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Cardiorespiratory Interactions

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Cardiorespiratory
       Interactions:
       The Heart - Lung
         Connection
Jon N. Meliones, MD, MS, FCCM
Professor of Pediatrics Duke University
Medical Director PCICU
Optimizing CRI
• Cardiorespiratory Economics
    O2: supply vs. demand
 CRI: The Heart
 CRI: The Lung
 Conventional Ventilation
 Non-Conventional Ventilation
 Clinical Applications
Cardiorespiratory
      Economics
• O2 Demand:
 O2 consumption = C. O. x (CaO2 - CvO2)
 O2 Consumption = amount of oxygen used
 for aerobic metabolism
•Failure to meet the demands
results in anaerobic metabolism
Cardiorespiratory Economics
       Optimizing CRI
     O2 delivery
 

      O2 content:  Hgb,  O2 sat,  PaO2
      cardiac output
          cardiac interventions: another talk
          pulm interventions: this talk
   O2 consumption:  patient WOB
Cardiorespiratory Interactions
           A Definition

Effects of intrathoracic pressure,
 lung volume, and gas exchange
 on:
  Cardiovascular events such as venous
   return, ventricular performance, and
   arterial outflow.
Normal Function

       LA
  RA


            LV


  RV

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Cardiorespiratory Interactions

