The Effect of Incremental Positive End-Expiratory Pressure on Right Ventricular Hemodynamics and Ejection Fraction

Biondi, James W.; Schulman, Douglas S.; Soufer, Robert; Matthay, Richard A.; Hines, Roberta; Kay, H. D.; Barash, Paul G.

doi:10.1213/00000539-198802000-00007

Cited by 123 publications

(42 citation statements)

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“…In accordance with the Frank-Starling relationship, the lowered RVEDV decreases RVSV; and the reduced RVSV results in comparable changes in LVSV (2,24), especially so in the setting of increased intrathoracic pressure when the pulmonary blood volume decreases and any buffering function of the pulmonary circulation is limited (30). It has been suggested that only PPV above 10 cmH 2 O lowers cardiac filling (4,5,22), but in our study even a PPV of 10 cmH 2 O was demonstrated to lower the volume and output of all four cardiac chambers.…”

Section: Discussionmentioning

confidence: 84%

The decrease of cardiac chamber volumes and output during positive-pressure ventilation

Kyhl

Ahtarovski

Iversen³

et al. 2013

American Journal of Physiology-Heart and Circulatory Physiology

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Positive-pressure ventilation (PPV) is widely used for treatment of acute cardiorespiratory failure, occasionally at the expense of compromised cardiac function and arterial blood pressure. The explanation why has largely rested on interpretation of intracardiac pressure changes. We evaluated the effect of PPV on the central circulation by studying cardiac chamber volumes with cardiac magnetic resonance imaging (CMR). We hypothesized that PPV lowers cardiac output (CO) mainly via the Frank-Starling relationship. In 18 healthy volunteers, cardiac chamber volumes and flow in aorta and the pulmonary artery were measured by CMR during PPV levels of 0, 10, and 20 cmH2O applied via a respirator and a face mask. All cardiac chamber volumes decreased in proportion to the level of PPV. Following 20-cmH2O PPV, the total diastolic and systolic cardiac volumes (±SE) decreased from 605 (±29) ml to 446 (±29) ml (P < 0.001) and from 265 (±17) ml to 212 (±16) ml (P < 0.001). Left ventricular stroke volume decreased by 27 (±4) ml/beat; heart rate increased by 7 (±2) beats/min; and CO decreased by 1.0 (±0.4) l/min (P < 0.001). From 0 to 20 cmH2O, right and left ventricular peak filling rates decreased by -146 (±32) and -187 (±64) ml/s (P < 0.05) but maximal emptying rates were unchanged. Cardiac filling and output decrease with increasing PPV in healthy volunteers. The decrease is seen even at low levels of PPV and should be taken into account when submitting patients to mechanical ventilation with positive pressures. The decrease in CO is fully explained by the Frank-Starling mechanism.

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Section: Discussionmentioning

confidence: 84%

The decrease of cardiac chamber volumes and output during positive-pressure ventilation

Kyhl

Ahtarovski

Iversen³

et al. 2013

American Journal of Physiology-Heart and Circulatory Physiology

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“…This effect has been demonstrated during different ventilation modalities, including PPV, high-frequency oscillatory ventilation, and high-frequency jet ventilation (18,20,22,23). The effect of high airway pressure is not limited to the pulmonary vasculature, with direct compressive effects observed on the newborn heart, resulting in reduced cardiac performance and ventricular output (21,24). This is further complicated by recent studies in preterm animals (25,26) and preterm infants (27,28) demonstrating that the preterm heart, particularly the myocardium, is structurally immature, translating to lower contractility in the days after birth and an inability to cope with increasing afterload.…”

