Does Positive End-Expiratory Pressure Ventilation Improve Left Ventricular Function?: A Comparative Study by Transesophageal Echocardiography in Cardiac and Noncardiac Patients

doi:10.1378/chest.114.2.556

Chest

Volume 114, Issue 2, August 1998, Pages 556-562

https://doi.org/10.1378/chest.114.2.556 Get rights and content

Study objectives

Positive end-expiratory pressure (PEEP) has been proposed to improve cardiac output in patients with left ventricular (LV) dysfunction. This study was designed to compare quantitative global and regional LV performance in response to PEEP in patients with normal and poor LV function.

Design

A prospective clinical trial.

Setting

Adult medical ICU in a university hospital.

Patients

Twelve critically ill patients requiring respiratory support and divided into two groups according to baseline transesophageal echocardiographic (TEE) measurements: normal LV dimensions and fractional area of contraction (FAC=61 ±5%) (n=7) and dilated cardiomyopathy with reduced FAC (21±1%) (n=5).

Measurements and results

All patients were studied when two successive levels of PEEP (best PEEP as the highest value of respiratory compliance and high PEEP as best PEEP+10 cm H₂O) were applied. Global systolic LV performance and quantitative regional wall motion analysis performed by the centerline method were assessed on the TEE transgastric short-axis view. End-systolic wall stress (ESWS) was used as a reliable indication of LV afterload. PEEP reduced LV dimensions asymmetrically in both groups of patients and septolateral diameter significantly decreased without affecting global LV systolic performance. Additionally, high PEEP produced a significant impairment in septal kinetics as evidenced by the centerline method. High PEEP also decreased ESWS for all patients (—27% in normal group and −23% in cardiac group, p<0.05) without significant improvement in global systolic LV performance (FAC: +2% in normal group and +0% in cardiac group; not significant).

Conclusions

PEEP cannot be recommended routinely to improve LV performance in patients with severe dilated cardiomyopathy.

Section snippets

Patients

Twelve critically ill patients (mean age, 62 years) who required continuous mechanical ventilation with PEEP for acute hypoxemic respiratory failure (PaO₂/fraction of inspired oxygen <200 mm Hg) were studied. Respiratory failure resulted from extensive bacterial pneumonia in two cases, acute exacerbation of COPD in five cases, and cardiogenic pulmonary edema in five cases (Table 1). Patients were divided into two groups according to baseline left ventricular echocardiographic measurements:

Results

Clinical data and outcome in both groups of patients are indicated in Table 1. Baseline left ventricular two-dimensional echocardiographic data (short-axis view) in both groups are indicated in Table 2 (ZEEP column). Whereas patients in group 1 had left ventricular dimensions and FAC in a normal range, patients in group 2 had a dilated left ventricle with reduced FAC.

The best PEEP level for the whole group was 9.6±0.2 cm H₂O, resulting in an average increase in pleural pressure of 3.3±0.2 mm Hg

Discussion

Changes in pleural pressure have been shown to influence left ventricular afterload. Indeed, a negative pleural pressure increases the left ventricular afterload14, 15 while a positive pleural pressure decreases it.4, 16 In the present study, the increase in pleural pressure induced by two successive levels of PEEP was slight and probably trivial in terms of afterload changes in patients with normal left ventricular function. However, it might be significant in cardiac patients because a

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Cited by (28)

