Mechanical Ventilation & Cardiopulmonary Interactions: Clinical Application in Non- Conventional Circulations. Eric M. Graham, MD

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1 Mechanical Ventilation & Cardiopulmonary Interactions: Clinical Application in Non- Conventional Circulations Eric M. Graham, MD

2 Background Heart & lungs work to meet oxygen demands Imbalance between supply and demand may result in hypoxia and death Critical to maintain cardiopulmonary function

3 Background Heart & lungs work to meet oxygen demands Imbalance between supply and demand may result in hypoxia and death Critical to maintain cardiopulmonary function Interventions aimed at improving one system can negatively affect the other

4 Basic Principles Ventilation induce changes in intrathoracic pressure & lung volume Independently affect cardiac output Preload (atrial filling) Afterload (impedence to ventricular emptying) Myocardial contractility Heart rate

5 Spontaneous Inspiration Negative pleural pressure transmitted to RA Increase in intraabdominal pressure Larger driving pressure gradient from extrathoracic veins to the RA Increasing RA filling

6 Spontaneous Inspiration Negative pleural pressure transmitted to RA Increase in intraabdominal pressure Larger driving pressure gradient from extrathoracic veins to the RA Increasing RA filling

7 Spontaneous Inspiration Negative pleural pressure transmitted to RA Increase in intraabdominal pressure Larger driving pressure gradient from extrathoracic veins to the RA Increasing RA filling

8 Spontaneous Inspiration Negative pleural pressure transmitted to RA Increase in intraabdominal pressure Larger driving pressure gradient from extrathoracic veins to the RA Increasing RA filling

9 Intermittent Positive Pressure IPPV produces inspiratory increase in intrathoracic and RA pressure Ventilation (IPPV) If PEEP is added, intrathoracic > atmospheric pressures Hinder RA filling

10 Superior Cavopulmonary Connection Glenn 1957 SVC to RPA BDG SVC to confluent PA s Hemi-Fontan

11 SCPC Circulation Cerebral & pulmonary circulations are in series Aortic blood brain SVC lungs Without a pulmonary ventricle Dependant on low resistance pulmonary vascular bed

12 SCPC Circulation Cerebral & pulmonary circulations are in series Aortic blood brain SVC lungs Without a pulmonary ventricle Dependant on low resistance pulmonary vascular bed

13 SCPC Circulation Cerebral & pulmonary circulations are in series Aortic blood brain SVC lungs Without a pulmonary ventricle Dependant on low resistance pulmonary vascular bed

14 SCPC Circulation Cerebral & pulmonary circulations are in series Aortic blood brain SVC lungs Without a pulmonary ventricle Dependant on low resistance pulmonary vascular bed

15 SCPC Circulation Cerebral & pulmonary circulations are in series Aortic blood brain SVC lungs Without a pulmonary ventricle Dependant on low resistance pulmonary vascular bed

16 Pulmonary Blood Flow Following SCPC Anatomic Patent anastamosis Pulmonary artery size Aortopulmonary collaterals Venovenous collaterals Cerebral & pulmonary autoregulation Ventilation, PC02 Pulmonary vasodilators

17 Pulmonary Blood Flow Following SCPC Anatomic Patent anastamosis Pulmonary artery size Aortopulmonary collaterals Venovenous collaterals Cerebral & pulmonary autoregulation Ventilation, PC02 Pulmonary vasodilators

18 The Effect Of Hyperventilation Hyperventilation PCO 2 Respiratory alkalosis ph Cerebral resistance Cerebral flow Pulmonary flow PVR Pulmonary flow?

19 Hyperventilation Following SCPC 12 patients Within 6 hours of SCPC Sedated & paralyzed Baseline hyperventilation baseline Cerebral flow measured with transcranial Doppler Bradley SM. Circulation 1998

20 Hyperventilation After BSCC Baseline Hypervent Baseline ph PCO

21 Arterial PO torr * Baseline Hypervent Baseline

22 Systemic O 2 Saturation % * Baseline Hypervent Baseline

23 Cerebral Blood Flow Velocity cm/sec * Baseline Hypervent Baseline Transcranial doppler of middle cerebral artery

24 Hyperventilation After BSCC Baseline Hypervent Baseline Syst PA O Airway pressure Peak Mean 4 8 4

25 Pulmonary Artery Pressure Transpulmonary Gradient mm Hg * * Baseline Hypervent Baseline PAP TPG

26 Hyperventilation After SCPC Impairs systemic oxygenation Despite decreasing PAP, TPG PCO 2 decreases cerebral, SVC, pulmonary blood flow Bradley SM. Circulation 1998

27 Hypoventilation Following SCPC 15 patients Within 8 hours of SCPC Sedated & paralyzed Baseline hypoventilation Sodium bicarbonate administered prior Cerebral flow measured with transcranial Doppler Bradley SM. J Thorac Cardiovasc Surg 2003

