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August 10, 1984, Vol 252, No. 6 >
ARTICLE | August 10, 1984

The Cardiovascular Effects of Mechanical Ventilation and Positive End-Expiratory Pressure FREE

John M. Luce, MD
[+] Author Affiliations

Reprint requests to Chest Service, Room 5K1, San Francisco General Hospital, San Francisco, CA 94110 (Dr Luce).


JAMA. 1984;252(6):807-811. doi:10.1001/jama.1984.03350060051030
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References

IN PATIENTS with diffuse lung disease due to the adult respiratory distress syndrome (ARDS), mechanical ventilation (MV), and positive endexpiratory pressure (PEEP) commonly are used to improve the Pao2. This is done despite the fact that MV and PEEP may depress cardiac output and thereby reduce systemic oxygen transport.1 In this article, the complex and often controversial cardiovascular effects of MV and PEEP are reviewed by focusing on the determinants of cardiac output. Guidelines to minimize the cardiovascular effects of MV and PEEP in patients with ARDS are also provided.

Determinants of Cardiac Output  Cardiac output is the product of the ventricular stroke volume and heart rate. Heart rate is influenced by sympathetic and parasympathetic nervous system activity that is mediated in part by the baroreceptor reflex involving receptors in the carotid sinus and aortic arch. Stroke volume is determined by three factors: (1) preload, the length of cardiac muscle

REFERENCES

1 +
Lutch JS, Murray JF:  Continuous positive-pressure ventilation: Effects on systemic oxygen transport and tissue oxygenation . Ann Intern Med 1972;;76:193-202.
2 +
Cournand A, Motley HL, Werko L, et al:  Physiological studies of the effects of intermittent positive pressure breathing on cardiac output in man . Am J Physiol 1948;;152:162-174.
3 +
Qvist J, Pontoppidan H, Wilson RS, et al:  Hemodynamic responses to mechanical ventilation with PEEP: The effect of hypervolemia . Anesthesiology 1975;;42:45-55.
4 +
Fewell JE, Abendschein DR, Carlson CJ, et al:  Continuous positive-pressure ventilation decreases right and left ventricular end-diastolic volumes in the dog . Circ Res 1980;;46:125-132.
5 +
Roos A, Thomas LJ Jr, Nagel EL, et al:  Pulmonary vascular resistance as determined by lung inflation and vascular pressures . J Appl Physiol 1961;;16:77-84.
6 +
Taquini AC, Fermoso JC, Aramendia P:  Behavior of the right ventricle following aortic constriction of the pulmonary artery . Circ Res 1960;;8:315-318.
7 +
McIntyre KM, Sasahara AS:  The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease . Am J Cardiol 1971;;28:288-294.
8 +
Prewitt RM, Wood LDH:  Effect of positive end-expiratory pressure on ventricular function in dogs . Am J Physiol 1979;;236:H534-H544.
9 +
Cassidy SS, Eschenbacher WL, Robertson CH, et al:  Cardiovascular effects of positive-pressure ventilation in normal subjects . J Appl Physiol 1979;;47:453-461.
10 +
Cassidy SS, Robertson CH, Pierce AK, et al:  Cardiovascular effects of positive end-expiratory pressure in dogs . J Appl Physiol 1978;; 44:743-750.
11 +
Katz AM:  Application of the Starling resistor concept to the lungs during CPPV . Crit Care Med 1977;;5:67-72.
12 +
Jardin F, Farcot JC, Boisante L, et al:  Influence of positive end-expiratory pressure on left ventricular performance . N Engl J Med 1981;;304:387-392.
