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Mani S, Mirza H, Ziegler J, Chandrasekharan P. Early Pulmonary Hypertension in Preterm Infants. Clin Perinatol 2024; 51:171-193. [PMID: 38325940 PMCID: PMC10850766 DOI: 10.1016/j.clp.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Pulmonary hypertension (PH) in preterm neonates has multifactorial pathogenesis with unique characteristics. Premature surfactant-deficient lungs are injured following exposure to positive pressure ventilation and high oxygen concentrations resulting in variable phenotypes of PH. The prevalence of early PH is variable and reported to be between 8% and 55% of extremely preterm infants. Disruption of the lung development and vascular signaling pathway could lead to abnormal pulmonary vascular transition. The management of early PH and the off-label use of selective pulmonary vasodilators continue to be controversial.
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Affiliation(s)
- Srinivasan Mani
- Section of Neonatology, Department of Pediatrics, The University of Toledo/ ProMedica Russell J. Ebeid Children's Hospital, Toledo, OH 43606, USA
| | - Hussnain Mirza
- Section of Neonatology, Department of Pediatrics, Advent Health for Children/ UCF College of Medicine, Orlando, FL 32408, USA
| | - James Ziegler
- Division of Cardiovascular Diseases, Department of Pediatrics, Hasbro Children's Hospital/ Brown University, Providence, RI 02903, USA
| | - Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY 32408, USA; Oishei Children's Hospital, 818 Ellicott Street, Buffalo, NY 14203, USA.
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2
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Jain A, Giesinger RE, Dakshinamurti S, ElSayed Y, Jankov RP, Weisz DE, Lakshminrusimha S, Mitra S, Mazwi ML, Ting J, Narvey M, McNamara PJ. Care of the critically ill neonate with hypoxemic respiratory failure and acute pulmonary hypertension: framework for practice based on consensus opinion of neonatal hemodynamics working group. J Perinatol 2022; 42:3-13. [PMID: 35013586 DOI: 10.1038/s41372-021-01296-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/17/2021] [Accepted: 12/02/2021] [Indexed: 11/09/2022]
Abstract
Circulatory transition after birth presents a critical period whereby the pulmonary vascular bed and right ventricle must adapt to rapidly changing loading conditions. Failure of postnatal transition may present as hypoxemic respiratory failure, with disordered pulmonary and systemic blood flow. In this review, we present the biological and clinical contributors to pathophysiology and present a management framework.
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Affiliation(s)
- Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | | | - Yasser ElSayed
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Robert P Jankov
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Souvik Mitra
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Mjaye L Mazwi
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Joseph Ting
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Michael Narvey
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
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3
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Nasrala MLS, Bolzan DW, Lage YG, Prado FS, Arena R, Lima PRL, Feguri G, Silva AMC, Marcondi NO, Hossne N, Guizilini S, Gomes WJ. Extended-time of Noninvasive Positive Pressure Ventilation Improves Tissue Perfusion after Coronary Artery Bypass Surgery: a Randomized Clinical Trial. Braz J Cardiovasc Surg 2018; 33:250-257. [PMID: 30043917 PMCID: PMC6089129 DOI: 10.21470/1678-9741-2017-0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 02/20/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare the effects of extended- versus short-time noninvasive positive pressure ventilation on pulmonary function, tissue perfusion, and clinical outcomes in the early postoperative period following coronary artery bypass surgery in patients with preserved left ventricular function. METHODS Patients were randomized into two groups according to noninvasive positive pressure ventilation intensity: short-time noninvasive positive pressure ventilation n=20 (S-NPPV) and extended-time noninvasive positive pressure ventilation n=21 (E-NPPV). S-NPPV was applied for 60 minutes during immediate postoperative period and 10 minutes, twice daily, from postoperative days 1-5. E-NPPV was performed for at least six hours during immediate postoperative period and 60 minutes, twice daily, from postoperative days 1-5. As a primary outcome, tissue perfusion was determined by central venous oxygen saturation and blood lactate level measured after anesthetic induction, immediately after extubation and following noninvasive positive pressure ventilation protocols. As a secondary outcome, pulmonary function tests were performed preoperatively and in the postoperative days 1, 3, and 5; clinical outcomes were recorded. RESULTS Significant drop in blood lactate levels and an improvement in central venous oxygen saturation values in the E-NPPV group were observed when compared with S-NPPV group after study protocol (P<0.01). The E-NPPV group presented higher preservation of postoperative pulmonary function as well as lower incidence of respiratory events and shorter postoperative hospital stay (P<0.05). CONCLUSION Prophylactic E-NPPV administered in the early postoperative period of coronary artery bypass surgery resulted in greater improvements in tissue perfusion, pulmonary function and clinical outcomes than S-NPPV, in patients with preserved left ventricular function. TRIAL REGISTRATION Brazilian Registry of Clinical trial - RBR7sqj78 - http://www.ensaiosclinicos.gov.br.
