Cardiopulmonary Interaction

in Mechanical Ventilation
Mohamed Salim Kabbani
Consultant Pediatric Cardiac ICU
King AbduAziz medical City, Riyadh- Saudi Arabia
 Heart – Lung Interactions
Adolf Kussmaul, 1873 (Pulsus Paradoxus)

“A 34 year old servant girl,

Had restrictive tuberculous pericarditis
Cachectic, with edema of the legs and ascites.
Her pulse noted to become smaller with inspiration or would become totally
impalpable on deep inspiration.
On expiration it returned to its former amplitude….
The disappearance or diminution of the pulse during inspiration was
manifest in all palpable arteries.”

Mechanical Ventilation 2
 Basic Concepts & Objectives

To identify:
Cardio-respiratory interactions during
spontaneous breathing:
– in healthy subjects
– In respiratory diseases
– In cardiac disease
Influence of MV in each situation.
 Heart & Lung
Intimately related
– By anatomic proximity within the thorax
– By responsibility to deliver the O2
During critical illness
– Failure of these two organ result in an inadequate
O2 delivery with tissue ischemia, progressive organ
dysfunction, and if untreated, death
Restoration and maintenance of normalized
cardiopulmonary function
– Essential and primary goal in the management of
critically ill patients

4
 Respiratory & Tissue Oxygenation
DO2 = CaO2 x CO Tissue
(Hb x 1.36 x SaO2)+(0.003xPaO2)

SaO2

PaO2 PvO2

PAO2

FiO2 ( PB -PH2O) -PA CO2/ R

 Cardiopulmonary Economics

+ - + -
Optimize Optimize
Pulmonary Cardiac
SaO2 CO

“Adequate” DO2
 2)Ventricular
interdependence 3)Trans-mural
pressure
1)ITP affects
RA filling

Extrathoracic
great veins

Archives of Disease in Childhood; May 1999;

Archives of Disease in Childhood; May 1999;
7
 Basic Concepts
Extrathoracic
SVC/
IVC Intrathoracic

3 Pericardial sac

Intra-thoracic
RA LA

Septum
Pressure

y
y RV Septum LV
2 ventricular
erdependence
int
1Trans-mural
Lungs pressure
Aorta
RA RV'd
or
 A v

Essential Concepts
Transmural pressure

Ventricular interdependence

Factors that affect pre-load and after

load of each ventricle

Mechanical Ventilation 9
 t
if
1. Trans-mural Pressure m
Fig. (4). Changes
s
Ventricular fillinginissystolic blood
affected bypressure induced
the internal by the
filling respiratory
pressure & ext t
cycle. pressure
ernal Adapted from
aroundref. the
[10].heart.
p
The pressure around heart is variable and can be positive or negat
ive
e
Leftpressure
Ventricular Afterload p
The true filling pressure is the difference between the internal
and The left pressures
external ventricular(Trans-mural
afterload isPressure).
dependent on the left c
Transmural pressure = pressure.
ventricular transmural internal pressure – external
The transmural pressure
pressure of an v
intrathoracic
The external structure such asisthe
pleural pressure -5 left ventricle
to -10 cm H2O isduring
a function of br
normal d
eathing
the measured pressure within that structure and the pressure t
This negativeit,
surrounding intra-thoracic
which in thispressure
case is increases venous
the pleural return & inc
(intrathoracic) d
rease afterload on left ventricle
pressure: H
F
LV Transmural Pressure = Systolic LV Pressure – Intrathoracic
Pressure
Mechanic c
The application
inspiration increase venous return
of positive intrathoracic pressure during al
Ventilatio a
expiration decreasevenous return
mechanical ventilation decreases the left ventricular transmural 10 n
Left Ventricular Afterload
Transmural pressure = (Systemic P – Intrathoracic P)

100 100

AO AO
D'Ll zig
120 80

LV LV

-20 +20
100- (-20)=120 100 – (20)= 80
Spontaneous ventilation Positive pressure ventilation
LVTM = 120 LVTM = 80
 2. Ventricular Interdependence

Greater RV volumes decrease Example : Pulmonary hypertension

LV diastolic compliance, leading to decreased LV compliance &
decrease LV preload
Teylor, et al, 1967
12
 Ventricular Interdependence

RV LV
RV LV
PPV

Increase RV size ----- Decrease RV size -----

Decreased LV compliance Increased LV compliance &
& LV preload LV preload
3. Intra-thoracic Pressure & Cardiac
blood flow during inspiration and expiration
 Cardiovascular effects of
spontaneous breathing

Right ventricle: Left ventricle

Increase venous return Increase LV after load +/-
(Pre-load) Mild decrease in cardiac output
Decrease in PVR during inspiration
Spontaneous Right PVR Left Net Cardiac
Breathing Preload After- Output
load

Exhalation
Normal +/-
inhalation

15
 Summary of cardiovascular effects of
spontaneous breathing

inh Exh inh Exh

Spontaneous
breathing

Mechanical Ventilation 16
 Cardiovascular effects
of positive pressure ventilation (PPV)
in normal heart and healthy individual

Mechanic
al
Ventilatio
17 n
 Right ventricular filling during
Positive Pressure ventilation
Opposite to spontaneous breathing, venous return decreases during inspiration

Mechanical Ventilation 18
 Right ventricular filling during
positive pressure ventilation
Vena Cava

Positive Pressure
Ventilation
RA
Thorax
RV

Venous
return
 Clinical signs that suggest these important cardiorespiratory

Cardio vascular effects of positive pressure ventilation

interactions include wide fluctuations in systolic arterial
pressure during inspiration. The variability of the systolic
in normal heart (Reversed Pulsus Paradoxus)
arterial pressure (difference between the maximal and minimal
systolic arterial pressures during a mechanical ventilation cycle)
has been shown to be a sensitive indicator of hypovolemia [9,
10] (Fig. 4).

