PULMONARY ARTERY/CENTRAL

PULMONARY
ARTERY/CENTRALVENOUS
VENOUSPRESSURE
PRESSURE
MEASUREMENT
MEASUREMENT
Expected Practice:
Verify the accuracy of the invasive pressure monitoring system by performing a square waveform test at the
beginning of each shift and anytime the system is disturbed (e.g., blood draw).
Position the patient supine position (head of bed (HOB) bed between 0 and 60), lateral position 20, 30 or 90 or
prone before pulmonary artery pressure (PAP), pulmonary artery occlusion pressure (PAOP), central venous
pressure (CVP) measurements. HOB elevation can be at any angle from 0 (flat) to 60 if the patient is in the
supine position. Allow the patient to stabilize 5-15 minutes after a position change.
Level and reference the transducer air-fluid interface to the phlebostatic axis (supine or prone position), 4th ICS
AP diameter of the chest or lateral angle specific reference using a laser or carpenters level before
PAP/PAOP/CVP measurements.
Obtain PAP/PAOP/CVP measurements from a graphic (analog) tracing at end-expiration or adjust the
measurement point if the patient is receiving airway pressure release ventilation (APRV) or is actively exhaling.
Use a simultaneous ECG tracing to assist with proper PAP/PAOP/CVP waveform identification.
PA catheters can be safely withdrawn and removed by competent registered nurses.

Scope and Impact of the Problem:

PAP and CVP aid in differential diagnosis and to guide treatment in critically ill patients who do not respond to standard
therapy. Technical aspects of monitoring affect the accuracy and reliability of these measurements.
Supporting Evidence:

The square waveform test, or dynamic response test, determines the ability of the transducer system to correctly
reflect invasive pressures.14,15 The dynamic response is affected by system problems, such as air bubbles in the
tubing, excessive tubing length, loose connections, and catheter patency. Removal of microbubbles during system set
up result in an adequate or optimal system in over 95% of cases.16,17 Any of these problems affect the accuracy of
PAP/PAOP/CVP measurements and must be corrected prior to pressure measurement. Perform the square waveform
test: on the initial system setup, at least once each shift, after opening the catheter system (e.g. for rezeroing, drawing
blood, or changing tubing), and whenever the PAP/PAOP/CVP waveform appears to be damped or distorted.14 (Level
A)

Consider the following changes in PA pressures as clinically significant (i.e., not reflective of the normal variability in
PA pressures):
PAS > 4-7 mm Hg; PAEDP > 4-7 mm Hg; PAOP > 4 mm Hg.18-20 (LevelB)

Studies in a variety of patient populations found that PAP/PAOP/CVP measurements are accurate when the HOB is
elevated to any angle between 0o and 60 21-27 or when the patient in a 20 28, 30 20,29 or 90 30 lateral position with the
HOB flat, as long as the correct angle-specific reference is used. PAP/PAOP/CVP measurements should not be
performed in Trendelenburg31 or if the legs are in a dependent position.21 There are no studies to support
PAP/PAOP/CVP measurements in reverse Trendelenburg. Reliable cardiac output (CO) measurements have been
obtained only in the supine position with backrest at 20 32 or 45 33 and in the prone position.34-37 Clinically significant
changes in CO may occur in the 20 lateral position,32,38 which may limit concurrent PAP/PAOP/CVP and CO
measurements. Because there are individual variations in response to a given position, evaluate each patients
PAP/PAOP/CVP compared to the flat, supine position using a standardized approach.17,39 (Level A)