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Affiliation(s)
- Mara L S Nasrala
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.,Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil
| | - Douglas W Bolzan
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Yumi G Lage
- Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil.,Physical Therapy Department, Hospital São Mateus, Cuiabá, MT, Brazil
| | - Fabiana S Prado
- Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil.,Physical Therapy Department, Hospital São Mateus, Cuiabá, MT, Brazil
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Paulo R L Lima
- Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil.,Physical Therapy Department, Hospital São Mateus, Cuiabá, MT, Brazil
| | - Gibran Feguri
- Physical Therapy Department, Hospital Santa Rosa, Cuiabá, MT, Brazil.,Physical Therapy Department, Hospital São Mateus, Cuiabá, MT, Brazil
| | - Ageo M C Silva
- Public Health Department, Universidade Federal do Mato Grosso (UFMT), Cuiabá, MT, Brazil
| | - Natasha O Marcondi
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Nelson Hossne
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Solange Guizilini
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.,Department of the Human Movement Sciences, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Walter J Gomes
- Cardiology and Cardiovascular Surgery Disciplines, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
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Katira BH, Giesinger RE, Engelberts D, Zabini D, Kornecki A, Otulakowski G, Yoshida T, Kuebler WM, McNamara PJ, Connelly KA, Kavanagh BP. Adverse Heart-Lung Interactions in Ventilator-induced Lung Injury. Am J Respir Crit Care Med 2017; 196:1411-1421. [PMID: 28795839 DOI: 10.1164/rccm.201611-2268oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
RATIONALE In the original 1974 in vivo study of ventilator-induced lung injury, Webb and Tierney reported that high Vt with zero positive end-expiratory pressure caused overwhelming lung injury, subsequently shown by others to be due to lung shear stress. OBJECTIVES To reproduce the lung injury and edema examined in the Webb and Tierney study and to investigate the underlying mechanism thereof. METHODS Sprague-Dawley rats weighing approximately 400 g received mechanical ventilation for 60 minutes according to the protocol of Webb and Tierney (airway pressures of 14/0, 30/0, 45/10, 45/0 cm H2O). Additional series of experiments (20 min in duration to ensure all animals survived) were studied to assess permeability (n = 4 per group), echocardiography (n = 4 per group), and right and left ventricular pressure (n = 5 and n = 4 per group, respectively). MEASUREMENTS AND MAIN RESULTS The original Webb and Tierney results were replicated in terms of lung/body weight ratio (45/0 > 45/10 ≈ 30/0 ≈ 14/0; P < 0.05) and histology. In 45/0, pulmonary edema was overt and rapid, with survival less than 30 minutes. In 45/0 (but not 45/10), there was an increase in microvascular permeability, cyclical abolition of preload, and progressive dilation of the right ventricle. Although left ventricular end-diastolic pressure decreased in 45/10, it increased in 45/0. CONCLUSIONS In a classic model of ventilator-induced lung injury, high peak pressure (and zero positive end-expiratory pressure) causes respiratory swings (obliteration during inspiration) in right ventricular filling and pulmonary perfusion, ultimately resulting in right ventricular failure and dilation. Pulmonary edema was due to increased permeability, which was augmented by a modest (approximately 40%) increase in hydrostatic pressure. The lung injury and acute cor pulmonale is likely due to pulmonary microvascular injury, the mechanism of which is uncertain, but which may be due to cyclic interruption and exaggeration of pulmonary blood flow.
