Cardiorespiratory Interactions:

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1 Cardiorespiratory Interactions: The Heart - Lung Connection Jon N. Meliones, MD, MS, FCCM Professor of Pediatrics Duke University Medical Director PCVICU

2 Optimizing CRI Cardiorespiratory Economics O2: supply vs. demand CRI: The Heart CRI: The Lung Conventional Ventilation Non-Conventional Ventilation Clinical Applications

3 Cardiorespiratory O2 Demand: Economics O2 consumption = C. O. x (CaO2 - CvO2) O2 Consumption = amount of oxygen used for aerobic metabolism Failure to meet the demands results in anaerobic metabolism

4 Cardiorespiratory Economics Optimizing CRI O2 delivery O2 content: Hgb, O2 sat, PaO2 cardiac output cardiac interventions: another talk pulm interventions: this talk O2 consumption: patient WOB

5 Cardiorespiratory Interactions Effects of intrathoracic pressure, lung volume, and gas exchange on: A Definition Cardiovascular events such as venous return, ventricular performance, and arterial outflow.

6 Right Ventricular Filling Vena Cava Effects on RV Thorax RA RV Positive Pressure Ventilation PA

7 Systemic Venous Return (RV Preload) P SV Right Atrial Pressure RAP = mean systemic venous pressure PPV increases right atrial pressure spontaneous breathing 0 0 Max Systemic Venous Return

8 Effects of PPV on Right Ventricle intrathoracic pressure C.O. RV preload PVR Best strategy for the failing RV is to limit intrathoracic pressure

9 Effects of PPV on LV Filling Thoracic Pump Augmentation Lung LA LV Lung Positive Pressure Ventilation AO

10 Effects of PPV on LV Afterload 100 AO 100 AO LV TM =130 LV TM = LV -30 Thorax 70 LV +30 Spontaneous PPV

11 Effects of PPV on Left Ventricle es in intrathoracic pressure C.O.: ing LV preload when low ing LV afterload preload when excessive (RV) effects Best strategy for the failing LV is to utilize intrathoracic pressure to optimize preload & afterload

12 Optimizing CRI Cardiorespiratory Economics CRI: The Heart CRI: The Lung The pulmonary vasculature Conventional Ventilation Non-conventional Ventilation Clinical Applications

13 Effect of Lung Volume on PVR Overexpansion PVR Atelectasis FRC Lung Volume Total PVR Small Vessels Large Vessels

14 Pulmonary Vasculature Optimize lung volume: avoid overexpansion / atelectasis Avoid hypoxic vasoconstriction, if possible Avoid hypercapnia; promote alkalosis Neonates at ed risk for pulm HTN Inhaled gases modify PVR

15 Overdistention 30 Volume 20 (ml) Exhalation Over Expansion Inspiration Airway Pressure (cmh20)

16 Overdistention and C.O Cardiac Output (ml/min) PEEP 5 PEEP Cheifetz: CCM 1998 Tidal Volume (ml/kg)

17 Overdistention and and PVR PVR 5000 PVR 5 ) (d-sec/cm PEEP 5 PEEP Tidal Volume (ml/kg)

18 Overdistention Pulmonary effects Barotrauma; pneumothroax Cardiac effects Increased RV afterload; increased PVR; decreased cardiac output

19 Beginning of Inspiration Intrinsic PEEP End of Inspiration Premature initiation of Inspiration Retained Gas Results in PEEPi Beginning of Exhalation Termination of Exhalation Premature Termination of Exhalation

20 Intrinsic PEEP Expiratory gas flow continues at the end of the time allotted for exhalation. PEEPi may lead to excessive MAP. Pulmonary effects: Barotrauma Cardiac effects: Impedance of venous return Decreased cardiac output

21 Optimizing CRI Cardiorespiratory Economics CRI: The Heart CRI: The Lung Conventional Ventilation Non-conventional Ventilation Clinical Applications