28 Hypoventilation After SCPC Na Bicarbonate + Baseline Hypoventilation PCO ph

29 Arterial PO 2 torr Baseline * 61 Hypoventilation

30 Systemic O 2 Saturation * % Baseline Hypoventilation

31 Cerebral Blood Flow Velocity cm/sec Baseline * Hypoventilation Transcranial doppler of middle cerebral artery

32 Hypoventilation After BSCC Baseline Hypovent Syst PA O Airway pressure Peak Mean 6 4

33 Pulmonary Artery Pressure Transpulmonary Gradient mm Hg Baseline * * Hypoventilation PAP TPG

34 Hypoventilation After SCPC Improves systemic oxygenation Despite increasing PAP & TPG PCO 2 increases cerebral, SVC, pulmonary blood flow Bradley SM. J Thorac Cardiovasc Surg 2003

35 Altering Ventilation After SCPC Remaining Questions Flows not directly measured Role of airway pressure Cerebral flow steal from lower body vs. increase in overall cardiac output

36 PCO 2 After SCPC 9 patients early after SCPC Sedated & paralyzed PCO 2 by adding inspired CO 2 Blood flow, cardiac output by Fick O 2 consumption by mass spectrometry Hoskote A. J Am Coll Cardiol 2004

37 PCO 2 After SCPC Baseline Inspired CO 2 PCO ph PO O 2 Sat 72 80

38 Blood Flows 5 l/min/m Q IVC Baseline Q P

39 5 Blood Flows 4.9 C.O. l/min/m Q IVC Baseline Inspired CO2 Q P

40 PCO 2 After SCPC 12 patients, 20 months after SCPC PCO 2 by adding inspired CO 2 Blood flows by MRI velocity mapping Fogel MA. Circulation 2004

41 PCO 2 After BSCC Baseline Inspired CO 2 PCO ph PO

42 Blood Flows l/min/m C.O. Q IVC Q P 0 Baseline Inspired CO2

43 Hypercarbia After SCPC Improves systemic oxygenation Cerebral, SVC, pulmonary flow Cardiac output; No steal from IVC Inspired CO 2 No Δ in airway pressures Early and late after SCPC Hoskote A. J Am Coll Cardiol 2004; Fogel MA. Circulation 2004

44 Pulmonary Vasodilators Oxygen Nitric oxide

45 Oxygen After SCPC 12 patients, 20 months after BSCC Flows by MRI velocity mapping 100% oxygen No Δ cerebral, pulmonary flow Fogel MA. Circulation 2004

46 Nitric Oxide After SCPC Selective pulmonary vasodilator 26 patients Systemic O 2 Sat < 75% 1 st day after SCPC Baseline nitric oxide baseline Adatia I. J Thorac Cardiovasc Surg 2005

47 Nitric Oxide After SCPC Baseline NO Baseline PAP 17 15* 16 TPG PO O 2 Sat

48 Pulmonary Vasodilators After SCPC Oxygen & Nitric Oxide PVR low, nonreactive Pulmonary vasoconstriction limits neither: Pulmonary blood flow Systemic oxygenation Fogel MA. Circulation 2004; Adatia I. J Thorac Cardiovasc Surg 2005

49 Nitric Oxide After SCPC Retrospective study over 30 months ino initiated within 3 hrs of operation SCPC pressures ~ 20 mmhg, instability 16 patients received ino vs 28 did not Pre-op cath: higher mpap and PVR Agarwal H. Ann Thorac Surg 2006

50 Nitric Oxide After SCPC Retrospective study over 30 months ino initiated within 3 hrs of operation SCPC pressures ~ 20 mmhg, instability 16 patients received ino vs 28 did not Pre-op cath: higher mpap and PVR 11 (69%) responded All 5 non-responders were found to have an anatomic lesion Agarwal H. Ann Thorac Surg 2006

51 11 Responders: Nitric Oxide After SCPC Baseline 1 hour ino 3 hour ino PAP 23 19* 17* Inotrope score 15 12* 11* PO 2 /FiO * 74* PO Agarwal H. Ann Thorac Surg 2006

52 Total Cavopulmonary Connection Fontan 1971 Pulmonary blood flow is cardiac output Passive diastolic phenomenon Strongly influenced by changes in intrathoracic pressures

53 Spontaneous Respiration Redington AN. Br Heart J 1991

54 Spontaneous Respiration Redington AN. Br Heart J 1991

55 Brief Valsalva Redington AN. Br Heart J 1991

56 Brief Valsalva Redington AN. Br Heart J 1991

57 Prolonged Valsalva Redington AN. Br Heart J 1991

58 Prolonged Valsalva Redington AN. Br Heart J 1991

59 Prolonged Valsalva Redington AN. Br Heart J 1991

60 Detrimental Effects of Positive Pressure Ventilation Antegrade pulmonary flow and hence cardiac output can be significantly reduced with increased intrathoracic pressure Intermittent positive pressure ventilation Short inspiratory time Low inspiratory pressures Minimal PEEP Early extubation

