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Ventilatory Effects On Cardiovascular Function
Ventilatory Effects On Cardiovascular Function
Ventilatory Effects On Cardiovascular Function
com
CURRENT TOPIC
The heart and lungs work closely to meet the throughout the respiratory cycle. Furthermore,
tissues oxygen demands. If the balance be- changes in intrathoracic pressure and lung vol-
tween oxygen demand and supply becomes ume can have additional important eVects in
disturbed in critical illness, tissue hypoxia and patients with interstitial or vascular pulmonary
cell death can rapidly result. An essential part pathology, or congenital heart disease, all of
of critical care is to maintain cardiopulmonary which are quite frequently encountered in the
function with the help of pharmacotherapy, paediatric population.
fluid management, and respiratory support.
Paradoxically, interventions aimed at improv-
Cardiovascular eVects of changes in
ing the function of one system can sometimes
intrathoracic pressure
have undesirable eVects on the other and,
EFFECT OF CHANGES IN INTRATHORACIC PRESSURE
although the pulmonary consequences of
ON VENOUS RETURN AND RIGHT HEART FUNCTION
cardiac disease are well recognised, the influ-
The Valsalva eVect, the physiological response
ences of changes in pulmonary physiology on
to a sustained increase in airway pressure
cardiac function are less well appreciated.
against a closed glottis, is characterised by an
Cardiopulmonary interactions (the eVects of
early increase in arterial pressure and a fall in
spontaneous and mechanical ventilation on the
cardiac output secondary to reduced venous
circulation) were first documented in 1733,
return. Although not an accurate physiological
when Stephen Hales showed that the blood
model of PPV, the Valsalva eVect clearly
pressure of healthy people fell during sponta-
demonstrates important influences of an in-
neous inspiration.1 Over a century later Kuss-
creased intrathoracic pressure on the right
maul described pulsus paradoxus (the inspira-
heart. One of the first and most important
tory absence of the radial pulse) in patients
physiological studies of the eVects of PPV on
with tuberculous pericarditis.2
cardiac function was by Cournands group,
Cardiopulmonary interactions are present in
who in the late 1940s demonstrated a variable
health, and can be exaggerated or abnormal in
reduction in cardiac output in healthy volun-
the presence of disease. This article will
teers receiving mask PPV.3 4 Cournand
provide an overview of this broad topic. By
showed that right ventricular (RV) filling was
emphasising the underlying physiological prin-
inversely related to intrathoracic pressure, and
ciples and the influence of disease states upon
as this became more positive so the RV preload
these, we hope that respiratory support will
fell, producing a detectable fall in cardiac out-
then be tailored to the individual patient.
put.
Let us consider the circulation to be a model
The influence of ventilation on cardiac with three compartments (fig 1): the thorax,
function the abdomen, and the periphery, where PRA is
Spontaneous and mechanical ventilation in- directly aVected by intrathoracic pressure,
duce changes in intrapleural or intrathoracic abdominal pressure is aVected by diaphrag-
pressure and lung volume, which can inde- matic descent, and the peripheral venous
pendently aVect the key determinants of pressure is related to atmospheric pressure.5
cardiovascular performance: atrial filling or PRA falls during inspiration and intra-
preload; the impedance to ventricular empty- abdominal pressure increases with inspiratory
Department of Critical ing or afterload; heart rate and myocardial diaphragmatic descent, whereas the peripheral
Care, Hospital For contractility. Changes in intrathoracic pressure venous pressure remains constant throughout
Sick Children, 555 are transmitted to the intrathoracic structures: the respiratory cycle. Systemic venous return,
University Avenue, namely the heart and pericardium, and the ordinarily the main determinant of cardiac
Toronto M5G 1X8,
Canada
great arteries and veins. Spontaneous inspira- output, depends on a pressure gradient be-
L Shekerdemian tion produces a negative pleural pressure, and tween the extrathoracic veins (the driving
D Bohn the reduction in intrathoracic pressure is trans- pressure) and the PRA (back pressure). Sponta-
mitted to the right atrium. In contrast, neous inspiration increases this gradient, and
Correspondence to: intermittent positive pressure ventilation so accelerates venous return. Thus, RV preload
Dr L Shekerdemian,
Paediatric Intensive Care (IPPV) produces inspiratory increases in intra- and stroke volume all increase during
Unit, Great Ormond Street thoracic pressure and therefore right atrial spontaneous2 (or indeed negative pressure68)
Hospital, London WC1N pressure (PRA), and if a positive end expiratory inspiration. Conversely, the increase in PRA
3JH, UK.
