prof. jean-louis teboul medical icu bicetre hospital university paris south france challenge in...

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