Influence of Positive End-Expiratory Pressure on Left Ventricular Performance

Jardin, François; Farcot, Jean-Christian; Boisante, L; N, Curien; Margairaz, A; Bourdarias, Jean-Pierre

doi:10.1056/nejm198102123040703

Cited by 634 publications

(209 citation statements)

References 26 publications

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“…However, mechanical ventilation has many undesirable side effects. These include barotrauma resulting in pulmonary air leaks (2) and alterations in pulmonary blood flow and cardiac output resulting from the use of PEEP (3). Attempts by clinicians to minimize these adverse effects in the ventilated neonate have been compromised by the inability to adequately monitor cardiopulmonary variables, e.g.…”

mentioning

confidence: 99%

Measurement of Cardiopulmonary Function in Ventilated Neonates with Respiratory Distress Syndrome Using Rebreathing Methodology

et al. 1986

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ABSTRACT. The feasibility of using a multiple gas rebreathing technique to evaluate cardiopulmonary function in the ventilated neonate was assessed by measuring functional residual capacity, diffusing capacity of lung for carbon monoxide, and effective pulmonary capillary blood flow in 10 neonates with respiratory distress syndrome. Measurements were first made on the level of positive end expiratory pressure (PEEP) selected by the clinicians caring for the infants ("clinical" PEEP, mean of 4.4 2 0.3 cm H20). To evaluate the effect of P E E P on cardiopulmonary function, P E E P was then changed above (mean of 6.7 f 0.4 cm H 2 0 ) and below (mean of 1.9 + 0.3 cm H 2 0 ) this level and measurements were repeated. Mean functional residual capacity on clinical P E E P (10.8 + 1.6 ml/kg) was far below the predicted normal and varied directly with changes in P E E P (mean change of 1.2 ml/kg/cm H20). Diffusing capacity of the lung for carbon monoxide on clinical P E E P was 0.04 + 0.01 ml/min/mm Hg/kg and did not change significantly with changes in PEEP. Mean effective pulmonary capillary blood flow was highest (70 ml/min/kg) a t the lowest level of PEEP. However, the effect of increasing P E E P on effective pulmonary capillary blood flow in individual infants varied. Increasing P E E P increased arterial oxygen tension but did not cause changes in systemic arterial pressure or heart rate. We conclude that infants with respiratory distress syndrome have severe lung injury with decreased functional residual capacity and diffusing capacity of the lung for carbon monoxide, and that lung volume improves with the use of PEEP. Although P E E P has a beneficial effect on arterial oxygenation, it may impair systemic oxygen transport in some infants because of its detrimental effect on cardiac output. This detrimental effect on cardiac output could not be detected by usual clinical monitoring techniques. (Pediatr Res 20: 316-320,1986) Abbreviations HDS, respiratory distress syndrome PEEP, positive end expiratory pressure FRC, functional residual capacity QCm, effective pulmonary capillary blood flow DI,CO, diffusing capacity of the lung for carbon monoxide TcP02, transcutaneous oxygen tension PAo, mean systemic arterial blood pressure

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confidence: 99%

Measurement of Cardiopulmonary Function in Ventilated Neonates with Respiratory Distress Syndrome Using Rebreathing Methodology

et al. 1986

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“…Next, a patient presenting with ARDS should be optimized to avoid a "low PvO 2 effect" [24,42]. The left ventricular (LV) systolic area is reduced when the PEEP is increased above 15 cm H 2 O [9]. Therefore, an adequate LV pre-load is even more relevant in the setting of a high PEEP.…”

Section: Cardiac Functionmentioning

confidence: 99%

“…Volemia, urine output, rhythm, contractility [44], right coronary perfusion pressure [72], an arterio-venous CO 2 gradient < 5 [73] or 6 mm Hg [74,75] ("CO 2 gap"), venous saturation (the difference between the arterial and superior vena cava saturation [SsvcO 2 ] < 30% or SsvcO 2 > 70−75% [1,76]), trend for lactates towards < 2 mmol L -1 , and the absence of leftward septal bulging/RV dilatation [9,24] should be optimized upfront as early as possible in the setting of severe ARDS. [Then, the PEEP should be increased stepwise and the RV observed [9] iteratively. As soon as the RV enlarges or the tricuspid annular plane systolic excursion (TAPSE) decreases over several ventilator cycles, the PEEP is decreased to the previous level.…”

Section: Cardiac Functionmentioning

confidence: 99%

“…[W]hat seems very important…is to convince clinicians to limit airway pressure in ARDS" [151]. Given the possibility of RV dysfunction [9] and increased IAP [152], just enough alveoli should be recruited for the shortest possible period to minimize overdistension (Tables 1 and 2 [118,132,136]), lowering the Pplat appears to be quite relevant for a restrictive disease such as ARDS. Given a constant APACHE score and Vt, the Pplat on day 1 after randomization independently predicted mortality (Fig.…”

Section: Physiology-based Trialsmentioning

confidence: 99%

“…PEEP ≥ 10− -24 cm H 2 O according to the NIH table; Table 4, part I) should be set early [8]. PEEP should be guided first by echocardiography [9], then, ideally by an esophageal catheter ("balloon") [10−12], or as a second-best by "trial" PEEP to minimize the effects of overdistension and PEEP (i.e., right ventricular (RV) failure, hypotension, positive fluid balance [13,14], and baro-trauma: Table 5, part I)]. ARDS is a very heterogeneous syndrome which combines an acute onset of cyanosis that is refractory to O 2, tachypnea, dyspnea/polypnea (i.e., increased ventilatory demands [15]), reduced compliance, diffuse alveolar infiltration (which becomes more or less severe as a function of the progression or regression of the disease) and an improvement with PEEP = 5−10 cm H 2 O [16].…”

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confidence: 99%

See 2 more Smart Citations

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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Severe acute respiratory distress syndrome (ARDS, PaO 2 /FiO 2 < 100 on PEEP ≥ 5 cm H 2 O) is treated using controlled mechanical ventilation (CMV), recently combined with muscle relaxation for 48 h and prone positioning. While the amplitude of tidal volume appears set £ 6 mL kg -1 , the level of positive end-expiratory pressure (PEEP) remains controversial. This overview summarizes several salient points, namely: a) ARDS is an oxygenation defect: consolidation/difuse alveolar damage is reversed by PEEP and/or prone positioning, at least during the early phase of ARDS b) ARDS is a dynamic disease and partially iatrogenic. This implies that the management of the ventilator may be a life-saver by reducing the duration of mechanical ventilation, or detrimental by extending this duration, leading into critical care-acquired diseases. Indeed, a high PEEP (10−24 cm H 2 O) appears to be a life-saver in the context of early severe diffuse ARDS; c) tidal volume and plateau pressure cannot be identical for all patients; d) the only remaining rationale for CMV and muscle relaxation is to suppress patient-ventilator asynchrony and to lower VO 2 , during the acute cardio-ventilatory distress. Therefore, in early severe diffuse ARDS, this review argues for a combination of a high PEEP (preferably titrated on transpulmonary pressure) with spontaneous ventilation + pressure support (or newer modes of ventilation). However, conditionalities are stringent: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone. As these propositions require evidence-based demonstration, the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation, and prone position.

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