The use of position-specific reference is critical to accurate PAP/PAOP/CVP measurement.20,40-44 In the supine
position the phlebostatic axis (4th ICS at the AP diameter of the chest) is the most commonly used reference
point.45 In the lateral position the following reference points should be used: 30 lateral ( distance from surface of
bed to the left sternal border). 90o right lateral position(4th ICS/midsternum) and in the 90o left position (4th ICS/left
parasternal border).41,42,45 A laser or carpenters level (not the eyeball technique) should be used to correctly
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reference the system.46 Once the correct reference location is identified, a mark should be placed on the chest wall.
(Level A)
Before obtaining PAP/PAOP/CVP measurements, patients may require 5-15 minutes for stabilization depending on
the patients left ventricular function.47 No specific recommendations are available for the stabilization period after
proning; measurements have been performed 20-30 minutes after repositioning from supine to prone for patients with
acute lung injury.35-37 and in patients with ARDS, measurements were performed 20 minutes after stabilization of the
SvO2 (60-90 minutes after proning).34 (Level A)
Changes in intrathoracic pressure during respiration alter intracardiac pressures. PAP/PAOP/CVP measurements are
obtained by convention at end-expiration when pleural pressure is minimal.48 For patients receiving airway pressure
release ventilation (APRV), the PAOP should be measured at the end of the positive pressure plateau, which can be
observed on the ventilator and is the point immediately before the release of airway pressure and the initiation of
inspiration.49 With active exhalation (suspect if respiratory-induced fluctuation in PAOP is greater than 10-15 mm Hg)
read the PAOP at the midpoint between the end-expiratory peak and the end-inspiratory lowpoint.50 The addition of
the airway pressure tracing to the analog strip may further improve measurement accuracy.51 (Level A)
A simultaneous ECG should be used to facilitate correct PAP/PAOP/CVP waveform measurement55-57 and should be
read from analog tracings or using the stop cursor method.52-54 Digital readouts should not be used as they reflect
pressures obtained throughout respiration and may be significantly different from end expiratory pressures. (Level A)
Registered nurses, who demonstrate competency, can safely withdraw and/or remove PA catheters.58,59 Before
incorporating withdrawing and/or removing PA catheters into nursing practice, verify that it is within your states scope
of practice for registered nurses. (Level B)
AACN Evidence Leveling System
Level A
Level B
Level C
Level D
Level E
Level M

Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a
specific action, intervention or treatment.
Well-designed, controlled studies with results that consistently support a specific action, intervention or treatment.
Qualitative studies, descriptive or correlational studies, integrative review, systematic reviews, or randomized
controlled trials with inconsistent results.
Peer-reviewed professional organizational standards with clinical studies to support recommendations.
Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational
standards without clinical studies to support recommendations.
Manufacturers recommendations only.

Actions for Nursing Practice:

Always identify and mark the phlebostatic axis or appropriate angle-specific reference, obtain PAP/PAOP/CVP with
the patient in the supine position (HOB bed between 0 and 60), lateral position 20, 30 or 90, or prone. Read
pressures from an analog recording at end expiration, and perform a square waveform test at appropriate intervals.
Assure that your critical care unit has written practice documents such as a policy, procedure or standard of care, that
include these expected practice alert standards.
Determine your units rate of compliance with these Practice Alert standards.
If compliance is < 90%, develop a plan to improve compliance13:
o Consider forming a unit task force to address the need for changes in PAP/PAOP/CVP measurement
practices.
o Educate staff about the inaccuracies which can occur in PAP/PAOP/CVP measurements with improper
techniques Incorporate content into orientation programs, initial and annual competency verifications.
o Develop various communication strategies to alert and remind staff of the importance of these
PAP/PAOP/CVP practices.
o Create an audit tool for measuring compliance with PAP/PAOP/CVP expected practice standards.

Need More Information or Help?

EducationalPrograms:
Programs:
Web-based
Web-based Educational
o The
Program
at www.pacep.org
The Pulmonary
PulmonaryArtery
ArteryCatheter
CatheterEducation
Primer from
the American
Thoracic Society at
o The
Pulmonary Artery Catheter Primer from the American Thoracic Society at
http://www.thoracic.org/clinical/critical-care/clinical-education/hemodynamic-monitoring/pulmonaryhttp://www.thoracic.org/sections/clinical-information/critical-care/hemodynamic-monitoring/pulmonaryartery-catheter-primer/index.php
artery-catheter-primer/
PAP Measurement
Educational PowerPoint Presentation at www.aacn.org/practicealert:
PAP Measurement
o Test of Educational
PA catheter PowerPoint
knowledge Presentation at www.aacn.org/practicealert:
o
Test
of
PA
catheter
knowledge
o Square waveform test information
o
waveform test information
o Square
Identifying correct PAP/CVP waveforms from simultaneous pressure and ECG tracings
o Identifying correct PAP/CVP waveforms from simultaneous pressure and ECG tracings
o Identifying correct phlebostatic axis or angle-specific location for leveling transducers
o Identifying correct phlebostatic axis or angle-specific location for leveling transducers
Contact
a clinical practice specialist for additional information www.aacn.org/prninfo
Contact a clinical practice specialist for additional information (www.aacn.org) then select Practice Resource Network.
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