64 Hemodynamic Benefits of Spontaneous Respiration 50 consecutive patients BDG (n=23) Fontan (n=27) Cardiac output determined utilizing extra vascular probes on ascending aorta (n=12) All patients extubated in the OR or within 1 hour after arrival to the ICU Lofland GK. Eur J Cardiothorac Surg 2001

65 Mean PAP mmhg Pre Post 6 hrs Post 12 hrs Post

66 Cardiac Index Pre Post 12 hrs Post

67 Benefits of Extubation in the OR Retrospective review 112 Fontan pts During the study period all patients were considered for extubation in the OR Clinical judgment Pts were grouped into those extubated in the OR and those extubated in the ICU 34% (n=38) extubated in the OR Morales DLS. Ann Thorac Surg 2008

68 Improved Hemodynamics Extubated in OR Mean PA pressure Mean systemic arterial pressure

69 Results Extubated OR Extubated ICU Inotropic support (days) ICU stay (days) Hospital stay (days) ICU cost ($) 32,000 49,000 Hospital cost ($) 44,000 64,000 Survival (%) 100% 99% All p < 0.05

70 Extubation in the OR Limited by nonrandom assignment Affirms the hemodynamic benefits of early extubation Safe Effective Reduced costs

Data from the STS Database 2010-2013 Association of early extubation with LOS Centers

71 Data from the STS Database Association of early extubation with LOS Centers stratified into tertiles by frequency of early extubation (<6 hrs) Mahle WT. Ann Thorac Surg 2016

72 Benefits of Early Extubation 92 centers Early extubation in 70% 1,153/1,653 Mahle WT. Ann Thorac Surg 2016

73 Benefits of Early Extubation 92 centers Early extubation in 70% 1,153/1, Mahle WT. Ann Thorac Surg 2016

74 Benefits of Early Extubation 92 centers Early extubation in 70% 1,153/1,653 9 Mahle WT. Ann Thorac Surg 2016

75 Benefits of Early Extubation 92 centers Early extubation in 70% 1,153/1,653 Median LOS was 9 days (IQR 7-14 days) Mahle WT. Ann Thorac Surg 2016

76 Benefits of Early Extubation 92 centers Early extubation in 70% 1,153/1,653 Median LOS was 9 days (IQR 7-14 days) No association with early extubation & LOS Mahle WT. Ann Thorac Surg 2016

77 Unfortunately early extubation is not always feasible, and paradoxically, it is in those children in whom this is most desirable that continued ventilator support is needed

78 Negative Pressure Ventilation Hemodynamic effects of NPV on Fontan N=9, immediate post-op period N=9, late phase (5mo-15yrs) after elective cath Paralyzed, sedated, IPPV Blood flow, cardiac output by Fick O 2 consumption by mass spectrometry IPPV NPV Subgroup 1: reinstitution of IPPV Subgroup 2: extended period of NPV Shekerdemian LS. Circulation 1997

79 Pulmonary Blood Flow

80 Pulmonary Blood Flow %

81 Results IPPV NPV Stroke volume (ml/m 2 ) Oxygen consumption (ml/min/m 2 ) Mixed venous saturation (%) Mean PA pressure (mmhg) PVR (U/m 2 ) All p < 0.05

82 Reinstitution of IPPV

83 Extended NPV

84 Predictors of Improvement with NPV Strong positive correlation Acute patients Preop Ventricular EDP Postop mean PA pressure Marked in pulmonary blood flow and cardiac output

85 Deshpande SR. Heart, lung, and Circ 2011

87 Deshpande SR. World J Cardiol 2014

88 Alternative Modes of Ventilation High-Frequency Jet Ventilation 13 pts following Fontan; IPPV HFJV Mean airway pressure: PVR: Cardiac index: ( all p 0.001) High-Frequency Oscillation 5 pts following Fontan No effect on cardiac output or PVR Meliones JN. Circulation 1991; Kornecki A. Pediatr Crit Care Med 2002

89 Alternative Modes of Ventilation High-Frequency Jet Ventilation 13 pts following Fontan; IPPV HFJV Mean airway pressure: PVR: Cardiac index: ( all p 0.001) High-Frequency Oscillation 5 pts following Fontan No effect on cardiac output or PVR Meliones JN. Circulation 1991; Kornecki A. Pediatr Crit Care Med 2002

90 Summary Avoid hyperventilation Encourage mild hypercarbia Pulmonary vasodilators not determinants Early extubation Alternative modes of ventilation Negative pressure High-frequency jet

Management of a Patient after the Bidirectional Glenn

Management of a Patient after the Bidirectional Glenn Melissa B. Jones MSN, APRN, CPNP-AC CICU Nurse Practitioner Children s National Health System Washington, DC No Disclosures Objectives qbriefly describe