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Affiliation(s)
- Bhushan H Katira
- 1 The Research Institute.,2 Department of Critical Care Medicine.,3 Interdepartmental Division of Critical Care Medicine
| | | | | | - Diana Zabini
- 5 Keenan Research Centre for Biomedical Sciences, St. Michael's Hospital, Toronto, Ontario, Canada; and
| | - Alik Kornecki
- 6 Department of Pediatrics, London Health Sciences Centre, London, Ontario, Canada
| | | | - Takeshi Yoshida
- 1 The Research Institute.,2 Department of Critical Care Medicine.,3 Interdepartmental Division of Critical Care Medicine
| | - Wolfgang M Kuebler
- 7 Department of Surgery, and.,8 Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,5 Keenan Research Centre for Biomedical Sciences, St. Michael's Hospital, Toronto, Ontario, Canada; and
| | | | - Kim A Connelly
- 5 Keenan Research Centre for Biomedical Sciences, St. Michael's Hospital, Toronto, Ontario, Canada; and
| | - Brian P Kavanagh
- 1 The Research Institute.,2 Department of Critical Care Medicine.,9 Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,3 Interdepartmental Division of Critical Care Medicine.,8 Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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Controversies in the identification and management of acute pulmonary hypertension in preterm neonates. Pediatr Res 2017; 82:901-914. [PMID: 28820870 DOI: 10.1038/pr.2017.200] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 08/05/2017] [Indexed: 12/22/2022]
Abstract
It is increasingly recognized that the abnormal physiologic consequences of pulmonary hypertension (PH) may contribute to poor cardiopulmonary health in premature babies. Conflicting literature has led to clinical uncertainty, pathological misinterpretation, and variability in treatment approaches among practitioners. There are several disorders with overlapping and interrelated presentations, and other disorders with a similar clinical phenotype but diverse pathophysiological contributors. In this review, we provide a diagnostic approach for acute hypoxemic respiratory failure in the preterm neonate, outline the pathophysiological conditions that may present as acute PH, and discuss the implications of high pulmonary vascular resistance (PVR) on the cardiovascular system. Although PVR and respiratory management are highly interrelated, there may be a population of preterm neonates in whom inhaled nitric oxide may improve illness severity and may relate to outcomes. A management approach based on physiology that considers common clinical conundrums is provided. A more comprehensive understanding of the physiology may help in informed decision-making in clinical situations where conclusive scientific evidence is lacking. Regardless, high-quality research is required, and appropriate definition of the target population is paramount. A thoughtful approach to cardiovascular therapy may also provide an avenue to improve neurodevelopmental outcomes while awaiting more clear answers.
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Morini F, Capolupo I, van Weteringen W, Reiss I. Ventilation modalities in infants with congenital diaphragmatic hernia. Semin Pediatr Surg 2017. [PMID: 28641754 DOI: 10.1053/j.sempedsurg.2017.04.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Neonates with congenital diaphragmatic hernia are among the more complex patients to support with mechanical ventilation. They have particular features that add to the difficulties already present in the neonatal patient. A ventilation strategy tailored to the patient's underlying physiology rather than mode of ventilation is a crucial issue for clinicians treating these delicate patients.
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Affiliation(s)
- Francesco Morini
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Willem van Weteringen
- Department of Pediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irwin Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
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Abstract
The lungs are the only organ that receives the entire cardiac output with every stroke. The pulmonary circulation is normally a high-flow, low-resistance, low-pressure system that carries blood into the pulmonary microcirculation. In pulmonary artery hypertension (PAH)vascular remodeling contributes to a sustained elevation of pulmonary vascular resistance (PVR) and pulmonary artery pressure (PAP) as a result of vascular remodeling characterized largely by vascular smooth muscle cell proliferation and medial hypertrophy, and endothelial cell proliferation resulting in lumen obliteration. The loss of pulmonary arterial compliance and development of elevated PVR puts an excessive burden on the right ventricle due to the increased workload necessary to overcome the downstream pressure, ultimately leading to right-sided heart failure. The functional status of the pulmonary circulation and the levels of PVR and PAP ultimately determine the outcome of patients with PAH. Study of the pressure-flow relationships in the pulmonary vascular bed will provide an improved appreciation of the pathophysiology of pulmonary hypertension.
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Peták F, Albu G, Lele E, Hantos Z, Morel DR, Fontao F, Habre W. Lung mechanical and vascular changes during positive- and negative-pressure lung inflations: importance of reference pressures in the pulmonary vasculature. J Appl Physiol (1985) 2008; 106:935-42. [PMID: 19112162 DOI: 10.1152/japplphysiol.00831.2007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The continuous changes in lung mechanics were related to those in pulmonary vascular resistance (Rv) during lung inflations to clarify the mechanical changes in the bronchoalveolar system and the pulmonary vasculature. Rv and low-frequency lung impedance data (Zl) were measured continuously in isolated, perfused rat lungs during 2-min inflation-deflation maneuvers between transpulmonary pressures of 2.5 and 22 cmH(2)O, both by applying positive pressure at the trachea and by generating negative pressure around the lungs in a closed box. ZL was averaged and evaluated for 2-s time windows; airway resistance (Raw), parenchymal damping and elastance (H) were determined in each window. Lung inflation with positive and negative pressures led to very similar changes in lung mechanics, with maximum decreases in Raw [-68 +/- 4 (SE) vs. -64 +/- 18%] and maximum increases in H (379 +/- 36 vs. 348 +/- 37%). Rv, however, increased with positive inflation pressure (15 +/- 1%), whereas it exhibited mild decreases during negative-pressure expansions (-3 +/- 0.3%). These results demonstrate that pulmonary mechanical changes are not affected by the opposing modes of lung inflations and confirm the importance of relating the pulmonary vascular pressures in interpreting changes in Rv.