email: 101732.2171@
pressure (PEEP) is added, these pressures during a Valsalva manoeuvre or positive press-
compuserve.com remain greater than atmospheric pressure ure inspiration causes the venous return to
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measurements of right or left atrial pressure, lessen the work of breathing, it should be
but anticipatory management can help prevent applied cautiously to avoid further cardiovas-
cardiovascular compromise at the onset of ven- cular deterioration. Adjunctive treatment
tilation. A fluid bolus can partially oVset the should be aimed at improving the intrinsic lung
reduction in venous return that can accompany mechanics with secretion clearance, broncho-
PPV, especially if high levels of PEEP are dilator treatment, and so on.
anticipated. Careful selection of anaesthetic
agents, and avoidance of those that cause ACUTE AIRWAY OBSTRUCTION
vasodilatation or negative inotropy, can also Pulmonary oedema precipitated by an acute
help maintain stability. Positive inotropes can and dramatic fall in intrathoracic pressure has
also be very useful adjuncts in patients with been reported in between 9% and 12% of chil-
impaired myocardial function, and systemic dren and adults with acute upper airway
vasoconstrictors can attenuate cardiovascular obstruction, and commoner causes of this are
depression in vasodilated patients. The ad- croup and other upper airway infections,
vance administration of an anticholinergic foreign body aspiration, and postextubation
agent can also help attenuate the vagal laryngospasm. As intrathoracic pressure falls
responses to intubation and ventilation, which well below zero (which is inevitable in this situ-
are exaggerated in smaller infants. ation), the intrathoracic great veins collapse,
The eVects on venous return of sustained thus any beneficial eVects on RV preload are
increases in intrathoracic pressure during PPV transient. The excessively negative intratho-
can be limited by applying the strategies racic pressure can increase LV afterload
described by Cournand. Moreover, if the suYciently to cause pulmonary oedema, and
patients clinical status allows, a method of this can be further exacerbated by an increased
ventilation that allows patient initiated breaths, pulmonary capillary pressure resulting from
such as intermittent mandatory ventilation, pulmonary vasoconstriction secondary to hy-
pressure support ventilation, or continuous poxia and hypercapnia. Acute management is
positive airway pressure (CPAP), will result in a aimed at correcting hypoxaemia, and control-
lower intrathoracic pressure than if all breaths ling the intrathoracic pressure with mechanical
are ventilator derived. ventilation.
we usually maintain a mild respiratory acidosis, Patients with the Fontan circulation
and in most cases we avoid the use of additional The Fontan operation was first introduced as a
inspired oxygen (we ventilate in air). surgical procedure to separate the systemic and
pulmonary circulations in patients with tricus-
pid atresia.32 Since its introduction, the Fontan
Patients with a left to right shunt operation and its modifications have been
Left to right shunts with increased pulmonary widely used as surgical palliation for a variety of
blood flow are commonly seen in babies and complex congenital cardiac lesions, which in
children with septal defects (atrial, ventricular, essence share a common feature: an absent or
or atrioventricular), or a persistent ductus arte- inadequate subpulmonary chamber. The surgi-
riosus (PDA). In the early neonatal period, the cal approaches can be divided broadly into
raised PVR partially protects the pulmonary those that anastomose the right atrium to the
vascular bed from excessive flow, and so pulmonary artery (atriopulmonary connec-
neonates with large lesions can initially be rela- tion), and those that directly join the superior
tively asymptomatic. However the PVR sponta- and inferior venae cavae to the pulmonary
neously falls at 4 to 6 weeks of age, thus artery (total cavopulmonary connection).
