Cardiovascular Issues in Respiratory Care

doi:10.1378/chest.128.5_suppl_2.592S

Chest

Volume 128, Issue 5, Supplement 2, November 2005, Pages 592S-597S

https://doi.org/10.1378/chest.128.5_suppl_2.592S Get rights and content

The hemodynamic effects of ventilation are complex but can be grouped under four clinically relevant concepts. First, spontaneous ventilation is exercise, and critically ill patients may not withstand the increased work of breathing. Initiation of mechanical ventilatory support will improve oxygen delivery to the remainder of the body by decreasing oxygen consumption. To the extent that mixed venous oxygen also increases, Pao₂ will increase without any improvement in gas exchange. Similarly, weaning from mechanical ventilatory support is a cardiovascular stress test. Patients who fail to wean also manifest cardiovascular insufficiency during the failed weaning attempts. Improving cardiovascular reserve or supplementing support with inotropic therapy may allow patients to wean from mechanical ventilation. Second, changes in lung volume alter autonomic tone and pulmonary vascular resistance (PVR), and at high lung volumes compress the heart in the cardiac fossa. Hyperinflation increases PVR and pulmonary artery pressure, impeding right ventricular ejection. Decreases in lung volume induce alveolar collapse and hypoxia, stimulating an increased pulmonary vasomotor tone by the process of hypoxic pulmonary vasoconstriction. Recruitment maneuvers, positive end-expiratory pressure, and continuous positive airway pressure may reverse hypoxic pulmonary vasoconstriction and reduce pulmonary artery pressure. Third, spontaneous inspiration and spontaneous inspiratory efforts decrease intrathoracic pressure (ITP). Since diaphragmatic descent increases intra-abdominal pressure, these combined effects cause right atrial pressure inside the thorax to decrease but venous pressure in the abdomen to increase, markedly increasing the pressure gradient for systemic venous return. Furthermore, the greater the decrease in ITP, the greater the increase in left ventricular (LV) afterload for a constant arterial pressure. Mechanical ventilation, by abolishing the negative swings in ITP, will selectively decrease LV afterload, as long as the increases in lung volume and ITP are small. Finally, positive-pressure ventilation increases ITP. Since diaphragmatic descent increases intra-abdominal pressure, the decrease in the pressure gradient for venous return is less than would otherwise occur if the only change were an increase in right atrial pressure. However, in hypovolemic states, positive-pressure ventilation can induce profound decreases in venous return. Increases in ITP decrease LV afterload and will augment LV ejection. In patients with hypervolemic heart failure, this afterload reducing effect can result in improved LV ejection, increased cardiac output, and reduced myocardial oxygen demand.

Learning Objectives

1. To review the complex physiologic interactions between the cardiovascular and respiratory systems as they apply to the critically ill patient. 2. To understand the effects of mechanical ventilation versus spontaneous respiration on cardiorespiratory responses. 3. To describe the impact of ventilator settings and weaning from mechanical ventilation on heart-lung interactions.

Section snippets

Spontaneous Ventilation Is Exercise

Although ventilation normally requires < 5% of total oxygen delivery,² in lung disease states the work of breathing is increased, such that its metabolic demand for oxygen may reach 25% of total oxygen delivery. If cardiac output also is limited, blood flow to other organs can be compromised, causing tissue hypoperfusion, ischemic dysfunction, and lactic acidosis.³ Mechanical ventilation will decrease the work of breathing, even if delivered by noninvasive ventilation mask continuous positive

Autonomic Tone

Inflation induces immediate changes in autonomic output,¹³ causing cardiac acceleration otherwise known as respiratory sinus arrhythmia,¹⁴ which implies normal autonomic responsiveness.¹⁵ Loss of respiratory sinus arrhythmia is seen in diabetic peripheral neuropathy, and its reappearance precedes the return of peripheral autonomic control.¹⁶ Lung inflation to larger tidal volumes (> 15 mL/kg) decreases heart rate by sympathetic withdrawal.¹⁷ Reflex arterial vasodilatation can also occur with

Ventilation Alters ITP

The heart is a pressure chamber within a pressure chamber. Therefore, changes in ITP will affect the pressure gradients for both systemic venous return to the RV and systemic outflow from the LV, independent of the heart. Increases in ITP, by increasing right atrial pressure and decreasing transmural LV systolic pressure, will reduce the pressure gradients for venous return and LV ejection decreasing intrathoracic blood volume. Decreases in ITP will augment venous return and impede LV ejection

Hemodynamic Effects of Ventilation Depend on Cardiopulmonary Status

A single ventilatory maneuver can have opposite cardiovascular effects in different patients. Importantly, the hemodynamic response to a specific ventilatory state may also be used to identify the cardiovascular reserve of that patient. In patients who are otherwise normal, their cardiovascular state is characterized by preload dependency. Thus, in normal subjects or those patients with hypovolemia (eg, hemorrhagic shock, severe vomiting, diarrhea, loss of vasomotor tone, spinal cord shock) and

