Acute Respiratory failure

of the critically ill cardiac

patient

Marco Maggiorini

Medical Intensive Care Unit

University Hospital Zürich

PathophysiologyDiastolic dysfunction

Pulmonary venous hypertension

Decreased left ventricular elastance following left ventricular systolic and diastolic dysfunction lead to pulmonary venous hypertension (PVH).

0

10

20

30

40

50

60

70

Pre

ssu

re (

mm

Hg

)

Time (sec)

Ppao 32 mmHg

mPpa 44 mmHg

TPP : mPpa – Ppao ≤ 12 mmHg

“Hydrostatic Capillary Leak”

Pc < 16 mmHg

Pc 16-19 mmHg

Pc > 19 mmHg

Pulmonary hemodynamics assessed by PAC

Drake R.E. et al, Am J Physiol 1987, 238:H430-H438

Pulmonary capillary filtration pressure

Critical pulmonary capillary pressure

Pc crit = 19.7 ± 5.4 mmHg

Zeit (Min.)

Ge

wic

htz

un

ah

me

(g

/10

0g

)

20.415.4

24.6

BMBM

CAVE: Remodeling

of the pulmonary

vessels ⇑ Pc crit.

Systemic / local Inflammation

INFLAMMATPRY RESPONCE

Decrease Pc Crit

&

Impairs alveolar fluid clearance

Hochman JS Circ 2003, 107:2998

iNOS

Systemic inflammation

Inflammatory cytokines

NOONOO

Vasodilation Permeability

Systemic perfusion

Coronary perfusion pressure

Permeability type of Pulmonary edema

LVEDPPulmonary congestion

Myocardial Infarction

Myocardial Dysfunction

Systolic Diastolic

Death

Infection on ICU admission

Rudiger et al SMW 2010

Infection during ICU stay

Rudiger et al SMW 2010

Conditions associated with

cardiogenic pulmonary edema

Acute heart failure with hypertension (Hypertensive crisis)

Acute heart failure with with normal blood pressure

Acute decompensated congestive heart failure

Severe cardiogenic shock

Acute heart failure with valvular dysfunction

High output failure

Adapted from ESC Guidelines 2005

Determinants of AHF patients

survival admitted to the ICU

Adamopoulos et al., Eur. J. Heart Fail., 2007, 9:935

355 patients admitted to the CCU/ICU for acutely decompensate heart failure

Is a pulmonary artery catheter (PAC) needed?

Hemodynamic monitoring of

cardiogenic pulmonary edema

Treatment goals:

Cardiac index > 2.2 l/min/m2

Mixed-venous oxygen saturation > 55%

Pulmonary artery occluded pressure < 20 mmHg)

0

10

20

30

40

50

Pre

ssure

(m

mH

g)

Pra Ppa Ppao

Targeting PAOP < 15 mmHg doesn't affect

time to clinical resolution of congestion

ESCAPE Trial, Binanay et al. JAMA 2005, 294:1695

Days alive and out of hospital Impact of intervention across subgroups

Fluid removal by targeting a PAOP < 15 mmHg

improves relative mitral regurgitation

ESCAPE Trial, Paladry et al. Circ Heart Failure 2009, 2:181

Assessment of fluid removal Improvement of mitral regurgitation

Median improvement relative to baseline

MR = mitral regurgitation; MR/LAA = MR in proportion of left atrium area

from

BL

mmHg

5 (12)

8 (9)

Monitoring changes in EVLW after ICU

admission and alternative to PAC?

Paop EVLW

CVP ITBV

BL 24h BL 24h

Bin

dels

et

al A

m J

Card

iol1999, 84:1

158

Resolution of cardiogenic pulmonary edema after intubation and MV

Monitoring changes in EVLW after ICU admission and alternative to PAC?

