Respiratory Management

in Acute Cardiac Care

Dewi Utari, MD, FIHA

RSUP Prof. Dr. R.D.Kandou Manado

Departemen Kardiologi dan Kedokteran Vaskular FK UNSRAT Manado
Outline

1. Acute respiratory failure: definition, types and how to

diagnose
2. Common cardiac conditions with acute respiratory failure
3. Management of acute respiratory failure due to critical
cardiac conditions : NIV & Mechanical
4. Hemodynamics effect of NIV & mechanical ventilation
Schematic Representation of Blood Gas Exchange Mechanisms

V/Q <1: ventilation

& perfusion
mismatch

Alveiolar
hypoventilation:
increase in PaCO2,
decrease in PaO2

Blood gas exchanges occur passively through the alveolar– capillary membrane, according to the
gradient in gas concentration between the capillary blood and the alveoli.
The respiratory system. Antoine Vieillard- Baron. The ESC Textbook of
Intensive and Acute Cardiovascular Care, 3rd Edition. 2021.
 1. Acute respiratory failure: definition
Respiratory failure is a condition in which the respiratory system is
unable to maintain adequate gas exchange to satisfy metabolic
demands (i.e. oxygenation and/ or elimination of CO2).

Respiratory failure is conventionally defined by:

• PaO2 of <8.0 kPa (<60 mmHg)
• PaCO2 of >6.0 kPa (>45 mmHg)
• or both

Luigi Camporota and Francesco Vasques. Mechanical ventilation. The ESC Textbook of Intensive and Acute Cardiovascular Care, 3rd Edition. 2021.
 Acute respiratory failure: classification
Respiratory failure is traditionally classified as either:
• Type 1, with oxygenation failure (resulting in hypoxaemia with
normocapnia or hypocapnia); most common mechanism is V/ Q
mismatching.
• Type 2, with ventilatory failure (characterized by alveolar
hypoventilation and subsequent predominant hypercapnia).

• Both types can be acute or chronic.

Luigi Camporota and Francesco Vasques. Mechanical ventilation. The ESC Textbook of Intensive and Acute Cardiovascular Care, 3rd Edition. 2021.
 Cardiac conditions with acute heart failure
and/ or respiratory failure

David H. Ingbar. Cardiogenic pulmonary edema: mechanisms and treatment - an intensivist's view. Curr Opin Crit Care 2019, 25:371–378
Acute HF (AHF)

▪ Acute HF (AHF) refers to rapid

onset or worsening of
symptoms and/or signs of HF.

▪ It is a life-threatening medical
condition requiring urgent evaluation
and treatment, typically leading to
urgent hospital admission.
▪ Congestion affects lung function and
increases intrapulmonary shunting,
resulting in hypoxaemia
1 Ponikowski,et al. 2016. ESC Guidelines for The Diagnosis and Treatment of Acute and Chronic Heart Failure: The
Task Force for The Diagnosis and Treatment of Acute and Chronic Heart Failure of The European Society of
Cardiology (ESC). Eur. J. Heart Fail.
3. Management of ARF due to critical
cardiac conditions : Noninvasive Ventilation
(NIV) & Mechanical Ventilation
Noninvasive Ventilation
NIV refers to the delivery of
ventilatory support or positive
pressure into the lungs
without an ETT
• Continuous positive airway
pressure (CPAP)
• Non-invasive pressure
support ventilation (bi-
level non- invasive
ventilation or BIPAP)
• High- flow nasal cannula
(HFNC)
NIV techniques leave the upper
airway intact → avoiding the
complications and drawbacks that
might occur during :
• the procedure of endotracheal
intubation
• mechanical ventilation
• time of extubation
 Principles of non-invasive ventilation

Pressure– time curves. Spontaneous breathing, CPAP (10 cmH2O), and bi- level pressure support (IPAP 22 cmH2O,
EPAP 10 cmH2O) with pressure, support (PS) 12 cmH2O.

Non- invasive ventilation. Josep Masip, Kenneth Planas, and Arantxa Mas. The ESC Textbook of Intensive and Acute Cardiovascular Care, 3rd Edition. 2021.
 Interfaces for NIV: (A) Helmet. (B) Boussignac mask. (C) Mouthpiece. (D) Nasal mask.
(E) Nasal pillows. (F) Oronasal mask. (G) and (H) Full face (total face) masks.

Non- invasive ventilation. Josep Masip, Kenneth Planas, and Arantxa Mas. The ESC Textbook of Intensive and Acute Cardiovascular Care, 3rd Edition. 2021.
Monitoring NIV in ARF
• Vital signs (respiratory rate, blood
pressure, heart rate)
• Dyspnoea/ accessory muscle use/
abdominal paradoxical breathing
• Consciousness level
• Mask comfort
• Collaboration
Ventilator parameters
TV (>4 mL/ kg: 6– 7 mL/ kg) and MV
Air leakage volume (<0.4 L/ sec)
PS and PEEP setting
Asynchrony (ineffective efforts, auto-
triggering, double triggering, short/ long
cycle)
Trigger/ slope (ramp)/ TI/ expiration
setting
Auto- PEEP
Alarms (maximal peak pressure, minimal
minute ventilation)
Monitoring NIV in ARF (continued)