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Patients with acute brain injury (ABI) are a peculiar population because ABI does not only affect the brain but also other organs such as the lungs, as theorized in brain–lung crosstalk models. ABI patients often require mechanical ventilation (MV) to avoid the complications of impaired respiratory function that can follow ABI; MV should be settled with meticulousness owing to its effects on the intracranial compartment, especially regarding positive end-expiratory pressure (PEEP). This scoping review aimed to (1) describe the physiological basis and mechanisms related to the effects of PEEP in ABI; (2) examine how clinical research is conducted on this topic; (3) identify methods for setting PEEP in ABI; and (4) investigate the impact of the application of PEEP in ABI on the outcome.
The five-stage paradigm devised by Peters et al. and expanded by Arksey and O'Malley, Levac et al., and the Joanna Briggs Institute was used for methodology. We also adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension criteria. Inclusion criteria: we compiled all scientific data from peer-reviewed journals and studies that discussed the application of PEEP and its impact on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in adult patients with ABI. Exclusion criteria: studies that only examined a pediatric patient group (those under the age of 18), experiments conducted solely on animals; studies without intracranial pressure and/or cerebral perfusion pressure determinations, and studies with incomplete information. Two authors searched and screened for inclusion in papers published up to July 2023 using the PubMed-indexed online database. Data were presented in narrative and tubular form.
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Effect of different levels of PEEP on mortality in ICU patients without acute respiratory distress syndrome: systematic review and meta-analysis with trial sequential analysis
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Citation Excerpt :
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The following author has indicated to the ACCP that no significant relationships exist with any company/organization whose products or services may be discussed in this article: Michael R Pinsky, MD, FCCP.

This publication was supported by an educational grant from Ortho Biotech Products. L. P.

This work was supported in part by National Institutes of Health grants HL67181, HL073198, and HL07820.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

View full text

Chest

Cardiovascular Issues in Respiratory Care

Learning Objectives

Section snippets

Spontaneous Ventilation Is Exercise

Autonomic Tone

Ventilation Alters ITP

Hemodynamic Effects of Ventilation Depend on Cardiopulmonary Status

Chest

Chest

Chest

Chest

J Crit Care

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Effects of spontaneous ventilation on the circulation

Lung

The respiratory muscles

N Engl J Med

Respiratory muscle contribution to lactic acidosis in low cardiac output

Am Rev Respir Dis

Effect of mechanical ventilation on respiratory muscle blood flow during shock [abstract]

Physiologist

Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation

Anesthesiology

Myocardial perfusion as assessed by thallium-201 scintigraphy during the discontinuation of mechanical ventilation in ventilator-dependent patients

Anesthesiology

Myocardial ischemia and weaning failure in patients with coronary artery disease: an update

Crit Care Med

Gastric intramural pH as a predictor of success or failure in weaning patients from mechanical ventilation

Ann Intern Med

Continuous recordings of mixed venous oxygen saturation during weaning from mechanical ventilation and the ramifications thereof

Am J Respir Crit Care Med

Contribution of the endotracheal tube and the upper airway to breathing workload

Am J Respir Crit Care Med

Reflex cardiovascular depression produced by stimulation of pulmonary stretch receptors in the dog

J Clin Invest

Respiratory variations of the heart rate: I. The reflex mechanism of the respiratory arrhythmia

Proc R Soc Lond B Biol Sci

Respiratory sinus arrhythmia in humans: an obligatory role for vagal feedback from the lungs

J Appl Physiol

Heart rate-respiration relationship: computerized method for early assessment of cardiac autonomic damage in diabetic patients

Acta Cardiol

Positive end-expiratory pressure ventilation elicits increases in endogenously formed nitric oxide as detected in air exhaled by rabbits

Anesthesiology

Control of the myocardial contractile state by carotid chemo- and baroreceptor and pulmonary inflation reflexes in conscious dogs

J Clin Invest

The effect of positive end-expiratory pressure on functional residual capacity: role of prostaglandin production

Am Rev Respir Dis

Cardiopulmonary effects of unilateral airway pressure changes in intact infant lambs

J Appl Physiol

Hemodynamic, gas exchange, and hormonal consequences of LBPP during PEEP ventilation

J Appl Physiol

Atrial natriuretic peptide release in response to different positive end-expiratory pressure levels

Crit Care Med

The cardiovascular effects of mechanical ventilation and positive end-expiratory pressure

JAMA

Hypoxia-induced activation in small isolated pulmonary arteries from the cat

J Appl Physiol