  • 1. Cardiorespiratory Interactions: The Heart - Lung Connection Jon N. Meliones, MD, MS, FCCM Professor of Pediatrics Duke University Medical Director PCICU
  • 2. Optimizing CRI • Cardiorespiratory Economics O2: supply vs. demand  CRI: The Heart  CRI: The Lung  Conventional Ventilation  Non-Conventional Ventilation  Clinical Applications
  • 3. Cardiorespiratory Economics • O2 Demand: O2 consumption = C. O. x (CaO2 - CvO2) O2 Consumption = amount of oxygen used for aerobic metabolism •Failure to meet the demands results in anaerobic metabolism
  • 4. Cardiorespiratory Economics Optimizing CRI O2 delivery   O2 content:  Hgb,  O2 sat,  PaO2  cardiac output cardiac interventions: another talk pulm interventions: this talk   O2 consumption:  patient WOB
  • 5. Cardiorespiratory Interactions A Definition Effects of intrathoracic pressure, lung volume, and gas exchange on: Cardiovascular events such as venous return, ventricular performance, and arterial outflow.
  • 6. Normal Function LA RA LV RV
  • 7. Decreased Function QuickTime™ and a Cinepak decompressor are needed to see this picture.
  • 8. Right Ventricular Filing Effects on RV Vena Cava Positive Pressure RA Thorax Ventilation RV PA
  • 9. Systemic Venous Return (RV Preload) PSV RAP = mean systemic venous pressure PPV increases right atrial pressure Right spontaneous Atrial breathing Pressure 0 0 Max Systemic Venous Return
  • 10. Effects of PPV on Right Ventricle   es in intrathoracic pressure  C.O.   ing RV preload   ing RV afterload by  ing PVR  Best strategy for the failing RV is to limit intrathoracic pressure
  • 11. Effects of PPV on LV Filling Thoracic Pump Augmentation Lung Lung Positive LA Pressure Ventilation LV AO
  • 12. Effects of PPV on LV Afterload 100 100 AO AO LVTM=130 LVTM=70 70 Thorax 130 LV LV +30 -30 Spontaneous PPV
  • 13. Effects of PPV on Left Ventricle es in intrathoracic pressure  C.O.:   ing LV preload when low   ing LV afterload  preload when excessive (RV) effects  Best strategy for the failing LV is to utilize intrathoracic pressure to optimize preload & afterload
  • 14. Optimizing CRI  Cardiorespiratory Economics  CRI: The Heart  CRI: The Lung  The pulmonary vasculature  Conventional Ventilation  Non-conventional Ventilation  Clinical Applications
  • 15. Effect of Lung Volume on PVR Overexpansion Atelectasis PVR Total PVR Small Vessels Large Vessels FRC Lung Volume
  • 16. LA RA QuickTime™ and a Microsoft Video 1 decompressor are needed to see this picture. LV RV
  • 17. RA RV TR Jet TR Jet = 103: PRV= 103 + PRA
  • 18. Effects of of pH on PVR Effects pH on PVR *p p <0.05vs Hypoxia * < 0.05 vs * 40 * 35 PVR 30 (mmHg) 25 (l x Min) 20 15 10 5 0 Hypoxia Respiratory Metabolic Hypoxia CTL Alkalosis Alkalosis Lyrene RK, 1985
  • 19. Effects of PaCO2 on PVR pH = 7.4 PCaO2 r=0.7, P<0.05 40 2 PCaO2 r=0.11, P=ns 30 2 20 Change in 10 PVR -10 -20 -30 -20 -10 10 20 30 Change in PaCO2 Malik, 1973, J Appl Phys
  • 20. Pulmonary Vasculature • Optimize lung volume: • Avoid overexpansion / atelectasis  Avoid hypoxic vasoconstriction  Avoid hypercapnia; promote alkalosis  Neonates at ed risk for pulm HTN  Inhaled gases modify PVR
  • 21. Overdistention Exhalation 40 Over 30 Volume Expansion (mL) 20 10 Inspiration 0 0 15 30 45 Airway Pressure (cmH20)
  • 22. Overdistention and C.O. 1000 950 PEEP 5 PEEP 10 900 Cardiac 850 Output 800 750 (mL/min) 700 650 600 550 500 10 15 20 Tidal Volume (mL/kg) Cheifetz: CCM 1998
  • 23. Overdistention and PVR 5000 4500 PEEP 5 PEEP 10 PVR 4000 5 (d-sec/cm 3500 ) 5 3000 2500 2000 1500 1000 10 15 20 Tidal Volume (mL/kg)
  • 24. Overdistention  Pulmonary effects Barotrauma; pneumothroax  Cardiac effect Increased RV afterload Increased PVR Decreased cardiac output
  • 25. Intrinsic PEEP Beginning Premature initiation of of Inspiration Inspiration End of Inspiration Retained Gas Results in PEEP Termination Beginning Premature of of Termination of Exhalation Exhalation Exhalation
  • 26. Intrinsic PEEP • Expiratory gas flow continues at the end of the time allotted for exhalation. • PEEPi may lead to excessive MAP. – Pulmonary effects: • Barotrauma – Cardiac effects: • Impedance of venous return • Decreased cardiac output
  • 27. Optimizing CRI  Cardiorespiratory Economics  CRI: The Heart  CRI: The Lung  Conventional Ventilation  Non-conventional Ventilation  Clinical Applications
  • 28. Non-conventional Ventilation  HFOV  HFJV  Negative pressure ventilation  Inhaled nitric oxide
  • 29. PIP at HFOV Machine PIP at MAP Alveolus at Alveolus Delta P at Machine Delta P at MAP Alveolus at PEEP Machine at Alveolus PEEP at Machine
  • 30. HFOV  HFOV decreases cardiac output??  Traverse et al Pediatr Res. 1988.  Traverse et al. Chest. 1989.  Laubscher et al. Arch Dis Child. 1996. Theme: Cardiac output decreases with “significantly” ed MAP But, studies did not control for preload.
  • 31. Preload Augmentation PSV HFOV Right Atrial Pressure CMV 0 0 Systemic Venous ReturnMax
  • 32. HFOV and CRI: Summary Cardiac output is maintained during HFOV  In a given pt, C.O may be ed if:  MAP is “significantly” ed.  Consider volume loading  Consider inotropes  Bottom line: Oxygen delivery  If C.O. can be maintained & oxygenation is ed  Oxygen delivery will 
  • 33. High-frequency Jet Ventilation  Intermittent pulse delivery of gas  Frequency: 180 - 900  Passive exhalation  Special ETT adaptor required  Weight/size limitation (Bunnell Jet)
