This document discusses hemodynamic monitoring of patients during acute respiratory distress syndrome (ARDS). It covers hemodynamic interactions between the lungs and heart during spontaneous breathing and mechanical ventilation. Positive pressure ventilation decreases venous return and right ventricular stroke volume while increasing pressures. It also discusses ventricular interdependence and the effects of PEEP and prone positioning. Tools for hemodynamic monitoring discussed include assessing afterload, contractility, the right ventricle, perfusion, preload, and preload responsiveness. Considerations for different monitoring tools like echocardiography, pulmonary artery catheters, and arterial pulse-wave analysis are provided.

2. European Society of Intensive Care Medicine
ESCIM Cardiovascular Dynamics section
ESC-Association for Acute CardioVascular Care
Hemodynamic monitorization of the
patient during ARDS
Dr. Chacón-Lozsán Francisco J. MD, MEd.
Critical Care Medicine-Venezuelan Central University
ESCIM CD section Representative Clinical Training Committee
francisco.lozsan@mkardio.hu
2022

3. Conflict of interest: None

4. Content:
• Hemodynamic Lung-Heart interactions
• Physical principles of hemodynamic
monitoring during MV.
• Tools for monitorization

5. Hemodynamic Lung-Heart interactions
Spontaneous breathing on venous return and RV.
Ann Transl Med 2018;6(18):348. DOI: 10.21037/atm.2018.06.19
Spontaneous inspiration
Decrease pleural pressure
Pleural pressure < RAP
Increase venous return
Increases RV SV

6. Hemodynamic Lung-Heart interactions
Spontaneous breathing on LV.
Ann Transl Med 2018;6(18):348. DOI: 10.21037/atm.2018.06.19
Spontaneous inspiration
->Decrease pleural pressure
Transmitted to art. Pressure -> ↑BP
↑LV ejection pressure -> ↑afterload
↑ LV isovolumetric contraction
↓LV Stroke volume

7. Hemodynamic Lung-Heart interactions
Mechanical ventilation.
Swiss Med Wkly. 2017 Sep 12;147:w14491. doi: 10.4414/smw.2017.14491.
Positive pressure MV
Increase pleural pressure
Pleural pressure > RAP
Decreases venous return
Decreases RV SV

8. Hemodynamic Lung-Heart interactions
Mechanical ventilation.
Denault, A. Y., Gorcsan, J., & Pinsky, M. R. (2001). Dynamic effects of positive-pressure ventilation on canine left ventricular pressure-volume relations.
Journal of Applied Physiology, 91(1), 298–308. doi:10.1152/jappl.2001.91.1.298
Spontaneous inspiration
->increases pleural pressure
Transmitted to art. Pressure -> ↓BP
↓LV ejection pressure ->
↓afterload
↓LV isovolumetric contraction
↑LV Stroke volume

9. Hemodynamic Lung-Heart interactions
Mechanical ventilation. PEEP and hemodynamics
Das, A., Haque, M., Chikhani, M., Wang, W., Ali, T., Cole, O., … Bates, D. G. (2015). Development of an integrated model of cardiovascular and
pulmonary physiology for the evaluation of mechanical ventilation strategies. 2015 37th Annual International Conference of the IEEE Engineering in
Medicine and Biology Society (EMBC). doi:10.1109/embc.2015.7319592
↓RV EDV
↓RV ESV
↓ RV SV
↑ RAP
↑ PVR
↓LV EDV
↓LV ESV
↓ LV SV
↓ LV afterload

10. Hemodynamic Lung-Heart interactions
Ventricular interdependence
Pinsky. Dynamic right and left ventricular interactions in the pig. DOI 10.113/EP088550
Ann Transl Med 2018;6(18):353. DOI: 10.21037/atm.2018.04.40
“Ventricular interdependence implies that changes in intrathoracic pressure and lung
volume occurring in one ventricle simultaneously influence the performance of the other”.
RV pressures
Diastolic RV to LV
interdependence
 LV diastolic
compliance dependent
of an intact pericardium
LV End systolic
pressure
 RV End systolic
elastance
With minimal effect on
RV diastolic function or
contraction synchrony

11. Hemodynamic Lung-Heart interactions
Madhivathanan, P. R., Corredor, C., & Smith, A. (2020). Perioperative implications of pericardial effusions and cardiac tamponade. BJA Education, 20(7), 226–234.
doi:10.1016/j.bjae.2020.03.006

12. Hemodynamic Lung-Heart interactions
Ruste, M., Bitker, L., Yonis, H., Riad, Z., Louf-Durier, A., Lissonde, F., … Richard, J.-C. (2018). Hemodynamic effects of extended prone position sessions in
ARDS. Annals of Intensive Care, 8(1). doi:10.1186/s13613-018-0464-9
WAIT! And what about prone position?

