Chest
Volume 97, Issue 5, May 1990, Pages 1181-1189
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Clinical Investigations in Critical Care
Hemodynamics During PEEP Ventilation in Patients with Severe Left Ventricular Failure Studied by Transesophageal Echocardiography

https://doi.org/10.1378/chest.97.5.1181Get rights and content

The effects of mechanical ventilation with PEEP were investigated in five patients with normal cardiopulmonary function (group A) and in 11 patients with severe left ventricular failure (group B). Cross-sectional area of the right and left atrium (RA/LA), left ventricle (LV), and right ventricle (RV) was determined at EDA/ESA using transesophageal echocardiography. Hemodynamic parameters and transesophageal pressure were measured simultaneously at PEEP levels 0, 4, 8, 12, and 16 cm H2O. End-diastolic area of the right atrium decreased significantly in both groups. The RA pressure increased, while transmural pressure remained unaltered. The CI decreased in both groups. The decrease in cardiac output by PEEP ventilation was related to the decrease in RV filling volume by external compression. In patients with congestive heart failure, PEEP ventilation with 8 to 10 cm H2O did not worsen LV function.

Section snippets

PATIENTS AND METHODS

The investigation was carried out in 16 patients divided into two groups according to cardiac function. Group A (n = 5) had normal cardiopulmonary function requiring ventilation for treatment of decreased central ventilatory drive or neuromuscular function (Table 1), and group B (n= 11) had severe left ventricular failure requiring ventilation after myocardial infarction with resuscitation (Table 2). Clinical and hemodynamic subsets were assigned according to the classification of Forrester et

RESULTS

Hemodynamic and echocardiographic results are shown in Tables 4 and 5. Figures 2A to 2C show the cross-sectional area and diameters of the left atrium and ventricle and the right ventricle in the long axis view. Examination of the heart after application of PEEP 16 cm H2O showed an acute decrease in right ventricular area and the septal lateral diameter and a displacement of the ventricular septum to the right. The left ventricular area decreased only slightly without marked change in

DISCUSSION

Echocardiography is a practical semi-invasive technique for evaluation of heart morphology and performance. The diagnostic value of the standard precordial technique is limited by thoracic deformation, obesity, emphysema, or after thoracic surgery in 20 percent to 30 percent of patients, particularly during mechanical ventilation. By contrast, the TEE transducer can be easily placed behind the heart and enables continuous evaluation of all four chambers without hindrance from lung

CONCLUSION

PEEP leads to a decrease in cardiac index, a right shift of the ventricular septum, and ventricular interdependence in the acute phase directly after application or discontinuation of PEEP These findings are primarily caused by a reduction of the right atrial and ventricular filling volume by external compression with unchanged transmural filling pressure and left ventricular contractility.

PEEP may be useful not only because of the ability to increase FRC and arterial oxygen content, but also

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This paper includes a part of the Inaugural Dissertation of Wenyan Lu.

Manuscript received May 12; revision accepted May 23.

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