1) Decrease venous
return

2) Increased PVR and

RV impedance (mild)

3) Reduced LV preload
& LV afterload

4) Ventricular
interdependence.
(mild)
Fig. (4). Changes in systolic blood pressure induced by the respiratory
cycle. Adapted from ref. [10].
Change in systolic pressure induced by
respiratory
Left Ventricular Afterload cycle during PPV
(5% to 10%
The left ventricular decrease
afterload in SBP) on
is dependent the left
ventricular transmural pressure. The transmural pressure of an
intrathoracic structure such as the left ventricle is a function of
20
the measured pressure within that structure and the pressure
 Cardiovascular effects of positive pressure
ventilation on left ventricle

x Increase LV pre-load when low

Decrease LV pre-load when high
Decrease LV after load
Left ventricle likes positive pressure ventilation
Best strategy is to use positive pressure ventilation to op
timize pre-load and after load of left
ventricle

Mechanical Ventilation 21
Effects of intra-thoracic pressure (ITP) in the presence
of normal LV contractility (decrease in stroke volume)

Δ LVEDV LV Pre-load >

SV1 Δ LVESV LV after-load
SV2

Pinsky, 1997
Effects of ITP in the presence of decreased LV Contractility
(increase in stroke volume)

ΔLVEDV LV Pre-load <

Δ LVESV LV after-load
SV1
SV2
Pinsky, 1997
Cardiovascular effect of (PPV) Mechanical ventilation
on Right ventricle in abnormal pathological conditions

I. Abnormal RV preload
1. Hypovolemic patients
II. Abnormal RV afterload
1 Decrease pulmonary blood flow (Oligemic lung)
2 Increase pulmonary blood flow (Pulmonary edema)
3 Collapsed lung
4 Stiff non-compliant lung (restrictive disease: ARDS)
5 Hyper-inflated lung (Obstructive disease : airtraping)
III.Abnormal Contractility:
1. RV dysfunction
IV.Abnormal anatomy (single ventricle)
Mechanic
al
Ventilatio
24 n
I. Volume status : Hypovolemia
Volume depleted Volume resuscitated

Fessler, 1992

Collapse of intra-abdominal Pressure gradient between abdomen a

veins and SVC occurs. nd thorax is maintained.
Intubation with PPV in hypovolemic state:
optimize intravascular volume and fluid status..!!!
2

• Intubation may be
necessary but could be
detrimental in some case due to ca
rdio-pulmonary inter-action!!
• Shock
• Arrest
• Hypovolemia,
• Restrictive cardiomyopathy
• Tamponade
• High intra-thoracic pressure
Venous Driving Pressure:
Importance of having adequate volume with imitation of PPV

• Hypovolemia
• Shock
• Vasodilatation
• Sedation/analgesia
Venous return

O Right Atrial Pressure

Arterial Pulse Pressure Variation
 What happens during positive
pressure ventilation?

Mechanical Ventilation 28
 Venous Return Curve
Effect of intra-thoracic pressure

Negative pressure ventilation Positive pressure ventilation

Mechanical Ventilation 29
 Right ventricular filling during
Positive Pressure ventilation
The higher the ITP, the lower venous return
Vena Cava

Positive Pressure
Ventilation

RA
Thorax

RV
Venous
return
 Effects of Excessive Positive Pressure
Ventilation on PVR and Lung Volume

Mechanical Ventilation
the least PVR value is in FRC 31
Effects of Excessive PPV on the Heart

•Decreases in Venous
Return

•Increase RV after load

(PVR)

•Decrease LV pre-load
•Ventricular
interdependence

•Decrease in CO
 Cardiovascular effects of
positive pressure ventilation

Positive
Right Left
pressure PVR
ventilation Preload After-load

Health +/-

Mechanical Ventilation 33
 Cardiovascular effects of excessive
positive pressure ventilation

Positive
Right Left
pressure PVR
ventilation Preload After-load
Health +/-
Disease

Mechanical Ventilation 34
 COPD
Effect of lung hyperinflation
Increase end expiratory lung vol
ume
Creation of intrinsic PEEP
Increase PVR and RV impedance
Decrease in Venous return
(↓RV pre-load)
Pulsus Paradoxus
Decrease LV pre-loadV/Q misma
tch
Increased O2 consumption
.
Mechanic
al
Ventilatio
35 n
Effect of Very high intra-thoracic pressure:
Detrimental venous return…!!!!!!!!....Arrest

Mechanic
al
Ventilatio
36 n
Effects of PPV in pulmonary edema,
congested lung or ARDS
Post TOF repair
PaO2 50, SpO2 80%
Vent settings:
FiO2 1, PEEP 4, Ti 0.5, Vt 10 mL
/kg
What would you do?

increase PEEP
or increase Fioz
 Conclusion

Cardiopulmonary interaction depends on

multiple factors
– Spontaneous breathing V.S positive
pressure ventilation
– Status of heart and lungs
{Normal or abnormal}
– Other hemodynamic factors (volume status)
– Effect of drugs and medication

Mechanical Ventilation 38
Thanks
39