Gas exchange
Continuous pulse oximetry (SpO2)
ABG sample (baseline and after 60 minutes of NIV for:
PaO2/ FiO2, pH, PaCO2, bicarbonate)
Venous blood gas sample (good for pH, may be an
alternative to ABG sample)
Indication and contraindication for the use of NIPPV
Indications
No indication for immediate intubation
No obvious contraindication for NIPPV
Hypercapnic respiratory failure
COPD exacerbation
Cardiogenic pulmonary edema
Hypoxemic respiratory failure due to
causes other than cardiogenic pulmonary
edema
Asthma exacerbations
Severe pneumonia
Early weaning from mechanical
ventilations
Post extubation support
Contraindications
Indication for emergent intubation
Inability to cooperate/agitation
Severely impaired consciousness
Iability to protect airway or clear
secretions
High aspiration risk/swallowing
impairment
Recent facial/upper airway/
gastrointestinal surgery
Facial or upper airway trauma
Upper gastrointestinal bleeding
Copious airway secretions
Anticipation of prolonged need for
respiratort support
 The criteria for NIV failure
Before Clinician inexperience After Inappropriate ventilator settings
Starting initiation
Inadequate equipment Wrong interface
High risk ARDS Excessive air lekage
of failure
Altered mental status Breathing asynchrony with the
Shock ventilator

High severity score Bad subjective tolerance

Neurological or underlying disease
Copious secretions impairment

Extreamly high RR After 60 No reduction in RR

min
Severe hypoxaemia in spite of high
FiO2 No improvement in pH
No improvement in oxygenations
No reduction in CO2
Sign of fatigue
 Management of ARF due to critical cardiac
conditions : Mechanical Ventilation

Airway pressures in spontaneous ventilation and in mechanical ventilation during inspiration (Insp) and
expiration (Exp). PALV, alveolar pressure; PPL, pleural pressure; TPP, transpulmonary pressure.

Luigi Camporota and Francesco Vasques. Mechanical ventilation. The ESC Textbook of Intensive and Acute Cardiovascular Care, 3rd Edition. 2021.
Ventilatory support in AHF
 Criteria for endotracheal intubation
◆ Cardiac and respiratory arrest
◆ Progressive worsening of pH and CO2 despite NIV
◆ Need to protect the airway
◆ Persistent haemodynamic instability
◆ Agitation and inability to tolerate the mask

Non- invasive ventilation. Josep Masip, Kenneth Planas, and Arantxa Mas. The ESC Textbook of Intensive and Acute Cardiovascular Care, 3rd Edition. 2021.
Mechanical Ventilation in AHF

▪ Overall failure rate (i.e., need for intubation)

of non-invasive ventilation is approximately
13% during AHF, but may affect up to 25%.1

▪ Mechanical ventilation (MV) is a life-saving

intervention for respiratory failure, including
AHF.2

▪ Management must be guided by a

knowledge of both the advantages and
dangers of invasive MV in order to realize its
benefits and avoid adverse effects.2

1 RicardJD and Roux D. Invasive Ventilation and Acute Heart Failure Syndrome in Mebazaa A, Gheorghiade M, Zannad FM, Parrillo JE. Acute
Heart Failure, 2008.
2 Kuhn BT, Bradley LA, Dempsey TM, Puro AC, Adams JY. Management of Mechanical Ventilation in Decompensated Heart Failure. Journal of

Cardiovascular Development and Disease, 2016

Mechanical Ventilation in AHF

▪ Relieve respiratory distress due to AHF-

induced respiratory muscle fatigue
▪ Improve pulmonary gas exchange
▪ Protect airways, without harming the injured
lung

✓ Reducing tidal volume (VT) in order to avoid

lung overdistention
✓ Adding moderate levels of PEEP
Ricard JD and Roux D. Invasive Ventilation and Acute Heart Failure Syndrome in Mebazaa A, Gheorghiade M, Zannad FM, Parrillo JE.
Acute Heart Failure, 2008.
 Cardiopulmonary interactions during normal
spontaneous inspiration and positive pressure
ventilation

IAP, Intraabdominal
pressure; ITP, intrathoracic
pressure.

David L. Brown, MD. CARDIAC INTENSIVE CARE. 2019. Elsevier. Mohamad Kenaan, Robert C. Hyzy. Mechanical Ventilation and Advanced
Respiratory Support in the Cardiac Intensive Care Unit.
Physiologic Effects of Mechanical Ventilation

▪ Acute respiratory failure complicating acute heart failure and cardiogenic pulmonary
edema is due to hypoxemia, increased work of breathing, augmented oxygen
consumption, and ultimately muscle fatigue

▪ Mechanical ventilation will alleviate both pulmonary and cardiac dysfunction

in cardiogenic pulmonary edema

Ricard JD and Roux D. Invasive Ventilation and Acute Heart Failure Syndrome in Mebazaa A, Gheorghiade M, Zannad FM, Parrillo JE. Acute Heart
Failure, 2008.
Hemodynamics effect of NIV & mechanical ventilation
TAKE HOME MESSAGE
• PPV often plays an important role in the management of patients
with cardiogenic pulmonary edema, cardiogenic shock, or cardiac
arrest, and those undergoing mechanical circulatory support.
• Noninvasive PPV, when appropriately applied to selected patients,
may reduce the need for invasive mechanical PPV and improve
survival.
• Cardiologists who practice in the CICU should be familiar with the
effects of PPV on cardiopulmonary physiology so that ventilator
management can be tailored to optimize hemodynamics,
oxygenation, and ventilation
Terima Kasih