13 +
Marini JJ, O'Quin R, Culver BH, et al:  Estimation of transmural cardiac pressure during ventilation with PEEP . J Appl Physiol 1982;;53:384-391.
14 +
Marini JJ, Culver BH, Butler J:  Effect of positive end-expiratory pressure on canine ventricular function curves . J Appl Physiol 1981;; 51:1367-1374.
15 +
Buda AJ, Pinsky MR, Ingels NB, et al:  Effect of intrathoracic pressure on left venticular performance. N Engl J Med 1979;;301:453-459.
16 +
Pinsky MR, Summer WR, Wise RH, et al:  Augmentation of cardiac function by elevation of intrathoracic pressure . J Appl Physiol 1983;; 54:950-955.
17 +
Pinsky MR, Summer WR:  Cardiac augmentation by phasic high intrathoracic pressure support in man. Chest 1983;;84:370-375.
18 +
Beach T, Millen E, Grenvik A:  Hemodynamic response to discontinuance of mechanical ventilation . Crit Care Med 1973;;1:85-90.
19 +
Tucker HJ, Murray JF:  Effects of end-expiratory pressure on organ blood flow in normal and diseased dogs . J Appl Physiol 1973;; 34:573-577.
20 +
Marini JJ, Culver BH, Butler J:  Compensatory circulatory response to positive end-expiratory pressure, abstracted . Am Rev Respir Dis 1983;;127:81.
21 +
Cassidy SS, Eschenbacher WL, Johnson RL:  Reflex cardiovascular depression during unilateral lung hyperinflation in the dog . J Clin Invest 1977;;64:620-626.
22 +
Hudson LD, Tooker J, Haisch C, et al:  Comparison of assisted mechanical ventilation and PEEP with IMV and CPAP in ARDS patients, abstracted . Am Rev Respir Dis 1978;; 117:129.
23 +
Pepe PE, Marini JJ:  Occult positive endexpiratory pressure in mechanically ventilated patients with airflow obstruction: The auto-PEEP effect . Am Rev Respir Dis 1982;;126:166-170.
24 +
Kirby RR, Downs JB, Civetta JM, et al:  High level positive end-expiratory pressure (PEEP) in acute respiratory insufficiency . Chest 1975;;67:156-163.
25 +
Luce JM, Robertson HT, Huang T, et al:  The effects of expiratory positive airway pressure on the resolution of oleic acid-induced lung injury in dogs . Am Rev Respir Dis 1982;;125:716-722.
26 +
Weisman IM, Ricaldo JE, Rogers RM:  Positive end-expiratory pressure in adult respiratory failure . N Engl J Med 1982;;307:1381-1384.
27 +
Prewitt RM, McCarthy J, Wood LDH:  Treatment of acute low pressure pulmonary edema in dogs: Relative effects of hydrostatic and oncotic pressure, nitroprusside, and positive end-expiratory pressure . J Clin Invest 1981;; 67:409-418.
28 +
Danek SJ, Lynch JP, Weg JG, et al:  The dependence of oxygen uptake on oxygen delivery in the adult respiratory distress syndrome . Am Rev Respir Dis 1980;;122:387-395.
29 +
Krouskap RW, Cabatu EE, Chelliah BP, et al:  Accuracy and clinical utility of an oxygen saturation catheter . Crit Care Med 1983;;11:744-749.
30 +
Tooker J, Huseby J, Butler J:  The effect of Swan-Ganz catheter height on the wedge pressure-left atrial pressure relationship in edema during positive-pressure ventilation . Am Rev Respir Dis 1978;;117:721-725.
31 +
O'Quin R, Marini JJ:  Pulmonary artery occlusion pressure: Clinical physiology, measurement, and interpretation . Am Rev Respir Dis 1983;;128:319-326.
32 +
Eaton RJ, Taxman RM, Avioli LV:  Cardiovascular evaluation of patients treated with PEEP . Arch Intern Med 1983;;143:1958-1961.