Hemodynamic effects of positive end-expiratory pressure during abdominal hyperpression: A preliminary study in healthy volunteers
2012, Journal of Critical Care
Citation Excerpt :
First, we did not measure either intra-abdominal or pleural pressures, so we do not know in what extent our MAST and PEEP load challenges could have influenced the pressure gradient. We previously showed that the mean increase in pleural pressure induced by a moderate PEEP was slight and probably trivial in terms of afterload changes in mechanically ventilated patients with normal left ventricular function [8]. It might, however, be significant in cardiac patients because a dilated ventricle is more sensitive to small afterload changes [14].
An increase in abdominal pressure induces an increase in left ventricular afterload under clinical conditions. We tested the hypothesis that positive end-expiratory pressure (PEEP) could reverse the hemodynamic consequences of abdominal hyperpression by opposing the increase in left ventricular afterload.
Eight healthy volunteers were investigated during 3 experimental conditions: (1) baseline, (2) increase in abdominal pressure by means of medical antishock trousers (MAST) inflation, and (3) addition of PEEP +10 cm H₂O. Heart loading conditions and left ventricular systolic and diastolic function were assessed by transthoracic echocardiography.
The application of PEEP significantly reduced the prior increase in end-systolic wall stress: 45 ± 11 vs 55 ± 14 kdyn/cm², P < .05. Medical antishock trousers inflation significantly altered the deceleration time of mitral E wave: 199 ± 23 vs 156 ± 38 milliseconds, P < .05. Left ventricular preload and global systolic performance were unaffected by MAST and PEEP applications.
The increase in left ventricular afterload induced by MAST inflation can be efficiently reduced by the use of a moderate PEEP. Potential clinical applications in the abdominal compartment syndrome or in the setting of laparoscopic surgery should be developed.
Abnormal septal motion affects early diastolic velocities at the septal and lateral mitral annulus, and impacts on estimation of the pulmonary capillary wedge pressure
2005, Journal of the American Society of Echocardiography
Abnormal motion of the interventricular septum (ASM), seen post cardiac operation, with left bundle branch block or right ventricular pacing, may affect septal mitral annular motion and correlation of the ratio between the velocity of early diastolic mitral inflow and the early diastolic mitral annular velocity (E/Ea) with pulmonary capillary wedge pressure (PCWP). We examined the effect of ASM on the relationship between E/Ea and E/Vp (propagation velocity of mitral inflow) ratios and PCWP in adult patients in the intensive care unit (14 with normal septal motion [NSM], 36 with ASM) undergoing echocardiography and pulmonary artery catheterization. E/Ea correlated well with PCWP during NSM (r = 0.86 lateral annulus, r = 0.75 septal annulus), but poorly during ASM (r = 0.36 lateral annulus, r = 0.39 septal annulus). E/Vp correlated poorly with PCWP (r = 0.05 NSM, r = 0.17 ASM). For patients who are critically ill, E/Vp ratios poorly estimate PCWP. During NSM, E/Ea ratios measured at the lateral or septal annulus correlate well with PCWP. ASM affects E/Ea ratios at both the septal and lateral annulus, making E/Ea ratios unreliable for estimating PCWP in this group.
Left ventricular regional wall motion abnormalities during pneumoperitoneum in children
2003, British Journal of Anaesthesia
Citation Excerpt :
In another investigation in mechanically ventilated patients with acute respiratory failure, application of PEEP of 16 cm H2O resulted in a marked reduction in systolic septal wall motion and hyperkinesia of the lateral wall.2 An explanation postulated for these findings is a non-uniform transmission of the increased intrathoracic pressure to the LV wall because of its proximity to the pleural space.3 The mechanism by which pneumoperitoneum induces regional wall motion abnormalities is most likely similar to that of PEEP.
In adult patients, certain levels of PEEP (16 and 20 cm H₂O) have been associated with left ventricular (LV) regional wall motion abnormalities. Since any increase in intra-abdominal pressure (IAP) exerted by a pneumoperitoneum is transmitted to the intrathoracic cavity, similar effects on LV regional wall motion cannot be ruled out.
To investigate the effects of pneumoperitoneum on LV regional wall motion, we performed a post hoc analysis of a transoesophageal echocardiography study in eight small children (mean age 3 yr, range 15–63 months) undergoing laparoscopic herniorrhaphy under anaesthesia with sevoflurane in nitrous oxide/oxygen and a PEEP of 5 cm H₂O. During carbon dioxide insufflation, end-tidal carbon dioxide concentration was kept constant by increasing minute volume.
An IAP of 12 mm Hg caused significant septal hypokinesia compared with baseline, while anterior and posterior wall motion was not affected. In addition, a lateral hyperkinesia occurred, though this change was not statistically significant.
Pneumoperitoneum may affect LV regional wall motion in paediatric patients undergoing laparoscopic surgery.
Patient characteristics of acute myocardial infarction in mechanical ventilation. Data from Spanish registry ARIAM
2001, Revista Espanola de Cardiologia
Aunque la ventilación mecánica se utiliza con relativa frecuencia en el manejo del infarto agudo de miocardio, no existe suficiente información sobre su empleo y la evolución de los pacientes tratados con esta técnica.
Estudio de cohorte histórica sobre pacientes con infarto agudo de miocardio, incluidos en la base de datos ARIAM. Se comparan las diferencias en las características clínicas y el pronóstico de los pacientes tratados con o sin ventilación mecánica.
De los 4.143 casos de infarto agudo de miocardio estudiados, 335 (8,1%) fueron sometidos a ventilación mecánica. Los pacientes con ventilación mecánica eran de mayor edad, en su mayoría mujeres, tenían con más frecuencia infarto de miocardio previo, infartos de localización anterior, Killip III o IV y mayor mortalidad. Además, tenían con más frecuencia diabetes e hipertensión arterial. La mortalidad fue del 65,7% en los pacientes con ventilación mecánica frente al 5,1% en los no ventilados. El análisis multivariante demostró que las concentraciones de creatinfosfocinasa superiores a 1.200 unidades, grados Killip III y IV y localización del infarto distinta a inferior fueron factores asociados independientes de necesidad de la técnica. De los 220 casos sometidos a ventilación mecánica que fallecieron, la edad, el porcentaje de sexo femenino, la estancia en la unidad coronaria y el porcentaje de grado Killip IV fue superior, mientras que el porcentaje de grado Killip III era mayor en los supervivientes. El análisis multivariante de los casos sometidos a ventilación mecánica demostró únicamente el grado Killip III como factor explicativo independiente de supervivencia (odds ratio mortalidad 0,26; IC del 95%: 0,09-0,77).
En un número relevante de casos de infarto agudo de miocardio complicado es preciso aplicar ventilación mecánica, asociándose a una mortalidad muy elevada relacionada con una mayor extensión miocárdica y una peor situación clínica.
Scarce information is available about the use, clinical course and follow-up of patients with acute myocardial infarction treated with mechanical ventilation.
Historical cohort study of patients with acute myocardial infarction, included in Spanish registry ARIAM. Differences in clinical characteristics and prognosis from patients treated with or without mechanical ventilation were compared.
Three hundred and thirty-three of the 4143 patients (8.1%) with acute myocardial infarction were treated with mechanical ventilation. Treated patients were older, more frequently female, and had more frequently reinfarcts, anterior infarction, Killip III and IV, and higher creatine phosphokinase peak. Diabetes and high blood pressure were more frequent in those in which the technique was applied. They had a higher mortality at the coronary care unit (65.7 vs 5.1%; p < 0.001) than the non-ventilated patients. In multivariate analysis, creatine phosphokinase peak levels higher than 1.200 units/ml, Killip III and IV, and an infarction localization different to inferior were independent predictors of mechanical ventilation application. The 220 treated patients who died were older, more frequently female, had been more frequently admitted to the coronary unit, and had Killip IV whereas Killip III was more frequent among survivors. In multivariate analysis, restricted to patients treated with mechanical ventilation, Killip III was an independent predictor of survival with an odds ratio for mortality of 0.26 (CI 95%: 0.09-0.77).
Mechanical ventilation is a vital support technique employed in a significant number of complicated acute myocardial infarction patients. The high mortality of these patients was related to more extended myocardial infarction and a worse clinical state.
Noninvasive assessment of cardiac index in healthy volunteers: A comparison between thoracic impedance cardiography and doppler echocardiography
2009, Anesthesia and Analgesia
Thoracic bioimpedance cardiography (ICG) has been proposed as a noninvasive, continuous, operator-independent, and cost-effective method for cardiac output monitoring. In the present study, we compared cardiac index (CI) measurements with ICG (Niccomo™ device) and transthoracic Doppler echocardiography in resting healthy volunteers undergoing hemodynamic load challenge.
Twenty-five healthy volunteers (7 men and 18 women, mean age 36 ± 6 yr, body surface area 1.75 ± 0.17 m²) were investigated during three experimental conditions: baseline, positive end-expiratory pressure + 10 cm H₂O and lower body positive pressure by means of medical antishock trousers inflated to 30 cm H₂O in the abdominal compartment.
ICG signal quality was >89% over all sets of measurements. A weak but significant relationship was observed between CI_TTE and CI_ICG (r = 0.36; P = 0.002). Agreement between both techniques was 0.94 L · min⁻¹ · m⁻² (95% CI: 0.77–1.11), limits of agreement were −0.47 to 2.35 L · min⁻¹ · m⁻², and percentage error was 53%. No statistically significant relationships were found between percent changes in CI_TTE and CI_ICG after applications of positive end-expiratory pressure + 10 cm H₂O (r = 0.21; P = 0.31) and medical antishock trousers (r = 0.22; P = 0.30).
Poor correlation and lack of agreement between absolute values of CI measured by ICG and transthoracic Doppler echocardiography were found in resting healthy volunteers. The Niccomo device was also unreliable for monitoring changes in CI during hemodynamic load challenge.
Increasing Levels of Positive End-expiratory Pressure Cause Stepwise Biventricular Stroke Work Reduction in a Porcine Model
2024, Anesthesiology

