Positive Pressure Ventilation in the Cardiac Intensive Care Unit

Abstract

Contemporary cardiac intensive care units (CICUs) provide care for an aging and increasingly complex patient population. The medical complexity of this population is partly driven by an increased proportion of patients with respiratory failure needing noninvasive or invasive positive pressure ventilation (PPV). 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. Invasive PPV can be lifesaving, but has both favorable and unfavorable interactions with left and right ventricular physiology and carries a risk of complications that influence CICU mortality. Effective implementation of PPV requires an understanding of the underlying cardiac and pulmonary pathophysiology. Cardiologists who practice in the CICU should be proficient with the indications, appropriate selection, potential cardiopulmonary interactions, and complications of PPV.

Demographics, Care Patterns, and Outcomes of Patients Admitted to Cardiac Intensive Care Units

“…While leadership of the CICU was guided historically by research interests and expertise in acute reperfusion therapy, based on observations from the CCCTN registry, the current training of practitioners with a career focus on cardiac critical care should include expertise in acute heart failure management, management of mechanical support, postcardiac arrest care, electrical storm, and the ability to integrate significant noninvasive cardiovascular imaging data into acute clinical decision-making. These core cardiology skills ought be further complemented with expertise in managing acute respiratory failure 16 and renal replacement therapy as well as preventive measures for patient safety, such as avoiding ventilatorassociated pneumonia and central line-associated bloodstream infections, and the management of delirium. Two studies sur-veying the organization and staffing of CICUs in the United States have documented low rates of staffing in CICUs by cardiologists with critical care skills.…”

Critical Care of Patients After Pulmonary Thromboendarterectomy

“…82 Prolonged positivepressure ventilation (PPV) in patients after PTE can impede neurologic assessment, lead to hemodynamic and pulmonary compromise, and is associated with a higher risk of ventilatorassociated pneumonia. 83,84 Although fast-track protocols increasingly are used to optimize timing of extubation in the general population, 85,86 no published reports describe their use for enhanced recovery after PTE surgery. Early extubation attempts should be made, if appropriate, to minimize potential harm of positive-pressure ventilation in this tenuous population.…”

Mechanical respiratory support in cardiogenic shock

“…3 In addition to significant haemodynamic effects from alterations in both preload and afterload, mechanical ventilation carries potentially deleterious effects such as infection, hyperoxaemia and ventilator-induced lung injury. 3 Although best described in acute respiratory distress syndrome, ventilator-induced lung injury and the subsequent proinflammatory state may also occur in uninjured lungs and potentially contribute organ dysfunction. 4 Given the proinflammatory cascade associated with the cardiogenic shock spiral, 5 we would suggest that mechanical ventilation as a mediator of inflammation deserves further consideration in this patient population.…”

“…Perhaps as a result of the perception that mechanical ventilation is often temporary, it has not garnered much attention from the cardiovascular community despite the intimate cardiopulmonary relationship between positive pressure ventilation and both left and right ventricular function . In addition to significant haemodynamic effects from alterations in both preload and afterload, mechanical ventilation carries potentially deleterious effects such as infection, hyperoxaemia and ventilator‐induced lung injury . Although best described in acute respiratory distress syndrome, ventilator‐induced lung injury and the subsequent proinflammatory state may also occur in uninjured lungs and potentially contribute to multiple system organ dysfunction .…”