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Affiliation(s)
- Ferenc Peták
- Department of Medical Informatics and Engineering, University of Szeged, Szeged, Hungary
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Logan JW, Cotten CM, Goldberg RN, Clark RH. Mechanical ventilation strategies in the management of congenital diaphragmatic hernia. Semin Pediatr Surg 2007; 16:115-25. [PMID: 17462564 DOI: 10.1053/j.sempedsurg.2007.01.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Most infants with congenital diaphragmatic hernia (CDH) require respiratory support. The goal of this report is to present an overview of mechanical ventilation strategies in the management of infants with CDH. The anatomic and physiologic limitations in the lungs of infants with diaphragmatic hernia make decisions on the best strategy and use of mechanical ventilation challenging. We will briefly review lung development in infants with CDH, identifying factors that provide a basis for lung protection strategies. Background on the use of specific mechanical ventilation modes and the rationale for each are provided. Finally, we review mechanical ventilation practices described in published case series of successful CDH management, with a brief review of additional treatments, including inhaled nitric oxide and extracorporeal membrane oxygenation. Although details of a single specific best strategy for mechanical ventilation for CDH infants cannot be identified from current literature, a lung protection ventilation approach, regardless of the device used, appears to reduce mortality risk.
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Affiliation(s)
- J Wells Logan
- Division of Neonatology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA
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Miranda DR, Klompe L, Cademartiri F, Haitsma JJ, Palumbo A, Takkenberg JJM, Lachmann B, Bogers AJJC, Gommers D. The effect of open lung ventilation on right ventricular and left ventricular function in lung-lavaged pigs. Crit Care 2006; 10:R86. [PMID: 16764730 PMCID: PMC1550948 DOI: 10.1186/cc4944] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2006] [Revised: 04/18/2006] [Accepted: 05/11/2006] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Ventilation according to the open lung concept (OLC) consists of recruitment maneuvers, followed by low tidal volume and high positive end-expiratory pressure, aiming at minimizing atelectasis. The minimization of atelectasis reduces the right ventricular (RV) afterload, but the increased intrathoracic pressures used by OLC ventilation could increase the RV afterload. We hypothesize that when atelectasis is minimized by OLC ventilation, cardiac function is not affected despite the higher mean airway pressure. METHODS After repeated lung lavage, each pig (n = 10) was conventionally ventilated and was ventilated according to OLC in a randomized cross-over setting. Conventional mechanical ventilation (CMV) consisted of volume-controlled ventilation with 5 cmH2O positive end-expiratory pressure and a tidal volume of 8-10 ml/kg. No recruitment maneuvers were performed. During OLC ventilation, recruitment maneuvers were applied until PaO2/FiO2 > 60 kPa. The peak inspiratory pressure was set to obtain a tidal volume of 6-8 ml/kg. The cardiac output (CO), the RV preload, the contractility and the afterload were measured with a volumetric pulmonary artery catheter. A high-resolution computed tomography scan measured the whole lung density and left ventricular (LV) volumes. RESULTS The RV end-systolic pressure-volume relationship, representing RV afterload, during steady-state OLC ventilation (2.7 +/- 1.2 mmHg/ml) was not significantly different compared with CMV (3.6 +/- 2.5 mmHg/ml). Pulmonary vascular resistance (OLC, 137 +/- 49 dynes/s/cm5 versus CMV, 130 +/- 34 dynes/s/cm5) was comparable between groups. OLC led to a significantly lower amount of atelectasis (13 +/- 2% of the lung area) compared with CMV (52 +/- 3% of the lung area). Atelectasis was not correlated with pulmonary vascular resistance or end-systolic pressure-volume relationship. The LV contractility and afterload during OLC was not significantly different compared with CMV. Compared with baseline, the LV end-diastolic volume (66 +/- 4 ml) decreased significantly during OLC (56 +/- 5 ml) ventilation and not during CMV (61 +/- 3 ml). Also, CO was significantly lower during OLC ventilation (OLC, 4.1 +/- 0.3 l/minute versus CMV, 4.9 +/- 0.3 l/minute). CONCLUSION In this experimental study, OLC resulted in significantly improved lung aeration. Despite the use of elevated airway pressures, no evidence was found for a negative effect of OLC on RV afterload or LV afterload, which might be associated with a loss of hypoxic pulmonary vasoconstriction due to alveolar recruitment. The reductions in the CO and in the mean pulmonary artery pressure were consequences of a reduced preload.
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Affiliation(s)
| | - Lennart Klompe
- Department of Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | | | - Jack J Haitsma
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Burkhard Lachmann
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Ad JJC Bogers
- Department of Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
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