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Chest

Clinical Investigations In Critical CareDoes Positive End-Expiratory Pressure Ventilation Improve Left Ventricular Function?: A Comparative Study by Transesophageal Echocardiography in Cardiac and Noncardiac Patients

Study objectives

Design

Setting

Patients

Measurements and results

Conclusions

Section snippets

Patients

Results

Discussion

Chest

Chest

Hemodynamic responses to mechanical ventilation with PEEP: the effect of hypervolemia

Anesthesiology

Changes in canine left ventricular size and configuration with positive end-expiratory pressure

Circ Res

Influence of positive end-expiratory pressure on left ventricular performance

N Engl J Med

Determinants of cardiac augmentation by elevations in intrathoracic pressure

J Appl Physiol

PEEP does not depress left ventricular function in patients with pulmonary edema

Am Rev Respir Dis

Cardiac performance in response to PEEP in patients with cardiac dysfunction

Crit Care Med

Hemodynamic response to changes in ventilatory patterns in patients with normal and poor left ventricular reserve

Crit Care Med

Effects of nitroprusside on venous return and central blood volume in the absence and presence of acute heart failure

Circulation

Noninvasive determination of left ventricular end-systolic stress: validation of the method and initial application

Circulation

Systemic vascular resistance: an unreliable index of left ventricular afterload

Circulation

Clinical Investigations In Critical Care
Does Positive End-Expiratory Pressure Ventilation Improve Left Ventricular Function?: A Comparative Study by Transesophageal Echocardiography in Cardiac and Noncardiac Patients