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1 +
Lutch JS, Murray JF:  Continuous positive-pressure ventilation: Effects on systemic oxygen transport and tissue oxygenation . Ann Intern Med 1972;;76:193-202.
2 +
Cournand A, Motley HL, Werko L, et al:  Physiological studies of the effects of intermittent positive pressure breathing on cardiac output in man . Am J Physiol 1948;;152:162-174.
3 +
Qvist J, Pontoppidan H, Wilson RS, et al:  Hemodynamic responses to mechanical ventilation with PEEP: The effect of hypervolemia . Anesthesiology 1975;;42:45-55.
4 +
Fewell JE, Abendschein DR, Carlson CJ, et al:  Continuous positive-pressure ventilation decreases right and left ventricular end-diastolic volumes in the dog . Circ Res 1980;;46:125-132.
5 +
Roos A, Thomas LJ Jr, Nagel EL, et al:  Pulmonary vascular resistance as determined by lung inflation and vascular pressures . J Appl Physiol 1961;;16:77-84.
6 +
Taquini AC, Fermoso JC, Aramendia P:  Behavior of the right ventricle following aortic constriction of the pulmonary artery . Circ Res 1960;;8:315-318.
7 +
McIntyre KM, Sasahara AS:  The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease . Am J Cardiol 1971;;28:288-294.
8 +
Prewitt RM, Wood LDH:  Effect of positive end-expiratory pressure on ventricular function in dogs . Am J Physiol 1979;;236:H534-H544.
9 +
Cassidy SS, Eschenbacher WL, Robertson CH, et al:  Cardiovascular effects of positive-pressure ventilation in normal subjects . J Appl Physiol 1979;;47:453-461.
10 +
Cassidy SS, Robertson CH, Pierce AK, et al:  Cardiovascular effects of positive end-expiratory pressure in dogs . J Appl Physiol 1978;; 44:743-750.
11 +
Katz AM:  Application of the Starling resistor concept to the lungs during CPPV . Crit Care Med 1977;;5:67-72.
12 +
Jardin F, Farcot JC, Boisante L, et al:  Influence of positive end-expiratory pressure on left ventricular performance . N Engl J Med 1981;;304:387-392.
13 +
Marini JJ, O'Quin R, Culver BH, et al:  Estimation of transmural cardiac pressure during ventilation with PEEP . J Appl Physiol 1982;;53:384-391.
14 +
Marini JJ, Culver BH, Butler J:  Effect of positive end-expiratory pressure on canine ventricular function curves . J Appl Physiol 1981;; 51:1367-1374.
15 +
Buda AJ, Pinsky MR, Ingels NB, et al:  Effect of intrathoracic pressure on left venticular performance. N Engl J Med 1979;;301:453-459.
16 +
Pinsky MR, Summer WR, Wise RH, et al:  Augmentation of cardiac function by elevation of intrathoracic pressure . J Appl Physiol 1983;; 54:950-955.
17 +
Pinsky MR, Summer WR:  Cardiac augmentation by phasic high intrathoracic pressure support in man. Chest 1983;;84:370-375.
18 +
Beach T, Millen E, Grenvik A:  Hemodynamic response to discontinuance of mechanical ventilation . Crit Care Med 1973;;1:85-90.
19 +
Tucker HJ, Murray JF:  Effects of end-expiratory pressure on organ blood flow in normal and diseased dogs . J Appl Physiol 1973;; 34:573-577.
20 +
Marini JJ, Culver BH, Butler J:  Compensatory circulatory response to positive end-expiratory pressure, abstracted . Am Rev Respir Dis 1983;;127:81.
21 +
Cassidy SS, Eschenbacher WL, Johnson RL:  Reflex cardiovascular depression during unilateral lung hyperinflation in the dog . J Clin Invest 1977;;64:620-626.
22 +
Hudson LD, Tooker J, Haisch C, et al:  Comparison of assisted mechanical ventilation and PEEP with IMV and CPAP in ARDS patients, abstracted . Am Rev Respir Dis 1978;; 117:129.
23 +
Pepe PE, Marini JJ:  Occult positive endexpiratory pressure in mechanically ventilated patients with airflow obstruction: The auto-PEEP effect . Am Rev Respir Dis 1982;;126:166-170.
24 +
Kirby RR, Downs JB, Civetta JM, et al:  High level positive end-expiratory pressure (PEEP) in acute respiratory insufficiency . Chest 1975;;67:156-163.
25 +
Luce JM, Robertson HT, Huang T, et al:  The effects of expiratory positive airway pressure on the resolution of oleic acid-induced lung injury in dogs . Am Rev Respir Dis 1982;;125:716-722.
26 +
Weisman IM, Ricaldo JE, Rogers RM:  Positive end-expiratory pressure in adult respiratory failure . N Engl J Med 1982;;307:1381-1384.
27 +
Prewitt RM, McCarthy J, Wood LDH:  Treatment of acute low pressure pulmonary edema in dogs: Relative effects of hydrostatic and oncotic pressure, nitroprusside, and positive end-expiratory pressure . J Clin Invest 1981;; 67:409-418.
28 +
Danek SJ, Lynch JP, Weg JG, et al:  The dependence of oxygen uptake on oxygen delivery in the adult respiratory distress syndrome . Am Rev Respir Dis 1980;;122:387-395.
29 +
Krouskap RW, Cabatu EE, Chelliah BP, et al:  Accuracy and clinical utility of an oxygen saturation catheter . Crit Care Med 1983;;11:744-749.
30 +
Tooker J, Huseby J, Butler J:  The effect of Swan-Ganz catheter height on the wedge pressure-left atrial pressure relationship in edema during positive-pressure ventilation . Am Rev Respir Dis 1978;;117:721-725.
31 +
O'Quin R, Marini JJ:  Pulmonary artery occlusion pressure: Clinical physiology, measurement, and interpretation . Am Rev Respir Dis 1983;;128:319-326.
32 +
Eaton RJ, Taxman RM, Avioli LV:  Cardiovascular evaluation of patients treated with PEEP . Arch Intern Med 1983;;143:1958-1961.

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