Right Ventricular Loading by Lung Inflation during Controlled Mechanical Ventilation

Slobod, Douglas; Assanangkornchai, Nawaporn; Alhazza, Manal; Mettasittigorn, Pattra; Magder, Sheldon

doi:10.1164/rccm.202111-2483oc

Cited by 26 publications

(26 citation statements)

References 23 publications

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“…In ARDS, at least in the early phases, the lung is non-homogeneously aerated. Hyperinflated regions move lung areas from West zone 3 to zone 2 or even zone 1, leading to RV overload [12]. In contrast, atelectatic lung also induces RV overload due to the decrease in diameter of the extra-alveolar pulmonary vessels, which is corrected by re-aeration of the lung [13].…”

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confidence: 99%

Hemodynamic impact of prone position. Let’s protect the lung and its circulation to improve prognosis

2023

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confidence: 99%

Hemodynamic impact of prone position. Let’s protect the lung and its circulation to improve prognosis

2023

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“…Hemodynamic compromise, due to inappropriately high PEEP levels as the result of increased right ventricular afterload is well documented [10]. Under such circumstances, the distending pressure of the alveoli, rather than pulmonary venous pressure, serve as a backward pressure for the pulmonary flow [11]. Inappropriately high PEEP levels compromising the pulmonary circulation in our cohort, have likely caused reduction in perfusion (manifesting as increasing Vd/Vt) and the dynamics of measured RC EXP reflected that phenomenon sooner than C RS .…”

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confidence: 99%

Evaluation of time constant, dead space and compliance to determine PEEP in COVID-19 ARDS: a prospective observational study

2023

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Multiple variables exist to identify optimal positive end-expiratory pressure (PEEP) to keep alveolar recruitment in acute respiratory distress syndrome (ARDS). These include increased respiratory system compliance (CRS ) and decreased dead space to tidal volume fraction (Vd/Vt). Increasing CRS reflects improved lung volume, whereas decreasing Vd/Vt reflects improved ventilation/perfusion matching. An increasing expiratory time constant (RCEXP ) reflects both, changes in CRS and alterations in tissue resistance. Whether RCEXP might reflect corresponding changes in Vd/Vt better than CRS during alveolar recruitment is unknown. This prospective observational study examined the correlation between these variables during ascending PEEP titration in patients with novel Coronavirus disease (COVID-19) related ARDS. PEEP titrations were performed in ten patients with COVID-19 ARDS under passive, pressure-controlled ventilation with a fixed driving pressure of 14 cmH2O. PEEP was increased stepwise between 5 and 20 cmH2O with 2 minutes allowed for Vd/Vt equilibration. RCEXP , Vd/Vt and CRS were recorded at each PEEP level and statistically assessed.The overall correlation between Vd/Vt and RCEXP was −0.72 (95% CI: −0.57 to −0.82); p < 0.0001. CRS had a weaker correlation with Vd/Vt (−0.47 (95% CI: −0.25 to −0.64); p < 0.0001). RCEXP was the highest at 12 cmH2O of PEEP whereas Vd/Vt was the lowest at 10 cmH2O of PEEP and CRS was the highest at PEEP of 15 cmH2O.Both parameters of exhalation, Vd/Vt and RCEXP, are strongly correlated which likely reflects corresponding mechanical and global ventilation/perfusion responses during ascending PEEP titration.

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“…Increasing RV EDV induces intraventricular septal shift into the LV and has direct influence on the shape and compliance of the LV, which is called the “ventricular diastolic interdependence.” Multiple clinical studies have documented that in the presence of significant increases in RV afterload (cor pulmonale, acute pulmonary embolism, pneumothorax, or diffuse HPV), by their associated increases in RV EDV, LV diastolic compliance decreases and can lead to cardiopulmonary collapse due to impaired LV diastolic filling. 40 41 42…”

Section: Hemodynamic Effect Of Elevated Pulmonary Vascular Resistance...mentioning

confidence: 99%

“…When pulmonary vascular resistance increases due to either increased pulmonary vasomotor tone or increased proportions of the vasculature in West zones 1 and 2, pulmonary artery pressure will also increase, increasing RV afterload. 39 Recent prospective physiologic study of postcardiac surgery patients showed more than 50% of the patients had nonzone 3 (aka zone 1 or 2) conditions at a tidal volume of 6 mL/kg, 40 and treating providers should be aware that positive pressure ventilation can cause increased pulmonary vascular resistance even during "lung protective strategy ventilation. "…”

Section: How Pulmonary Vascular Resistance Affects Right Ventricular ...mentioning

confidence: 99%

Heart–Lung Interactions

Hamahata

Pinsky

2023

Semin Respir Crit Care Med

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The pulmonary and cardiovascular systems have profound effects on each other. Overall cardiac function is determined by heart rate, preload, contractility, and afterload. Changes in lung volume, intrathoracic pressure (ITP), and hypoxemia can simultaneously change all of these four hemodynamic determinants for both ventricles and can even lead to cardiovascular collapse. Intubation using sedation depresses vasomotor tone. Also, the interdependence between right and left ventricles can be affected by lung volume-induced changes in pulmonary vascular resistance and the rise in ITP. An increase in venous return due to negative ITP during spontaneous inspiration can shift the septum to the left and cause a decrease in left ventricle compliance. During positive pressure ventilation, the increase in ITP causes a decrease in venous return (preload), minimizing ventricular interdependence and will decrease left ventricle afterload augmenting cardiac output. Thus, positive pressure ventilation is beneficial in acute heart failure patients and detrimental in hypovolemic patients where it can cause a significant decrease in venous return and cardiac output. Recently, this phenomenon has been used to assess patient's volume responsiveness to fluid by measuring pulse pressure variation and stroke volume variation. Heart–lung interaction is very dynamic and changes in lung volume, ITP, and oxygen level can have various effects on the cardiovascular system depending on preexisting cardiovascular function and volume status. Heart failure and either hypo or hypervolemia predispose to greater effects of ventilation of cardiovascular function and gas exchange. This review is an overview of the basics of heart–lung interaction.

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Right Ventricular Loading by Lung Inflation during Controlled Mechanical Ventilation

Cited by 26 publications

References 23 publications

Hemodynamic impact of prone position. Let’s protect the lung and its circulation to improve prognosis

Hemodynamic impact of prone position. Let’s protect the lung and its circulation to improve prognosis

Evaluation of time constant, dead space and compliance to determine PEEP in COVID-19 ARDS: a prospective observational study

Heart–Lung Interactions

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