict that a spontaneous breathing trial
The test is not feasible in prone positioning patients, and will lead to weaning-induced pulmonary oedema (51).
a reverse Trendelenburg manoeuvre has been described as a
reliable alternative to the PR test in these cases (50).
Positive test, negative test?

No index or any of the tests that detect preload

When and how to use these tests and indices?
responsiveness is perfect. First, they all have their own
It should always be remembered that preload responsiveness terms and conditions of use, as we have seen. Then, even
is a physiological state and that patients should not receive under the optimal conditions of their use, their sensitivity
fluid for the sole reason that the indices or tests of preload and specificity is not perfect.
dependence are positive. Two questions must be asked In addition, none of the diagnostic thresholds proposed
beforehand. The first is whether there are arguments to should be considered in an absolute manner. There is
believe that the cardiac output is too low compared to the necessarily a grey zone, in which the sensitivity and
oxygen requirements of the organism. Hyperlactatemia, a specificity are not absolute (52). This may be linked to the
lowering of central venous oxygen saturation, a decrease in unreliability of the test, but also to the lack of precision
urine flow or an increase in the veno-arterial carbon dioxide of the measurement method used to estimate its effects.
gap are, for example, arguments for this. Finally, it should be borne in mind that the relationship
The second question is whether the risks of fluid between cardiac preload and cardiac output is curvilinear,
administration are not greater than the benefits that can be and is not a biphasic relationship. There is a continuum
expected. The increase in the fluid balance is a deleterious between the state of preload responsiveness and that of
condition which must be avoided (3). Fluids are treatments preload responsiveness, and patients in whom the preload
that are both inconsistent and dangerous. As with all responsiveness or responsiveness is weak. Therefore, the
treatments of this type used in frail patients, we must decision whether or not to administer fluid based on the test
carefully predict their effectiveness and estimate the risk result should be made with more confidence if the changes
associated with their use. The level of extravascular lung observed are far from the threshold value reported in the
water and pulmonary permeability, the level of CVP, the literature (4). In the future, it is very likely that this rather
ratio between the arterial partial pressure of oxygen and the rough way of predicting treatments effects will be replaced,
inspired fraction of oxygen, the level of intra-abdominal at least in part, by more sophisticated predictive analytics
pressure are undoubtedly indices which help to assess the based on machine learning (53).
risk of volume expansion (3).
It should be borne in mind that there are conditions in
Conclusions
which preload responsiveness is obviously constant, and in
which the fluid must be administered without considering It is now clearly demonstrated that volume expansion is
any of the indices and tests that we have described. In the a dangerous treatment whose efficacy is inconstant. It is
event of obvious fluid or blood loss, or in the initial phase therefore reasonable to predict its effects, in order to avoid
of sepsis, when no fluid has yet been administered, the administering fluid to a patient who is not dependent on
implementation of tests and indices of fluid responsiveness cardiac preload. Several tests are currently available to do
would only lead to a dangerous delay in treatment (4). this. The advantage of having several tests is to be able to
Finally, if tests are used in the resuscitation phase to bypass the limits of each, and to base the diagnosis when
decide whether to administer fluid or not, they can be very their result is close to the recommended threshold value.
useful in the de-escalation phase. In this phase, removing In addition to a proper evaluation of the fluid efficacy once

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Page 8 of 10 Monnet and Teboul. Fluid responsiveness in spontaneous breathing

it has been administered (1,17), the attitude of detecting Hemodynamically Unstable Patient Respond to a Bolus of
preload responsiveness may contribute to guide the fluid Intravenous Fluids? JAMA 2016;316:1298-309.
strategy in a safer and more precise way. 3. Malbrain ML, Van Regenmortel N, Saugel B, et al.
Principles of fluid management and stewardship in septic
shock: it is time to consider the four D's and the four
Acknowledgments
phases of fluid therapy. Ann Intensive Care 2018;8:66.
Funding: None. 4. Monnet X, Marik PE, Teboul JL. Prediction of fluid
responsiveness: an update. Ann Intensive Care 2016;6:111.
5. Guérin L, Teboul JL, Persichini R, et al. Effects of passive
Footnote
leg raising and volume expansion on mean systemic
Provenance and Peer Review: This article was commissioned pressure and venous return in shock in humans. Crit Care
by the Guest Editors (Glenn Hernández and Guo-wei Tu) 2015;19:411.
for the series “Hemodynamic monitoring in critically ill 6. Calvin JE, Driedger AA, Sibbald WJ. Does the pulmonary
patients” published in Annals of Translational Medicine. The capillary wedge pressure predict left ventricular preload in
article was sent for external peer review organized by the critically ill patients? Crit Care Med 1981;9:437-43.
Guest Editors and the editorial office. 7. Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European
intensive care units: results of the SOAP study. Crit Care
Conflicts of Interest: Both authors have completed the Med 2006;34:344-53.
ICMJE uniform disclosure form (available at http:// 8. Marik PE, Cavallazzi R. Does the central venous pressure
dx.doi.org/10.21037/atm-2020-hdm-18). The series predict fluid responsiveness? An updated meta-analysis
“Hemodynamic monitoring in critically ill patients” was and a plea for some common sense. Crit Care Med
commissioned by the editorial office without any funding or 2013;41:1774-81.
sponsorship. XM and JLT report personal fees from Pulsion 9. Cecconi M, Hofer C, Teboul JL, et al. Fluid challenges
Medical Systems, during the conduct of the study. XM and in intensive care: the FENICE study: A global inception
JLT report personal fees from Getinge/Pulsion Medical cohort study. Intensive Care Med 2015;41:1737-8.
System, outside the submitted work. 10. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis
Campaign guidelines for management of severe sepsis and
Ethical Statement: The authors are accountable for all septic shock. Intensive Care Med 2004;30:536-55.
aspects of the work in ensuring that questions related 11. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis
to the accuracy or integrity of any part of the work are Campaign: International Guidelines for Management of
appropriately investigated and resolved. Severe Sepsis and Septic Shock, 2012. Intensive Care Med
2013;39:165-228.
Open Access Statement: This is an Open Access article 12. Teboul JL, Monnet X, Chemla D, et al. Arterial Pulse
distributed in accordance with the Creative Commons Pressure Variation with Mechanical Ventilation. Am J
Attribution-NonCommercial-NoDerivs 4.0 International Respir Crit Care Med 2019;199:22-31.
License (CC BY-NC-ND 4.0), which permits the non- 13. Vignon P, Repesse X, Begot E, et al. Comparison
commercial replication and distribution of the article with of Echocardiographic Indices Used to Predict Fluid
the strict proviso that no changes or edits are made and the Responsiveness in Ventilated Patients. Am J Respir Crit
original work is properly cited (including links to both the Care Med 2017;195:1022-32.
formal publication through the relevant DOI and the license). 14. Bortolotti P, Colling D, Colas V, et al. Respiratory
See: https://creativecommons.org/licenses/by-nc-nd/4.0/. changes of the inferior vena cava diameter predict fluid
responsiveness in spontaneously breathing patients with
cardiac arrhythmias. Ann Intensive Care 2018;8:79.
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Cite this article as: Monnet X, Teboul JL. Prediction of fluid

responsiveness in spontaneously breathing patients. Ann Transl
Med 2020;8(12):790. doi: 10.21037/atm-2020-hdm-18

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(12):790 | http://dx.doi.org/10.21037/atm-2020-hdm-18