22 Non-conventional Ventilation HFOV HFJV Negative pressure ventilation Inhaled nitric oxide

23 Low Cardiac Output Syndrome Decrease in CI in Newborns post ASO Wessel DL. Managing LCOS after CHD surgery. Crit Care Med 2001; 29:s

24 PIP at Machine HFOV Delta P at Machine MAP at Machine PIP at Alveolus MAP at Alveolus Delta P at Alveolus PEEP at Alveolus PEEP at Machine

25 HFOV HFOV decreases cardiac output?? Traverse et al Pediatr Res Traverse et al. Chest Laubscher et al. Arch Dis Child Common theme: Cardiac output decreases with significantly ed MAP. But, studies did not control for preload.

26 Preload Augmentation P SV HFOV Right Atrial Pressure CMV 0 0 Max Systemic Venous Return

27 Fluid responsiveness predicted by elevation of PEEP in patients with septic shock In this observational clinical study, we found that a decrease of MAP by elevation of PEEP from 10 to 20 cm H2O predicted fluid responsiveness in patients with septic shock. A modest or no decrease in MAP (less than 8%) ruled out a positive response to a subsequent fluid challenge defined as an increase in CO of 15 % or more. Acta Anaesthesiologica Scandinavica Volume 58, Issue 1, pages 27-35, 11 NOV 2013 DOI: /aas

28 HFOV and CRI: Summary Cardiac output is usually maintained during HFOV. In a given pt, C.O may be ed if: MAP is significantly ed. Consider volume loading Consider inotropes Bottom line: Oxygen delivery If C.O. can be maintained & oxygenation is ed, oxygen delivery will

29 High-frequency Jet Ventilation Intermittent pulse delivery of gas Frequency: Passive exhalation- continuous Special ETT adaptor required Weight/size limitation (Bunnell Jet) Many missconceptions

30 Airway Pressure HFJV HFJV Volume Limited MAP MAP

31 Effects of HFJV on on CRI 10 * * * p < 0.01 vs HFJV Pre HFJV Post Paw * PVR * 3.7 * * C.I.

32 High-frequency Jet Ventilation CMV provides: MAP / Oxygentaion Need more oxygenation simply Oxygenation all about MAP PEEP HFJV provides: Gentalation Need more ventilation? Simply PIP, Rate

33 Inhaled NO P O cgmp A 2, Ca++, PVR Interstitium Endothelial Cells Injured EDRF NO NO NO Oxygen Epithelial Cells cgmp CA++ Relaxation Muscle Hgb Capillary Met Hgb

34 Nitric Oxide In CHD OI Miller, SF Tang, A Keech, NB Pigott, E Beller and DS Celermajer: Lancet Pts, randomized Less Pulm HTN crisis, Less Vent Days. No difference in mortality Patients with passive flow, worse response, better in small vessels Use lowest dose, wean daily. Use sildenafil

35 RV Dysfunction Pulmonary HTN Ventilation Manipulations Conventional Ventilatory Strategies MAP but maintain FRC Alkalinize with normocapnia Nonconventional Modes HFJV Negative pressure ventilation Inhaled Medical Gases FiO2 ( CaO2) Nitric oxide

36 LV Dysfunction Conventional Ventilatory Strategies Thoracic pump augmentation of LV preload ( low ventilatory rate with high TV) LV afterload MAP but maintain FRC Nonconventional Modes HFJV or HFOV if MAP > cm H 2 O (optimize O2 delivery & barotrauma) Inhaled Medical Gases FiO2 ( CaO2)

37 Respiratory Dysfunction Ventilation Manipulations Conventional Ventilatory Strategies Maintain ideal lung volume Titrate PEEP / optimize MAP Alkalosis Nonconventional Modes HFOV if PAW > cm H 2 O (optimize O2 delivery & barotrauma) Inhaled Medical Gases FiO2 ( CaO2) Nitric oxide

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