What are the controversies about the use of pulmonary artery catheterization (PAC)?

Updated: Dec 22, 2017
  • Author: Bojan Paunovic, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Over 1 million PACs are used annually in North America. Given the frequency and duration of their use, it is surprising that only recently were quality randomized clinical trials published. Initially, observational studies from the 1980s and 1990s indicated a greater mortality rate in patients who underwent placement of a PAC than in those who did not. The major criticism of these studies is that the more acutely ill (and therefore at greatest risk of death initially) are more likely to receive a PAC.

However, since then a number of randomized clinical trials were published.

Sandham et al enrolled nearly 2000 surgical patients (ASA class 3 or 4) aged 60 years or older. The treatment group received a PAC and a guided therapy protocol while the control group received a central venous catheter and therapy based on physician discretion. No difference was noted in the 2 groups in mortality rate (8%), length of stay, or organ dysfunction. [6]

Richard et al randomized almost 700 patients with early shock, ARDS, or both to use of PAC or not. Treatment was left to physician discretion. No significant difference in mortality or morbidity was noted. [7]

Rhodes et al randomized 201 patients and found no difference in 28-day mortality, ICU, or hospital length of stay in patients with or without a PAC. A formal management protocol was not used. [8]

The PACMAN trial enrolled more than 1000 patients to management with or without a PAC. The timing of insertion and management were at the discretion of the treating physician. No difference in hospital mortality (primary outcome) was noted. [9]

The ESCAPE trial enrolled more than 400 patients who were admitted with severe heart failure. Patients were randomized to having therapy guided by clinical assessment and PAC or clinical assessment alone. No difference was noted in overall mortality or hospitalization. [10]

Shah et al published a large meta-analysis that consisted of 13 randomized clinical trials and more than 5000 patients (including the above mentioned trials). Neither an increase in mortality or length of hospital stay nor a significant benefit could be attributed to the use of a PAC. [11]

In 2006, the ARDSNET group looked at the role of the PAC in acute lung injury patients. Patients were randomized to protocolized hemodynamic management with either a PAC or a central venous catheter (CVC). No difference in mortality (primary outcome), ICU length of stay, or lung function was appreciated. [12] As well, economic analysis follow-up confirmed increased cost associated with PAC use. [13]

As well, even in the hallowed ground of PAC use in cardiac surgery patients, Djaiani et al showed that the use of PAC derived data lead to more interventions but no overall clinical benefit. [14]

Two observational, propensity-matched analyses in both trauma and cardiac surgery populations failed to show any benefit for the use of the PAC. In fact, these studies showed increased mortality and morbidity in the PAC use groups. [15, 16]

Unfortunately, a Cochrane Review of 12 studies was only able to support the need for "efficacy studies... to determine optimal management protocols and patient groups who could benefit from management with a PAC." [17] A more recent updated Cochrane Review included the ARDSNET trial but essentially came to similar conclusions. [18]


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