prof. jean-louis teboul medical icu bicetre hospital university paris south france challenge in...
TRANSCRIPT
Prof. Jean-Louis TEBOUL
Medical ICUBicetre hospital
University Paris SouthFrance
Challenge in Right Heart Failure
1- In case of acute RV failure, fluid infusion may decrease CO
3- In case of MV with PEEP, fluid infusion may increase CO
through an increase in systemic venous return (RV preload effect)
2- In case of acute RV failure, fluid infusion may increase CO
4- In case of MV with PEEP, fluid infusion may increase CO
through a beneficial effect on PEEP-induced RV dysfunction
(RV afterload effect)
• Acute pulmonary embolism
Major causes of acute RV failure
in critically ill patients
• Sepsis-induced myocardial dysfunction
• RV failure secondary to ARDS
• Deleterious effects of MV
Challenge in acute RV failure
Fluid administration
and
RV failure
preload responsiveness
preload unresponsiveness
Stroke Volume
Ventricular preload
If RV is dilated, fluid infusion → no increase in RV stroke volume
RV end diastolic volume
RV end diastolic pressure
AB
C
D
If RV is dilated, fluid infusion → large increase in RV EDP
RV LV RV LV
Biventricular interdependence → decrease in LV stroke volume
If RV is dilated, fluid infusion → no increase in RV stroke volume
If RV is dilated, fluid infusion → large increase in RV EDP
Fluid infusion not only does not increase but can even decrease CO
1- Inadequate (low) RV preload can be responsible for low CO
in case of acute RV failure such as pulmonary embolism
Fluid infusion not only does not increase but can even decrease CO
But
Hemodynamic effects of fluid loading in acute massive pulmonary embolism
Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors
Critical Care Medicine 1999; 27: 540-544
Hemodynamic effects of fluid loading in acute massive pulmonary embolism
Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors
Critical Care Medicine 1999; 27: 540-544
r = 0.89
Fluid responders had lower RVEDI
RAP cannot be used for identifying pts
who can benefit from fluid influsion
Hemodynamic effects of fluid loading in acute massive pulmonary embolism
Alain Mercat, Jean-Luc Diehl, Guy Meyer, Jean-Louis Teboul, Herve Sors
Critical Care Medicine 1999; 27: 540-544
1- Inadequate (low) RV preload can be responsible for low CO
in case of acute RV failure such as pulmonary embolism
Fluid infusion not only does not increase but can even decrease CO
But
2- In case of MV, more complex relationships between the effects
of fluid infusion and the right ventricle
• Mechanical insufflation and the RV
Mechanical ventilation and the right ventricle
• PEEP and the RV
Mechanical insufflation and venous return
Mechanical insufflation and RV
Pabd
PRA
Pms PRA – Pms
Palv
Pit
PRA
Pra1 Pra2
Effects of cyclic increase in intrathoracic pressure
Pms1 Pms2
Increased PIT Increased Pabd
venous returnCardiac output or
CO1CO2
PRA
Pra1 Pra2
Effects of cyclic increase in intrathoracic pressure
Pms1 Pms2
Increased PIT Increased Pabd
venous returnCardiac output or
CO1CO2
Pms3
Fluids
Mechanical insufflation and RV ejection
Mechanical insufflation and venous return
• Pulmonary vascular resistance and lung volume
Mechanical insufflation and RV
extra-alveolar vessels
intra-alveolar vessels
high lung volume
lung volume
Lung volume
improves the RV ejection
by decreasing resistance of extra-alveolar vessels
Lung volume
RV FRC TLC
PVR
extra-alveolar vessels
Palv
Lung volume
improves the RV ejection
by decreasing resistance of extra-alveolar vessels
impedes the RV ejection
by compressing the
intra-alveolar vessels
Transpulmonary pressure
Pit
Ptranspulm
= Palv - Pit
Lung volume
RV FRC TLC
PVR
extra-alveolar vessels
intra-alveolar vessels
Lung volume
RV FRC TLC
PVR
Mechanical insufflation and RV ejection
Mechanical insufflation and venous return
• Pulmonary vascular resistance and lung volume
• Pulmonary vascular resistance and West’s zones
Mechanical insufflation and RV
Zone 1