13. Good Perfusion
VO2
CaO2-CvO2 CO
DO2
CO
HR SV
Preload
(CVP, IVC, LVEDA,
RVEDA)
Contractility
(CPI, EF)
Afterload
(SVR,
elastance)
CaO2
Hb PaO2 SO2
Physical principles of hemodynamic monitoring
BALANCE

14. Tools for monitorization
Variable Parameters Considerations
Afterload 1. Diastolic pressure
2. SVR
3. Dynamic arterial
elastance
1. Good correlation with LV afterload.
2. Classic afterload parameter, but reflects not the LV afterload
but the entire system resistance
3. Helps also to guide vasopressor dose reduction/initiation.
Contractility 1. CO and CI
2. CPI
3. LVEF
1. Can be measured by TPT, TTE
2. Better parameter for cardiac systolic function
3. Helps to follow up, easy to assess by TTE
Right ventricle
(please don’t forget it)
1. TAPSE
2. FAC
3. RV/LV diameter
4. TAPSE/PASP
1. Easy to do using TTE
2. Good correlation with RV systolic function
3. Good predictor of RV failure
4. Good predictor of mortality for RV failure
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

15. Tools for monitorization
Variable Parameters Considerations
Perfusion 1. MAP
2. NIRS
3. Urine output
4. Lactate
5. SvO2/SvcO2
6. CRT/skin mottling
1. MAP is a product of total CO and SVR. As MAP increases
are related to increases in afterload, balances between the
effects of increased afterload and adequate tissue perfusion
should be weighed.
2. Helps monitoring cerebral and low extremities perfusion
3. Needs hourly evaluation in order to observe early changes
and give therapy, in places with low personal its hard to do it.
4. Level changes helps monitoring therapy response
5. Difficult to interpret, pCO2 gap and detailed invasive
hemodynamic monitoring may serve as complementary tools
to assess the hemodynamic status
6. Bedside, may predict poor outcome.
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

16. Tools for monitorization
From Pinsky, M. R., Teboul, J.-L., & Vincent, J.-L. (Eds.). (2019). doi:10.1007/978-3-319-69269-2

17. Tools for monitorization
Variable Parameters Considerations
Preload 1. CVP
2. RVEDA or LVEDA
3. IVC
1. Static barometric parameter, needs to be observed
over time to stablish reference range and follow
up.
2. In absence of GEDV, using TTE, TEE its very good
tool.
3. May give false negatives at high PEEP
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186
Wagner and Leatherman. Chest 1998; 133: 1048-1054

18. Tools for monitorization
Variable Parameters Considerations
Preload
responsiveness
(VR)
1. PPV, SVV
2. IVCDV
3. PLR
4. End-expiratory
occlusion
maneuver
(EEOM)
1. May loss ability to prediction in low tidal volume
but can be indexed by variation of transpulmonary
pressure.
2. May loss ability to predict VR at high PEEP values
3. Really good and easy to do, not helpful in patients
with increased intracranial pressure
4. Patients must tolerate a 15 second pause in
ventilation. May be invalid at a tidal volume <6
mL/kg.
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

19. Tools for monitorization
Cut-offs and “Grey Zones” for Parameters
Chacón-Lozsán Francisco, Mesquida Jaume. ESICM Sepsis and septic shock ACE Course 2021

20. Tools for monitorization
Variable Considerations
Pulmonary artery
catheter (PAC)
• Allows PAOP, SvO2, PVR, SVR and RV CO
• With high PEEP, calculating the transmural value of PAOP
allows estimation of true LV filling pressure
Transpulmonary
thermodilution (TPTD)
• You can measure EVLW plus SvO2, PVR, GEDI, PPV, SVV,
LV CO in real time
• We forget the RV
Arterial pulse-wave
analysis (APWA)
• APWA systems become unreliable when major
hemodynamic or vasomotor tone changes exist.
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

21. Tools for monitorization
Variable Considerations
Echocardiography • Non invasive
• Measures CO and CI by VTI at LVOT, SVV, LVOT ∆Vmax
• Preload by RVEDV, LVEDV
• RV function
• Combined with LUS we can estimate Pulm. oedema
• Only intermittent measurements
• High operator dependency
• TTE depends on good acoustic window, TEE can be more
invasive
• No possible in prone position
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

22. Tools for monitorization
Vieillard-Baron, A., Matthay, M., Teboul, J. L., Bein, T., Schultz, M., Magder, S., & Marini, J. J. (2016). Experts’ opinion on management of hemodynamics in ARDS
patients: focus on the effects of mechanical ventilation. Intensive Care Medicine, 42(5), 739–749. doi:10.1007/s00134-016-4326-3

23. And still this is just watching
by the keyhole…

24. Francisco J. Chacón-Lozsán, MD, MEd
http://ve.linkedin.com/in/chaconlozsanfrancisco
francisco.lozsan@mkardio.hu
Thanks for your attention
Gracias por su atención
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