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Estimating cardiac filling pressure in mechanically ventilated patients with hyperinflation

Teboul, JL and Pinsky, MR and Mercat, A and Anguel, N and Bernardin, G and Achard, JM and Boulain, T and Richard, C (2000) Estimating cardiac filling pressure in mechanically ventilated patients with hyperinflation. Critical Care Medicine, 28 (11). 3631 - 3636. ISSN 0090-3493

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Objective: When positive end-expiratory pressure (PEEP) is applied, the intracavitary left ventricular end-diastolic pressure (LVEDP) exceeds the LV filling pressure because pericardial pressure exceeds 0 at end-expiration. Under those conditions, the LV filling pressure is itself better reflected by the transmural LVEDP (tLVEDP) (LVEDP minus pericardial pressure). By extension, end-expiratory pulmonary artery occlusion pressure (eePAOP), as an estimate of end-expiratory LVEDP, overestimates LV filling pressure when pericardial pressure is >0, because it occurs when PEEP is present. We hypothesized that LV filling pressure could be measured from eePAOP by also knowing the proportional transmission of alveolar pressure to pulmonary vessels calculated as index of transmission = (end-inspiratory PAOP - eePAOP)/(plateau pressure - total PEEP). We calculated transmural pulmonary artery occlusion pressure (tPAOP) with this equation: tPAOP = eePAOP - (index of transmission x total PEEP). We compared tPAOP with airway disconnection nadir PAOP measured during rapid airway disconnection in subjects undergoing PEEP with and without evidence of dynamic pulmonary hyperinflation. Design: Prospective study. Setting: Medical intensive care unit of a university hospital. Patients: We studied 107 patients mechanically ventilated with PEEP for acute respiratory failure. Patients without dynamic pulmonary hyperinflation (group A; n = 58) were analyzed separately from patients with dynamic pulmonary hyperinflation (group B; n = 49). Intervention: Transient airway disconnection. Measurements and Main Results: In group A, tPAOP (8.5 ± 6.0 mm Hg) and nadir PAOP (8.6 ± 6.0 mm Hg) did not differ from each other but were lower than eePAOP (12.4 ± 5.6 mm Hg; p < .05). The agreement between tPAOP and nadir PAOP was good (bias, 0.15 mm Hg; limits of agreement, -1.5-1.8 mm Hg). In group B, tPAOP (9.7 ± 5.4 mm Hg) was lower than both nadir PAOP and eePAOP (12.1 ± 5.4 and 13.9 ± 5.2 mm Hg, respectively; p < .05 for both comparisons). The agreement between tPAOP and nadir PAOP was poor (bias, 2.3 mm Hg; limits of agreement, -0.2-4.8 mm Hg). Conclusions: Indexing the transmission of proportional alveolar pressure to PAOP in the estimation of LV filling pressure is equivalent to the nadir method in patients without dynamic pulmonary hyperinflation and may be more reliable than the nadir PAOP method in patients with dynamic pulmonary hyperinflation.


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Item Type: Article
Status: Published
CreatorsEmailPitt UsernameORCID
Teboul, JL
Pinsky, MRpinsky@pitt.eduPINSKY0000-0001-6166-700X
Mercat, A
Anguel, N
Bernardin, G
Achard, JM
Boulain, T
Richard, C
Date: 1 January 2000
Date Type: Publication
Journal or Publication Title: Critical Care Medicine
Volume: 28
Number: 11
Page Range: 3631 - 3636
DOI or Unique Handle: 10.1097/00003246-200011000-00014
Schools and Programs: School of Medicine > Critical Care Medicine
Refereed: Yes
ISSN: 0090-3493
PubMed ID: 11098965
Date Deposited: 22 Mar 2012 21:00
Last Modified: 30 Jan 2020 16:55


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