Lecture presented by Dr.Lluis Blanch at Pulmonary Critical Care Egypt, the leading critical care medical event and exhibition organized by the Egyptian College of Critical Care Physicians.www.pccmegypt.com

1. 22-23 January 2014 Cairo, Egypt
Cardio-Pulmonary Interactions during MV
Lluis Blanch MD, PhD
Senior Critical Care Department
Director Research and Innovation
Corporació Sanitaria Parc Tauli. Sabadell. Spain.
Universitat Autònoma de Barcelona. Spain.

2. Consequences & ComplicationsConsequences & Complications
of Mechanical Ventilationof Mechanical Ventilation
•• endotracheal intubationendotracheal intubation
•• heartheart--lung interactionlung interaction
•• dynamic hyperinflationdynamic hyperinflation
•• barotraumabarotrauma
•• ventilator induced lung injuryventilator induced lung injury
•• difficult patientdifficult patient--ventilator interactionventilator interaction
•• infectionsinfections

3. Intrathoracic pressure is transmitted directly to the heart;
all bedside intracardiac pressure measurement represent
the sum of intracardiac pressure
plus
intrathoracic pressure

4. Heart is surrounded by pericardium and the thorax.
Intracardiac pressure measurements therefore are subject
to influence of blood volume in the cardiac chambers,
the pericardial pressure, and the intrathoracic pressure.

5. Physiologic principles
Intracardiac pressure (mmHg) Hemodynamic monitoring
Intrapericardial pressure and intrathoracic are equal and
subatmospheric in healty patients (cmH2O)
P intracardiac – P intrathoracic = P transmural
or distending pressure Preload

6. P intracardiac – P intrathoracic = P transmural
RAP - ∆∆∆∆PPL (Pes) = RAP transmural
+5 - (-2) = + 7 mmHg
+5 - (+4) = + 1 mmHg
cmH2O = 0.74 mmHg

7. Spontaneous breathing: activation of inspiratory muscles
decrease intrathoracic pressure!!
VR
RA LA
Cardiac filling
Paradoxic PRA, wedge and PAP
This occurs because the inspiratory decrease in the intrathoracic pressure
exceeds the inspiratory increase in transmural intracardiac pressures.
RA and LA are normally very compliant structures accepting the
increased venous return with a minimal increase in transmural pressure.

8. Sharkey SW. Lippincott- Raven 1997
End-expiration
Influence of laboured respiration on wedge pressure waveform

9. MECHANICAL VENTILATION (MV)
CL Ccw CO
Emphysema
Clung Ccw CO
ARDS
wL
L
AWPL
CC
C
PP
+
×∆≅∆

10. Relationship between Venous Return & Cardiac FunctionRelationship between Venous Return & Cardiac Function
Effects of Positive Pressure Breaths & Fluid AdministrationEffects of Positive Pressure Breaths & Fluid Administration
Miro AM, Pinsky MR. Principles & Practice of MV. 1994.Miro AM, Pinsky MR. Principles & Practice of MV. 1994.

11. Alveolar vessel: surrounded by alveolar pressure
Extraalveolar vessel: surrounded by interstitial
pressure (= intrathoracic pressure)

13. Pepe PE, Marini JJ. Am Rev Respir Dis 1982;126:168.Pepe PE, Marini JJ. Am Rev Respir Dis 1982;126:168.
Effect of Discontinuation of MV in a PatientEffect of Discontinuation of MV in a Patient
with Severe Airflow Obstructionwith Severe Airflow Obstruction

14. Apnea during Severe Asthma
Relative Lung Volume by Inductive Plethysmography

15. Rossi A & Ranieri VM. Principles and Practice of MV. Tobin MJ, eRossi A & Ranieri VM. Principles and Practice of MV. Tobin MJ, ed. 1994.d. 1994.
Effects
Effects of PEEPEffects of PEEP
on:on:
OxygenationOxygenation
Cardiac OutputCardiac Output
Oxygen deliveryOxygen delivery
PEEPPEEP00 1515

16. Ppeak & Pplat
Overdistension
Air Trapping
Adverse Physiologic Effects of IRV

17. Chest 1993;104:871-5
*
**
*

18. AcidosisAcidosis
Intracellular Corrected in Hours
Renal Compensation 1 – 2 days
PulmonaryPulmonary
Vasoconstriction & Increase in PVR
- Aggravates PHT & Potentiates HPV
Increase Intrapulmonary Shunt
Laffey JG & Kavanagh BP. Permissive Hypercapnia. In Tobin MJ.
Principles & Practice of Mechanical Ventilation. 2006 & 2013.
CardiovascularCardiovascular
Systemic Vasodilation
- Endogenous Catecholamine Production
Increase in Cardiac Output
Cellular &Cellular &
MolecularMolecular
Attenuation of Inflammatory Response
- Inhibit Release of TNF-ά, IL-1 & IL-8 in Macrophages
- Neutrophil Activation
- Free Radical Generation & Activity
- Regulates Gene Expression: inhibits endotoxin-
induced NF-kB activation
Physiologic Effects of HypercapniaPhysiologic Effects of Hypercapnia