Zone 2
Zone 3
PalvPPA
PPA
PPA
PPV
PPV
PPV
Palv
Palv
Palv > PPA > PPV
PPA > Palv > PPV
PPA > PPV > Palv
PVR
up
bottom
Zone 3
Lung volumesRV FRC TLC
PVR
extra-alveolar vessels
intra-alveolar vessels
Zone 1
Zone 2
Zone 3
Zone 1 Zone 2
Zone 1
Zone 2
Zone 3
PalvPPA
PPA
PPA
PPV
PPV
PPV
Palv
Palv
Palv > PPA > PPV
PPA > Palv > PPV
PPA > PPV > Palv
PVR
bottom
up
Hypovolemia favors zones 1 and 2 by reducing intravascular pressures
Reduced central blood volume
should amplify
the deleterious impact of MV
on RV afterload and RV function
*
*
**
**
*
*
RV
RA
LVACP defined
as RVEDA/LVEDA > 0.6
and septal dyskinesia
Incidence of ACP: 25%
Crit Care Med 2001, 29:1551-1555
ARDS with protective ventilation (Pplat < 30 cm H2O)
Definition of acute cor pulmonale
• mean PAP > 25 mmHg
• RAP > PAOP
• Stroke Index < 30 mL/m2
145 ARDS pts with PAC
with lung protective ventilation
10%
90%
ACP +
ACP -
145 ARDS patients
with lung protective ventilation
Reduction of transpulmonary pressure
using ventilatory strategies
aimed at limiting plateau pressure,
is associated with
high reduction of incidence and severity
of acute cor pulmonale during ARDS
• Mechanical insufflation and RV
• PEEP and RV
PEEP and venous return
Mechanical ventilation and the right ventricle
PRA
Venous return
Pra1 Pra2 Pms Pms2
Increased PIT Increased Pabd
By increasing ITPPEEP should decrease venous return
and thus cardiac output
CO1CO2
• Mechanical insufflation and RV
• PEEP and RV
PEEP and venous return
PEEP and RV ejection
Mechanical ventilation and the right ventricle
Lung volume
RV FRC TLC
PVRIf PEEP overdistends lung
and increases the end-expiratory volume
above theoretical FRC,
PVR should increase
Lung volume
RV FRC TLC
PVRIf PEEP recruits lung units
and increases the end-expiratory
lung volume toward theoretical FRC,
PVR should decrease
Lung volume
RV FRC TLC
PVRIf the resultant effect is overdistension
PVR should increase
Lung volume
RV FRC TLC
PVRIn this case, tidal insufflation further
increases PVR to a high value
Lung volume
RV FRC TLC
PVRIf the resultant effect is lung
recruitment, PVR should decrease
Lung volume
RV FRC TLC
PVRIn this cas, mechanical insufflation
induces little change in PVR
• Mechanical insufflation and RV
• PEEP and RV
PEEP and venous return
PEEP and RV ejection The hemodynamic effects of PEEP are variable, depending on:
its capacity of recruiting or overdistending lungs its capacity of improving arterial oxygenation degree of airway pressure transmission adaptative mechanisms volume status
Mechanical ventilation and the right ventricle
TV6 mL/kg
Low PEEP
High PEEP
13 cmH2O
TV6 mL/kg
5 cmH2O
Pplat : 30 cmH2O
Passive Leg Raising
45°
CI L/min/m2
• Decrease in RV preload?
• Increase in RV afterload?*
PVR
dyne
s.s.
m2 /
cm2
• Decrease in RV preload
• Increase in RV afterload*
RVED
A /
LVED
A
*
• Decrease in RV preload
• Increase in RV afterload
CI L/min/m2 *
PVR
dyne
s.s.
m2 /
cm2
*
Decrease in RV afterload
with volume challenge
RVED
A /
LVED
A
*
Decrease in RV afterload
with volume challenge
Zone 1
Zone 2
Zone 3
PalvPPA
PPA
PPA
PPV
PPV
PPV
Palv
Palv
Palv > PPA > PPV
PPA > Palv > PPV
PPA > PPV > Palv
PVR
up
bottom
Volume loading may favor zones 3
PPA > PPV > Palv Zone 3
1- In case of acute RV failure, fluid infusion may decrease CO
3- In case of MV with PEEP, fluid infusion may increase CO
through an increase in systemic venous return (RV preload effect)
2- In case of acute RV failure, fluid infusion may increase CO
4- In case of MV with PEEP, fluid infusion may increase CO
through a beneficial effect on PEEP-induced RV dysfunction
(RV afterload effect)
1- Inadequate (low) RV preload can be responsible for low CO
in case of acute RV failure such as pulmonary embolism
In case of acute RV failure, fluid infusion
not only does not increase but can even decrease CO
2- In case of MV with PEEP, increase in central blood volume with
fluid may improve PEEP-induced RV dysfunction
However
Conclusion
Thank you