Clinical Physiology of Circulation

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery


Mechanical ventilation in prone-position and setting optimal РEEР by transpulmonary pressure in a patient with a reduced left ventricular ejection fraction and respiratory failure in the early postoperative period

Authors: Leushin K.Yu., Rybka M.M., Donakanyan S.A., Raynes E.V., Mironenko V.A.

Company:
Bakoulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russian Federation

E-mail: Сведения доступны для зарегистрированных пользователей.

DOI: https://doi.org/10.24022/1814-6910-2022-19-2-160-167

UDC: 616-083.98:616.124.2]-089.1

Link: Clinical Physiology of Blood Circulaiton. 2022; 2 (19): 160-167

Quote as: Leushin K.Yu., Rybka M.M., Donakanyan S.A., Raynes E.V., Mironenko V.A. Mechanical ventilation in proneposition and setting optimal РEEР by transpulmonary pressure in a patient with a reduced left ventricular ejection fraction and respiratory failure in the early postoperative period. Clinical Physiology of Circulation. 2022; 19 (2): 160–7 (in Russ.). DOI: 10.24022/1814-6910-2022-19-2-160-167

Received / Accepted:  18.02.2022 / 15.03.2022

Download
Full text:  

Abstract

The patient, after the Bentall–De Bono operation with the imposition of Kabrol anastomosis, had a low cardiac output syndrome under ventilator conditions, and hypoxemia was noted. To increase oxygenation, a method was chosen to adjust the optimal level of РEEР by transpulmonary pressure under the control of central hemodynamic parameters. When selecting the optimal level of РEEР, at which Ptp PEEP ≥ 0, in the supine position, oxygenation increased by 50%, however, an increase in left ventricular preload was noted, which was accompanied by a decrease in cardiac output, oxygen delivery and a decrease in tissue perfusion. In the prone-position, oxygenation increased by more than 3 times, while the optimal РEEР was 2 times lower, in conditions of normovolemia, optimal preload for left ventricle, normokinetic type of hemodynamics with increased oxygen transport and improved tissue perfusion were provided. In the prone position, the alveolar-arterial difference in oxygen tension (AaDO2) and shunt fraction (Qs/Qt) decreased. After 16 hours spent in the prone-position in a protective ventilator, an increase in the ejection fraction of the left ventricle was noted.