19. Crit Care Med 2001;29:1551-5
Individual Predictors of Acute Cor Pulmonale in ARDS
n = 75
Mortality 32 % 32 % NS

20. N Engl J Med 2013;368:806-13.
N Engl J Med 2013;368:795-805.
Why?: deleterious effects of heavy sedation and NBA,
hemodynamic compromise due to adverse effects of
high mean airway pressure on the right ventricle, or
increased VALI among HFOV non-responders.
Durbin CG, Blanch L, Fan E, Hess D. Respir Care 2014 (in press)

21. PEEP & AutoPEEP in COPD Patients
Blanch L, Fernandez R. In: Mancebo J, Brochard L, eds. Arnette 1996; 329-345.

22. PEEP-Induced Changes in
Lung Volume & Cardiac
Index in COPD Patients
Changes occur only when
external PEEP is higher
than the critical pressure
value:
85% of autoPEEP
Ranieri et al
ARRD 1993;147:5-13
Baigorri F et al.
Crit Care Med 1994;22:1782-91

23. Heart Lung Interactions duringHeart Lung Interactions during
Mechanical VentilationMechanical Ventilation
•• Positive pressure ventilation causes:Positive pressure ventilation causes:
–– increase in ITP pressureincrease in ITP pressure
–– increase in lung volumeincrease in lung volume
•• Increase in ITP & lung volume affect:Increase in ITP & lung volume affect:
–– heart rateheart rate
–– venous returnvenous return
–– RV & LV filling and afterloadRV & LV filling and afterload
•• Reduced cardiac output by:Reduced cardiac output by:
–– increase PVRincrease PVR
–– reduced preloadreduced preload
–– ventricular interdependenceventricular interdependence
–– changes in contractilitychanges in contractility

24. Tobin M & Jubran A. PPMV 2013
Weaning Failure Patient

25. Jubran A et al. Am J Respir Crit Care Med 1998; 158:1763.Jubran A et al. Am J Respir Crit Care Med 1998; 158:1763.
Pathophysiologic Factors for RespiratoryPathophysiologic Factors for Respiratory
Distress during a Weaning TrialDistress during a Weaning Trial
Tissue oxygenation: TOTissue oxygenation: TO22 EOEO22
Elevations in right & left
ventricular afterload
n=11
n=8
↑SAP
↑PCWP
↓CI

26. Lemaire F, Teboul JL, et al. Anesthesiology 1988; 69:171.
Pathophysiologic Factors for Respiratory
Distress during a Weaning Trial
Heart & lung interaction: acute LV dysfunction

27. Pulse Pressure Variation and Frank-Starling Curve
Teboul JL, Monnet X. Minerva Anesthesiol 2013;79:398-407

28. Arterial Pressure in a MV Patient
PPV(%)=PPmax-PPmin/[(PPmax+PPmin/2)]x100
Teboul JL, Monnet X. Minerva Anesthesiol 2013;79:398-407

29. Analysis of ∆Pp is a simple method for predicting and assessing the
hemodynamic effects of volume expansion and is a more reliable
indicator of fluid responsiveness
Am J Respir Crit Care Med. 2000 Jul;162(1):134-8.

30. PPV in ARDS & Low VT
PPV marker of preload responsiveness.
PPV > 10-12% still good predictive value.
PPV < 10% false negatives may occurs and
passive leg raising (PPV↓) or end-expiratory
occlusions (PP↑) are needed.
Limits: SB, arrhythmias, low lung
compliance, right ventricle dysfunction.
Teboul JL, Monnet X. Minerva Anesthesiol 2013;79:398-407

31. MECHANICAL VENTILATION (MV)
AFTERLOAD
INSPIRATION
right V
afterload
left V
afterload
Compression of
iuxta-alveolar
vessels
Thoracic-
extrathoracic
aorta pressure
gradient
(HYPERINFLATION:
asthma, emphysema
high PEEP)

32. Pinsky MR in Principles and Practice of Mechanical Ventilation. Tobin ed McGraw-Hill 1994
In patients with a failing myocardium, CO is relatively insensitive
to end diastolic volume changes and is primarily affected
by changes in afterload
PEEP improve cardiovascular performance LV afterload

33. CPAP vs O2
IOT < 60%
NIV in ACPE
Masip J JAMA 2005;294:3124-30
Need to Intubate

34. CPAP vs O2
Mortality < 47%
NIV in ACPE
Masip J JAMA 2005;294:3124-30
Mortality

35. Thank you
lblanch@tauli.cat