Section: Hemodynamic Consequences Of the Initiation Of Positive Pressmentioning

confidence: 99%

Respiratory support for premature neonates in the delivery room: effects on cardiovascular function and the development of brain injury

et al. 2014

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“…Both ventricles also show an ability to increase substantially their outputs when the preload of a ventricle is increased by a ductal or atrial shunt, confirming a degree of myocardial reserve. We speculate that the effect of positive pressure ventilation in reducing systemic venous return, and so cardiac output, may be as important in preterm infants as it has been recognised to be in adults.25 27 There are few studies on the effect of ventilation on cardiac output in preterm infants. Hausdorf and Hellwege5 demonstrated a 25% to 30% reduction in ventricular stroke and minute volumes, with no effect on blood pressure, by increasing PEEP from zero to 8 cm H20 in a group of preterm infants.…”

Section: Right Ventricular Outputmentioning

confidence: 99%

Early determinants of right and left ventricular output in ventilated preterm infants.

Evans

Kluckow

1996

Archives of Disease in Childhood - Fetal and Neonatal Edition

254

181

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One hundred and twenty ventilated preterm infants, birthweight <1500 g, were examined within the first 36 hours with colour Doppler echocardiography, to determine the cardiorespiratory influences on right (RVO) and left ventricular output (LVO). Forty nine of these infants had three further daily scans. Measurements included left ventricular (LV) ejection fraction, Doppler determination of RVO and LVO, and ductal and interatrial shunt direction, velocity and colour Doppler diameter. Infants were grouped by respiratory disease severity: mild, mean F102 in first 24 hours <0 5; moderate/severe, mean FI02 <05; and fatal, death resulting directly from acute respiratory distress.In the early studies ventricular outputs varied widely (RVO: 62-412 ml/kg/minute, LVO: 75-505 ml/kg/minute). The incidence of low ventricular outputs (<150 ml/kg/ minute) increased with worsening respiratory disease. The incidence of low RVO in the mild group was 19%, in the moderate/severe group 42%, and in the fatal group 85%. More infants had a low RVO than a low LVO, reflecting the impact of ductal shunting. Ductal and atrial shunting was predominantly left to right except in those with fatal respiratory disease. In those studied longitudinally, RVO and LVO increased with age and low outputs were not seen after day 3.Multilinear regression analyses, with RVO as the dependent variable, revealed increasing LVO and atrial shunt diameter as significant positive influences and increasing ductal shunt diameter and mean airway pressure as a significant negative influence. With LVO as the dependent variable, increasing RVO, ductal shunt diameter, and age were significant positive influences and increasing atrial shunt diameter was a significant negative influence.Low ventricular outputs are more common with worsening respiratory disease. Mean airway pressure and ductal shunting are two negative influences on ventricular outputs over which there is some therapeutic control.(Arch Dis Child 1996; 74: F88-F94) Keywords: cardiac output, ductus arteriosus, respiratory disease, Doppler echocardiography.A fundamental aim in intensive care of preterm infants is the maintenance of adequate and stable systemic and pulmonary perfusion. The haemodynamics of the preterm cardiovascular system are complex with the problems of the transitional circulation and changing pulmonary vascular resistance being compounded by an immature myocardium1 and shunting across the fetal channels of the ductus arteriosus and foremen ovale.2 3 Such shunting usually diverts blood left to right from the systemic back into the pulmonary circulation. For the ductus arteriosus, such shunting has been shown to 'steal' blood from the systemic circulation4; atrial shunting could have a similar effect. Occasionally these shunts are right to left and so divert blood from the pulmonary to the systemic circulation with resultant hypoxaemia. Positive pressure ventilation, often essential to maintain oxygenation, can also compromise cardiac output.5The output from each ventricle will refl...

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The Effect of Incremental Positive End-Expiratory Pressure on Right Ventricular Hemodynamics and Ejection Fraction

Cited by 123 publications

References 0 publications

The decrease of cardiac chamber volumes and output during positive-pressure ventilation

The decrease of cardiac chamber volumes and output during positive-pressure ventilation

Respiratory support for premature neonates in the delivery room: effects on cardiovascular function and the development of brain injury

Early determinants of right and left ventricular output in ventilated preterm infants.

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