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
Decreased Function

QuickTime™ and a
Cinepak decompressor
are needed to see this picture.
 Right Ventricular Filing
Effects on RV
Vena Cava
Positive
RA Pressure
Thorax RV Ventilation

PA
 Systemic Venous Return
(RV Preload)
PSV RAP = mean systemic venous pressure

PPV increases
right atrial pressure
Right
Atrial spontaneous
Pressure breathing

0
0 Max
Systemic Venous Return
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
Effects of PPV on LV Filling
Thoracic Pump Augmentation

Lung Lung
LA Positive
Pressure
Ventilation
LV

AO
Effects of PPV on LV Afterload
100 100
AO AO

LVTM=130 LVTM=70

130 Thorax 70
LV LV

-30 +30
Spontaneous PPV
 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
 Optimizing CRI
 Cardiorespiratory Economics
 CRI: The Heart
 CRI: The Lung
 The pulmonary vasculature
 Conventional Ventilation
 Non-conventional Ventilation
 Clinical Applications
Effect of Lung Volume on PVR
Overexpansion

PVR Atelectasis
Total PVR
Small Vessels
Large Vessels
FRC
Lung Volume
RA LA
QuickTime™ and a
Microsoft Video 1 decompressor
are needed to see this picture.

LV
RV
 RA

RV

TR Jet
TR Jet = 103: PRV= 103 + PRA
 Effects
Effects of of
pHpH
onon PVR
PVR
* p* p<<0.05 vsHypoxia
0.05 vs
40
35
* *
PVR 30
(mmHg) 25
(l x Min) 20
15
10
5
0
CTL Hypoxia Respiratory Metabolic Hypoxia
Alkalosis Alkalosis
Lyrene RK, 1985
 Effects of PaCO2 on PVR
pH = 7.4
PCaO22
r=0.7, P<0.05 40
PCaO22
r=0.11, P=ns 30
20
Change in 10
PVR
-10
-20
-30 -20 -10 10 20 30
Malik, 1973, J Appl Phys Change in PaCO2
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
 Overdistention
Exhalation
40
30 Over
Volume Expansion
(mL) 20
10 Inspiration

0
0 15 30 45
Airway Pressure (cmH20)
 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
Cheifetz: CCM 1998 Tidal Volume (mL/kg)
 Overdistention and PVR
5000

4500 PEEP 5 PEEP 10

PVR 4000
55 3500
(d-sec/cm )
3000
2500

2000

1500

1000
10 15 20
Tidal Volume (mL/kg)
 Overdistention

 Pulmonary effects
Barotrauma; pneumothroax
 Cardiac effect
Increased RV afterload
Increased PVR
Decreased cardiac output
 Intrinsic PEEP
Beginning
of Premature initiation
Inspiration of Inspiration
End
of
Inspiration

Retained Gas
Results in PEEP

Beginning Termination
of of Premature
Exhalation Exhalation Termination of
Exhalation
 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
 Optimizing CRI
 Cardiorespiratory Economics
 CRI: The Heart
 CRI: The Lung
 Conventional Ventilation
 Non-conventional Ventilation
 Clinical Applications
Non-conventional Ventilation

 HFOV
 HFJV
 Negative pressure ventilation
 Inhaled nitric oxide
 PIP
at
Machine HFOV
PIP
at MAP
Alveolus at
Alveolus
Delta P
at
Machine
Delta P
MAP at
at Alveolus
Machine PEEP
at
Alveolus

PEEP
at
Machine
 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.
 Preload Augmentation
PSV

HFOV
Right Atrial
Pressure CMV

0
0
Systemic Venous ReturnMax
 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 
High-frequency Jet Ventilation

 Intermittent pulse delivery of gas

 Frequency: 180 - 900
 Passive exhalation
 Special ETT adaptor required
 Weight/size limitation (Bunnell Jet)
 HFJV
20
Volume
Limited
Airway Pressure

15 HFJV
MAP
10
MAP
5

0 0.1 0.2 0.3 0.4 0.5 0.6

 RA LA

QuickTime™ and a
RV Cinepak decompressor
are needed to see this picture.

LV
 Effects of HFJV on CRI
* p < 0.01 vs HFJV
* *
10 Pre
9.4 HFJV
8 9.4 Post
6
* *
4 4.6 *
*
3.8 3.7
2 2.9
2.3 2.4
1.6
0
Paw PVR C.I.
 Inhaled NO
 PAAO2,2,  cGMP Oxygen
 Ca++,  PVR NO
Epithelial Cells
Interstitium
Endothelial Cells Muscle
NO cGMP
Injured
CA++
EDRF
NO Relaxation

Hgb Capillary
Met Hgb
 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
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
 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)
 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
 Optimizing CRI
• Clinical Applications
 Single Ventricle
Physiology made
easy….sure
AORTA
 Single Ventricle

Vena Cava Pulm Veins

RA LA
65 99

80 LV
RV

PA 80 AO
PDA
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
Norwood With BT Shunt
Procedure:
3 1. Create unobstructed
SBF
outlfow to aorta = create
PBF neoaorta
2. Unobstructed mixing in
atrium = atrial
septectomy
2 1 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%)
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
2 1 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
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
 Qp / Qs Ratio =
Ratio of Oxygen Extraction of the
Systemic vs Pulmonary Bed

Qp SaO2 – SmvO2

Qs SpvO2 – SpaO2

a= arterial
mv= mixed venous
pv= pulmonary vein
pa= pulmonary artery
 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
 Qp:Qs Ratio
If one assumes Pulmonary
Venous Sat. = 95% then:
Qp:Qs =
SaO2 – SmvO2
In a SV patient: 95 – SaO2
Assume:
SpaO2 = SaO2
SPVO2 = 95

Measure:
SaO2 and SmvO2
 Qp:Qs Ratio = 1/1
Balanced Pulmonary Blood
Flow

80 – 65 15 1
= = 1
95 – 80 15
In a SV patient:
Assume:
SpaO2 = SaO2 = 80
SPVO2 = 95
Measure:
SaO2 = 80
SmvO2 = 65
 Qp:Qs Ratio = 2/1
Excessive Pulmonary Blood
Flow

80 – 50 30 2
= = 1
95 – 80 15
In a SV patient:
Excessive shunt flow:
Increase PVR: CO2, Keep FI02 low
Decrease SVR: Milrinone, Nipride
 Qp:Qs Ratio = 1 / 2
Inadequate Pulmonary Blood
Flow

75 – 65 10 1
= = 2
95 – 75 20
In a SV patient:
Decreased shunt flow:
Decrease PVR: Lower CO2, O2
Increase SVR: Epin.
 Qp:Qs Ratio = 1/1
Balanced Pulmonary Blood
Flow

60 – 25 35 1
= = 1
95 – 60 35
In a SV patient:
Balanced shunt flow: Low CO
Increase CO: Epin., Milrinone
 Effects of Inspired Gas on
Pre-op Single Ventricle
6
Difference in DO2

0
Hypoxia Hypercapnea
Pre Post
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
 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

 Optimizing CRI
• Cardiorespiratory Economics
O2: supply vs. demand
 CRI: The Heart
 CRI: The Lung
 Conventional Ventilation
 Non-Conventional Ventilation
 Clinical Applications