increasing the flow into an unprotected pulmo- Patients with the Fontan circulation have
nary bed. Depending on the degree of the unique cardiopulmonary physiology: in the
shunt, myocardial function, and general status absence of a right ventricle, pulmonary blood
of the child, this can produce symptoms of flow, the major determinant of cardiac output,
heart failure: tachypnoea, failure to thrive, and is a passive diastolic phenomenon, which is
recurrent chest infections. exquisitely sensitive to changes in intrathoracic
Positive pressure ventilation plays an impor- pressure. It is enhanced as the pleural pressure
tant role in the haemodynamic treatment of becomes negative during spontaneous inspira-
patients with a large shunt secondary to exces- tion, but reduced or even zero when the
sive pulmonary blood flow. Some patients intrathoracic pressure is made more positive.33
require mechanical ventilation purely because For this reason, when ventilating these pa-
of uncontrollable symptomatic cardiac failure; tients, conservative settings should be used,
others, such as premature neonates with a with short inspiratory times, low inspiratory
PDA, might already be ventilated for a combi- pressures, and minimal PEEP, and haemody-
nation of reasons. In all cases, ventilatory namic management should include early extu-
strategies should be directed at avoiding factors bation where possible.
Patients with the Fontan circulation are typi-
that increase pulmonary blood flow, such as
cally resistant to conventional manoeuvres to
hyperventilation and excessive oxygen admin-
improve their cardiac output, and often the key
istration. A slightly raised CO2 may be
to optimising their haemodynamics lies in
beneficial and, in many patients, saturations
achieving early extubation. However, this is not
might best be maintained at around 90%, always possible and, paradoxically, it is in those
thereby providing adequate tissue oxygenation children in whom this is most desirable that
while protecting pulmonary flow. PEEP also continuing ventilatory support is needed. By
plays an important role in these patients: a mimicking spontaneous respiration, negative
reduction in LV afterload and venous return pressure ventilation augments the cardiac out-
may be desirable in patients with a large shunt, put of Fontan patients to levels that are
especially in the presence of reduced myocar- unrivalled by other forms of treatment. There-
dial function. Finally, a modest elevation of fore, this can be an extremely useful haemody-
PVR with PEEP may limit pulmonary blood namic tool in Fontan patients with a low output
flow, producing an additional beneficial eVect. state in whom early extubation is not
possible.34 35
Post-bypass patients
Cardiopulmonary bypass leads to diVuse Summary
endothelial damage with increased vascular It is easy to underestimate the eVects of venti-
permeability, and this inevitably leads to a lation on the cardiovascular system, or to mis-
degree of pulmonary and myocardial injury interpret cardiopulmonary interactions as pri-
that fortunately is usually reversible.30 31 Al- mary cardiovascular events. We have described
though not always clinically apparent, alveolar, how simple ventilatory interventions can some-
interstitial, and chest wall oedema can reduce times be used to obviate the unnecessary esca-
lung compliance; so necessitating higher in- lation of pharmacological support, and have
spiratory pressures and PEEP to deliver discussed how in other situations, anticipatory
adequate tidal volumes. These ventilatory management with fluids or vasoactive agents
strategies should be applied with care because can minimise cardiovascular compromise dur-
cardiovascular instability can be easily precipi- ing mechanical ventilation. Mechanical ventila-
tated in the early post-bypass patient, and tion plays a crucial role in the haemodynamic
compensatory fluid boluses can be poorly management of critically ill children, and
tolerated in patients with borderline myocar- application of the principles that have been
dial function and a high systemic vascular described are an essential part of intensive care
resistance. Certain patients with congenital management.
heart disease are particularly susceptible to the
hazardous eVects of PPV, and these will be dis- 1 Hales S. Statical essays: containing haemostatics. In: Willius
FA, Keys TE, eds. Cardiac classics. St Louis: Mosby,
cussed below. 1941:1337.
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Notes