References

  1. Sullivan B. Postoperative care of the cardiac surgical patient. In: Hensley F.A., Gravlee G.P., Martin D.E. A practical approach to cardiac anesthesia, 5th ed. LWW; 2012: 265–91.
  2. Al-Qubati F.A.A., Damag A., Norman T. Incidence and outcome of pulmonary complications after open cardiac surgery. Egyp. J. Chest. Dis. Tuberc. 2013; 62 (4): 775–80. DOI: 10.1016/j.ejcdt.2013.08.008
  3. Kor D.J., Lingineni R.K., Gajic O., Park P.K., Blum J.M., Hou P.C. et al. Predicting risk of postoperative lung injury in high-risk surgical patients: a multicenter cohort study. Anesthesiology. 2014; 120: 1168–81. DOI: 10.1097/ALN.0000000000000216
  4. Liu Y., Song M., Huang L., Zhu G. A nomogram to predict acute respiratory distress syndrome after cardiac surgery. Heart Surg. Forum. 2021; 24 (3): E445–50. DOI: 10.1532/hsf.3809
  5. Papazian L., Aubron C., Brochard L., Chiche J.-D., Combes A., Dreyfuss D. et al. Formal guidelines: management of acute respiratory distress syndrome. Ann. Intensive Care. 2019; 9: 69. DOI: 10.1186/s13613-019- 0540-9
  6. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline. Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am. J. Respir. Crit. Care. Med. 2017; 195 (9): 1253–63. DOI: 10.1164/rccm.19511erratum
  7. Rong L.Q., Di Franco A., Gaudino M. Acute respiratory distress syndrome after cardiac surgery. J. Thorac. Dis. 2016; 8 (10). DOI: 10.21037/jtd.2016.10.74
  8. Kogan A., Preisman S., Levin S., Raanani E., Sternik L. Adult respiratory distress syndrome following cardiac surgery. J. Card. Surg. 2014; 29: 41–6. DOI: 10.1111/jocs.12264
  9. Ярошецкий А.И., Грицан А.И., Авдеев С.Н., Власенко А.В., Ерёменко А.А., Заболотских И.Б. и др. Диагностика и интенсивная терапия острого респираторного дистресс-синдрома (Клинические рекомендации Общероссийской общественной организации «Федерация анестезиологов и реаниматологов»). Анестезиология и реаниматология. 2020; 2: 5–39. DOI: 10.17116/anaesthesiology20200215
  10. Gattinoni L., Giosa L., Bonifazi M., Pasticci I., Busana M., Macri M. et al. Targeting transpulmonary pressure to prevent ventilator-induced lung injury. Expert Rev. Respir. Med. 2019; 13 (8): 737–46. DOI: 10.1080/17476348.2019.1638767
  11. Piraino T., Cook D.J. Optimal PEEP guided by esophageal balloon manometry. Respir. Care. 2011; 56 (4): 510–3. DOI: 10.4187/respcare.00815
  12. Albert R.K., Hubmayr R.D. The prone position eliminates compression of the lungs by the heart. Am. J. Respir. Crit. Care. Med. 2000; 161 (5): 1660–5. DOI: 10.1164/ajrccm.161.5.9901037
  13. Munshi L., Del Sorbo L., Adhikari N.K.J., Hodgson C.L., Wunsch H., Meade M.O. et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann. Am. Thorac. Soc. 2017; 14 (Suppl. 4): S280–8. DOI: 10.1513/AnnalsATS.201704-343OT
  14. Ерёменко А.А., Левиков Д.И., Егоров В.М. Влияние вентиляции легких в положении на животе на оксигенирующую функцию легких и показатели гемодинамики у кардиохирургических больных с дыхательной недостаточностью в послеоперационном периоде. Анестезиология и реаниматология. 1998; 3: 42–5. PMID: 9693433. Eremenko A.A., Levikov D.I., Egorov V.M. Effect of ventilation in the abdominal position on the oxygenating function of the lungs and hemodynamic parameters in cardiosurgical patients with respiratory failure in the postoperative period. Russian Journal of Anaesthesiology and Reanimatology. 1998; 3: 42–5 (in Russ.). PMID: 9693433.
  15. Murray J.F., Matthay M.A., Luce J.M., Flick M.R. An expanded definition of the adult respiratory distress syndrome. Am. Rev. Respir. Dis. 1988; 138: 720–3; erratum 1989; 139: 1065. DOI: 10.1164/ajrccm/138.3.720
****
  1. Sullivan B. Postoperative care of the cardiac surgical patient. In: Hensley F.A., Gravlee G.P., Martin D.E. A practical approach to cardiac anesthesia, 5th ed. LWW; 2012: 265–91.
  2. Al-Qubati F.A.A., Damag A., Norman T. Incidence and outcome of pulmonary complications after open cardiac surgery. Egyp. J. Chest. Dis. Tuberc. 2013; 62 (4): 775–80. DOI: 10.1016/j.ejcdt.2013.08.008
  3. Kor D.J., Lingineni R.K., Gajic O., Park P.K., Blum J.M., Hou P.C. et al. Predicting risk of postoperative lung injury in high-risk surgical patients: a multicenter cohort study. Anesthesiology. 2014; 120: 1168–81. DOI: 10.1097/ALN.0000000000000216
  4. Liu Y., Song M., Huang L., Zhu G. A nomogram to predict acute respiratory distress syndrome after cardiac surgery. Heart Surg. Forum. 2021; 24 (3): E445–50. DOI: 10.1532/hsf.3809
  5. Papazian L., Aubron C., Brochard L., Chiche J.-D., Combes A., Dreyfuss D. et al. Formal guidelines: management of acute respiratory distress syndrome. Ann. Intensive Care. 2019; 9: 69. DOI: 10.1186/s13613-019- 0540-9
  6. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline. Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am. J. Respir. Crit. Care. Med. 2017; 195 (9): 1253–63. DOI: 10.1164/rccm.19511erratum
  7. Rong L.Q., Di Franco A., Gaudino M. Acute respiratory distress syndrome after cardiac surgery. J. Thorac. Dis. 2016; 8 (10). DOI: 10.21037/jtd.2016.10.74
  8. Kogan A., Preisman S., Levin S., Raanani E., Sternik L. Adult respiratory distress syndrome following cardiac surgery. J. Card. Surg. 2014; 29: 41–6. DOI: 10.1111/jocs.12264
  9. Yaroshetskiy A.I., Gritsan A.I., Avdeev S.N., Vlasenko A.V., Eremenko A.A., Zabolotskikh I.B. et al. Diagnostics and intensive therapy of acute respiratory distress syndrome (Clinical guidelines of the Federation of Annesthesiologist and Reanimatologists of Russia). Russian Journal of Anaesthesiology and Reanimatology. 2020; 2: 5–39 (in Russ.). DOI: 10.17116/anaesthesiology20200215
  10. Gattinoni L., Giosa L., Bonifazi M., Pasticci I., Busana M., Macri M. et al. Targeting transpulmonary pressure to prevent ventilator-induced lung injury. Expert Rev. Respir. Med. 2019; 13 (8): 737–46. DOI: 10.1080/17476348.2019.1638767
  11. Piraino T., Cook D.J. Optimal PEEP guided by esophageal balloon manometry. Respir. Care. 2011; 56 (4): 510–3. DOI: 10.4187/respcare.00815
  12. Albert R.K., Hubmayr R.D. The prone position eliminates compression of the lungs by the heart. Am. J. Respir. Crit. Care. Med. 2000; 161 (5): 1660–5. DOI: 10.1164/ajrccm.161.5.9901037
  13. Munshi L., Del Sorbo L., Adhikari N.K.J., Hodgson C.L., Wunsch H., Meade M.O. et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann. Am. Thorac. Soc. 2017; 14 (Suppl. 4): S280–8. DOI: 10.1513/AnnalsATS.201704-343OT
  14. Eremenko A.A., Levikov D.I., Egorov V.M. Effect of ventilation in the abdominal position on the oxygenating function of the lungs and hemodynamic parameters in cardiosurgical patients with respiratory failure in the postoperative period. Russian Journal of Anaesthesiology and Reanimatology. 1998; 3: 42–5 (in Russ.). PMID: 9693433.
  15. Murray J.F., Matthay M.A., Luce J.M., Flick M.R. An expanded definition of the adult respiratory distress syndrome. Am. Rev. Respir. Dis. 1988; 138: 720–3; erratum 1989; 139: 1065. DOI: 10.1164/ajrccm/138.3.720

About Authors

  • Konstantin Yu. Leushin, Resuscitator; ORCID
  • Mikhail M. Rybka, Dr. Med. Sci., Head of Department of Anesthesiology; ORCID
  • Sergey A. Donakanyan, Dr. Med. Sci., Head of Department of Intensive Care Unit;
  • Elena V. Raynes, Resuscitator;
  • Vladimir A. Mironenko, Dr. Med. Sci., Head of Department of Reconstructive Surgery and Aortic Root; ORCID

 If you found mistakes, select text and press Alt+A