Ritter et al preliminary data

6.2%

22.4%

0

5

10

15

20

25

30

Survivors Non Survivors

Pe

rce

nt (%

)

Percent of cardiogenic pulmonary edema patients with a decrease in EVLW of <

10% during first 3 ICU Days

(17 Pts) (9 Pts)

p = 0.03

EVLW EVLW

Intra-thoracal blood volume (ITBV)

Assessment of extra-vascular lung water (EVLW)

using the trans-thoracal thermodilution method

Management of acute respiratory

failure of cardiac origine

Left-ventricular filling pressures

Str

oke v

olu

me

congestive and

low output

symptoms

congestive

symptoms

low output

symptoms

Inotropic + vasodilator

Vasodilator + diuretic

Vasodilator

normal

heart failure Diuretic

Pro

port

ion o

f P

atients

(%

)

Nitroglycerin

(N=143/143)

Nesiritide

(N=203/204)

Placebo

(N=142/142)

-40

-30

-20

-10

0

10

20

30

40

50

60

70

80

90

100

p=0.191p=0.034 Markedly

Better

ModeratelyBetter

MinimallyBetter

No Change

Minimally*Worse

* No patients mod-markedly worse

Dyspnoe at 3 hours after initiation of a

vasodilator therapy (VMAC-trial)

JAMA 2002, 287:1531

Randomized trial of high-dose isosorbide dinitrate plus

low-dose furosemide vs. high-dose furosemide plus low-

dose isosorbide dinitrate in severe pulmonary edema

(Cotter G et al. Lancet 1998; 351: 389-93)

Group A Group B p-value

(n = 52) (n = 52)

Required MV 7 (13%) 21 (21%) 0.0041

Myocardial Inf. 9 (17%) 19 (37%) 0.047

Any adv. event 12 (25%) 24 (46%) 0.041

p < 0.0063

Inotropics are indicated in servere

cardiogenic shock

Kivikko et al Circ 2003, 107:81

Time (h)

Stroke volume

Time (h)

Pulmonary artery occluded pressure

Levosimendan

Placebo

Levosimendan

Placebo

Non-invasive mechanical ventilation in

congestive heart failure

SaO

2%

PaO2:FiO2 (mmHg) PaCO2 (mmHg)

NIVPS Standart

Intubation 5% 33% .037

Resolution time (Min.) 30 105 .002

Masip et al

Lancet 2000,

356:2126

Pressure support

Vt > 400 ml

PEEP: 5 cmH2O

Trigger 0.5 cmH2O

n = 40

Gray AJ et al. NEJM 2008, 359:143

Non-invasive ventilation in cardiogenic pulmonary edema

Non-invasive ventilation vs. Standard

treatment in cardiogenic pulmonary edema

Gray AJ et al. NEJM 2008, 359:143

• NIV for at least 2 hours

CPAP: 5 – 15 cm H2O

NIPPV: EPAP 4-10 cmH2O, IPAP 8-20

cmH2O

• SaO2 at baseline (all): 90 ± 8 %

• PaO2 at baseline (all): 13.4 ± 8.6 kPa

• PaCO2 at baseline (all): 7.7 ± 2.3 kPa

NIV in

congestive

heart failure

Masip et al

JAMA 2005,

294:3124

Effects of NIV on

the need to intubate

in acute heart

failure

NIV in

congestive

heart failure

Masip et al

JAMA 2005,

294:3124

Effects on death

rate of NIV in acute

heart failure

Summary: management of acute

respiratory failure in cardiac patients

RESTORE OXYGEN DELIVERY TO THE TISSUE

To assure arterial oxygenation, improve physiology and

patient confort using NIV

Decrease cardiac afterload if appropriate using i.v.

Vasodilators

RESTORE MYOCARDIAL FUNCTION

PCI, ACBP, Valve repair

Convert to Sinus Rhythm is necessary

Intra-Aortic Balloon Pump (IABP)

INOTROPICS

Improve cardiac contractility: Dobutamine,

Levosimendan, Milrinone