  • 34. HFJV 20 Volume Limited Airway Pressure HFJV 15 MAP 10 MAP 5 0.3 0.6 0.1 0.2 0.4 0.5 0
  • 35. RA LA QuickTime™ and a RV Cinepak decompressor are needed to see this picture. LV
  • 36. Effects of HFJV on CRI * p < 0.01 vs HFJV * * 10 Pre HFJV 9.4 9.4 8 Post 6 * * 4 4.6 * * 3.8 3.7 2.9 2 2.3 2.4 1.6 0 Paw PVR C.I.
  • 37. Inhaled NO  PAO2,  cGMP Oxygen A 2,  Ca++,  PVR NO Epithelial Cells Interstitium Muscle Endothelial Cells cGMP NO Injured CA++ EDRF Relaxation NO Capillary Hgb Met Hgb
  • 38. NNitric Oxide In CHD OI Miller, SF Tang, A Keech, NB Pigott, E Beller and DS Celermajer: Lancet 2000 • 126 Pts, randomized • Less Pulm HTN crisis, Less Vent Days. • No difference in mortality • Patients with passive flow, worse response, better in “small vessels” • Use lowest dose, wean daily. • Use sildenafil
  • 39. RV Dysfunction Pulmonary HTN Ventilation Manipulations • Conventional Ventilatory Strategies – MAP but maintain FRC – Alkalinize with normocapnia • Nonconventional Modes – HFJV – Negative pressure ventilation • Inhaled Medical Gases –FiO2 ( CaO2) –Nitric oxide
  • 40. LV Dysfunction • Conventional Ventilatory Strategies –Thoracic pump augmentation of LV preload (“low” ventilatory rate with “high” TV) – LV afterload MAP but maintain FRC •Nonconventional Modes –HFJV or HFOV if MAP > 15 - 20 cm H2O (optimize O2 delivery &  barotrauma) • Inhaled Medical Gases –FiO2 ( CaO2)
  • 41. Respiratory Dysfunction Ventilation Manipulations • Conventional Ventilatory Strategies –Maintain ideal lung volume –Titrate PEEP / optimize MAP –Alkalosis • Nonconventional Modes –HFOV if PAW > 15 - 20 cm H2O –(optimize O2 delivery &  barotrauma) • Inhaled Medical Gases –FiO2 ( CaO2) –Nitric oxide
  • 42. Optimizing CRI • Clinical Applications  Single Ventricle Physiology made easy….sure
  • 43. AORTA
  • 44. Single Ventricle Pulm Veins Vena Cava LA RA 65 99 LV 80 RV 80 PA AO PDA
  • 45. Causes of Systemic Desaturations • Sao2 is dependent on – 1. SmvO2 – 2. SpvO2 – 3. Volume of Pulmonary venous vs systemic venous return • Decreased oxygen delivery to the tissues – Lowering of SmvO2 i.e QS • Alveolar arterial gradient – Lowering SpvO2 • Alterations in QP/QS
  • 46. Norwood With BT Shunt Procedure: 3 1. Create unobstructed SBF outlfow to aorta = create PBF neoaorta 2. Unobstructed mixing in atrium = atrial septectomy 21 3. Stable PBF = BT shunt vs RV-PA shunt (Sano) Benefits: – Not ductal dependent – RV is systemic pump – Coronary perfusion stable Problems: – Gore-Tex doesn’t grow – Shunts clot – Still cyanotic (80%)
  • 47. Norwood With Sano Procedure: 1. Create unobstructed SBF outlfow to aorta = create 3 PBF neoaorta 2. Unobstructed mixing in atrium = atrial septectomy 3. Stable PBF = RV-PA 21 shunt (Sano) Benefits: – Not ductal dependent – RV is systemic pump and SANO may provided better function – Coronary perfusion stable Problems: – Shunts clot – Still cyanotic (and lower SaO2 vs BT shunt) – RV is still volume
  • 48. Single Ventricle Management Key Points Pulmonary Blood BT shunt Sano flow Flow occurs during Systole & Systole diastole SaO2 Higher lower Less diastolic run off No Yes and possible better ventricular function
  • 49. Qp / Qs Ratio = Ratio of Oxygen Extraction of the Systemic vs Pulmonary Bed Qp SaO2 – SmvO2 SpvO2 – SpaO2 Qs a= arterial mv= mixed venous pv= pulmonary vein pa= pulmonary artery
  • 50. Qp:Qs Ratio Since Aortic and Pulmonary Blood Flow both come from the Aorta: Aortic Sat. = Pulmonary Sat. SaO2 – SmvO2 SpvO2 – SaO2 In a SV patient: a= arterial mv= mixed venous pv= pulmonary vein
  • 51. Qp:Qs Ratio If one assumes Pulmonary Venous Sat. = 95% then: Qp:Qs = SaO2 – SmvO2 95 – SaO2 In a SV patient: Assume: SpaO2 = SaO2 SPVO2 = 95 Measure: SaO2 and SmvO2
  • 52. Qp:Qs Ratio = 1/1 Balanced Pulmonary Blood Flow 15 1 80 – 65 = = 1 15 95 – 80 In a SV patient: Assume: SpaO2 = SaO2 = 80 SPVO2 = 95 Measure: SaO2 = 80 SmvO2 = 65
  • 53. Qp:Qs Ratio = 2/1 Excessive Pulmonary Blood Flow 30 2 80 – 50 = = 1 15 95 – 80 In a SV patient: Excessive shunt flow: Increase PVR: CO2, Keep FI02 low Decrease SVR: Milrinone, Nipride
  • 54. Qp:Qs Ratio = 1 / 2 Inadequate Pulmonary Blood Flow 10 1 75 – 65 = = 2 20 95 – 75 In a SV patient: Decreased shunt flow: Decrease PVR: Lower CO2, O2 Increase SVR: Epin.
  • 55. Qp:Qs Ratio = 1/1 Balanced Pulmonary Blood Flow 35 1 60 – 25 = = 1 35 95 – 60 In a SV patient: Balanced shunt flow: Low CO Increase CO: Epin., Milrinone
  • 56. Effects of Inspired Gas on Pre-op Single Ventricle 6 Difference in DO2 5 4 3 2 1 0 Hypoxia Hypercapnea Pre Post
  • 57. What are the Key Issues for the management of a post Norwood patient? • SaO2 target is between 70-80% so keep Hgb >15 • SmvO2 target = >55 but usually common atrial line so use cerebral O2 (are they any good? Yes for trends) • Lactates are followed on all pts. If < 2.5 good. If increases > 1/hr bad sign. Keep they alive. • Chest is usually open… risk for tamponade! • The answer is always!!! Increase QT! • Steroids although no data
  • 58. Post Op Management • Balance Qp/QS (careful! Just increase the PaCO2) – Low FI02 with B-T shunt – FIO2 = 0.4 with sano – Consider adding CO2 – NEVER use hypoxia – NEVER bag with FIO2 = 1.0
  • 59. Optimizing CRI • Cardiorespiratory Economics O2: supply vs. demand  CRI: The Heart  CRI: The Lung  Conventional Ventilation  Non-Conventional Ventilation  Clinical Applications