Cardiac index and oxygen delivery during low and high tidal volume ventilation strategies in patients with acute respiratory distress syndrome: a crossover randomized clinical trial

Critical Care

Achille Bernardini²  Carlo De Feo³  Carmine R Militano²  Pierluigi Ferretti²  Antonio Rosano²  Cosetta Minelli¹  Giuseppe Natalini² 

[1] Centre for Biomedicine, EURAC research, Bolzano, Italy;General Intensive Care Unit, Poliambulanza Foundation Hospital, Brescia, Italy;Intensive Care Unit, Desenzano del Garda Hospital, Desenzano del Garda, Italy

关键词: Hemodynamics;    Adult;    Respiratory Distress Syndrome;    Tidal Volume;    Cardiac Output;   

Others  :  818009
DOI  :  10.1186/cc12825

 received in 2012-12-20, accepted in 2013-07-23,  发布年份 2013

【 摘 要 】

Introduction

The beneficial effect of low tidal volume (TV) ventilation strategy on mortality in patients with acute respiratory distress syndrome (ARDS) has been attributed to the protective effect on ventilator-induced lung injury, and yet its effect on cardiovascular function might also play an important role. The aim of this study was to assess whether low TV ventilation improves cardiac output and oxygen delivery compared with high TV ventilation strategy in patients with ARDS.

Methods

In this crossover randomized clinical trial 16 ARDS patients were recruited in an intensive care unit at a university-affiliated hospital. Each patient was ventilated for 30 min with low (6 mL/kg) and 30 min with high (12 mL/kg) TV. The two experimental periods, applied in random order and with allocation concealment, were separated by 30 min of basal ventilation. Minute ventilation was constantly maintained by appropriate respiratory rate changes.

Results

Compared with high TV ventilation, low TV ventilation showed decreased pH (7.37 vs. 7.41, P = 0.001) and increased PaCO₂ (49 vs. 43 mmHg; P = 0.002). Cardiac index and oxygen delivery index were increased with low compared with high TV ventilation (3.9 vs. 3.5 L.min^-1.m^-2, P = 0.012, and 521 vs. 463 mL.min^-1.m^-2, P = 0.002, respectively), while oxygen extraction ratio decreased (0.36 vs. 0.44, P = 0.027). In four patients oxygen extraction ratio was >0.5 during high TV but not during low TV strategy. The magnitude of the change in cardiac index was positively associated with PaCO₂ variation (P = 0.004), while it was unrelated to the magnitude of changes in TV and airway pressure. The decrease of cardiac index was predicted by PaCO₂ reduction, with and area under ROC curve of 0.72.

Conclusions

Our findings suggest that a low TV ventilation strategy increases cardiac index and oxygen delivery, thus supporting the hypothesis that the beneficial effect of low TV ventilation in patients with ARDS could be partially explained by hemodynamic improvement. In other words, low tidal volume ventilation could be protective also for the cardiovascular system and not only for the lung. The slight increase of PaCO₂ during low TV ventilation seems to predict the increase of cardiac index.

Trial registration

ClinicalTrials.gov: NCT00713713

【 授权许可】

   
2013 Natalini et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 2000, 342:1301-1308.
• [2]Ranieri VM, Suter PM, Tortorella C, De Tullio R, Dayer JM, Brienza A, Bruno F, Slutsky AS: Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA 1999, 282:54-61.
• [3]Protti A, Cressoni M, Santini A, Langer T, Mietto C, Febres D, Chierichetti M, Coppola S, Conte G, Gatti S, Leopardi O, Masson S, Lombardi L, Lazzerini M, Rampoldi E, Cadringher P, Gattinoni L: Lung stress and strain during mechanical ventilation: any safe threshold? Am J Respir Crit Care Med 2011, 183:1354-1362.
• [4]Bruhn A, Bugedo D, Riquelme F, Varas J, Retamal J, Besa C, Cabrera C, Bugedo G: Tidal volume is a major determinant of cyclic recruitment-derecruitment in Acute Respiratory Distress Syndrome. Minerva Anestesiol 2011, 77:418-426.
• [5]Pinsky MR: Cardiovascular issues in respiratory care Chest 2005, 128:592S-597S.
• [6]Pinsky MR: Heart--lung interactions. Curr Opin Crit Care 2007, 13:528-531.
• [7]Boutellier U, Farhi LE: Influence of breathing frequency and the tidal volume on cardiac output. Respir Physiol 1986, 66:123-133.
• [8]Cheifetz IM, Craig DM, Quick G, McGovern JJ, Cannon ML, Ungerleider RM, Smith PK, Meliones JN: Increasing tidal volumes and pulmonary overdistention adversely affect pulmonary vascular mechanics and cardiac output in a pediatric swine model. Crit Care Med 1998, 26:710-716.
• [9]Leatherman JW, Lari RL, Iber C, Ney AL: Tidal volume reduction in ARDS. Effect on cardiac output and arterial oxygenation. Chest 1991, 99:1227-1231.
• [10]Kiiski R, Takala J, Kari A, Milic-Emili J: Effect of tidal volume on gas exchange and oxygen transport in the adult respiratory distress syndrome. Am Rev Respir Dis 1992, 146:1131-1135.
• [11]Kiiski R, Kaitainen S, Karppi R, Takala J: Physiological effects of reduced tidal volume at constant minute ventilation and inspiratory flow rate in acute respiratory distress syndrome. Intensive Care Med 1996, 22:192-198.
• [12]Ranieri VM , Mascia L , Fiore T , Bruno F , Brienza A , Giuliani R: Cardiorespiratory effects of positive end-expiratory pressure during progressive tidal volume reduction (permissive hypercapnia) in patients with acute respiratory distress syndrome. Anesthesiology 1995, 83:710-720.
• [13]Sitbon P, Teboul JL, Duranteau J, Anguel N, Richard C, Samii K: Effects of tidal volume reduction in acute respiratory distress syndrome on gastric mucosal perfusion. Intensive Care Med 2011, 27:911-915.
• [14]Cheng IW, Eisner MD, Thompson BT, Ware LB, Matthay MA: Acute effects of tidal volume strategy on hemodynamics, fluid balance, and sedation in acute lung injury. Crit Care Med 2005, 33:63-70.
• [15]Kondili E, Xirouchaki N, Vaporidi K, Klimathianaki M, Georgopoulos D: Short-term cardiorespiratory effects of Proportional Assist and Pressure-support Ventilation in patients with Acute Lung Injury/Acute Respiratory Distress Syndrome. Anesthesiology 2006, 105:703-708.
• [16]Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R: The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994, 149:818-824.
• [17]Putensen C, Mutz NJ, Putensen-Himmer G, Zinserling J: Spontaneous breathing during ventilatory support improves ventilation-perfusion distributions in patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 1999, 159:1241-1248.
• [18]Sassoon CS, Zhu E, Caiozzo VJ: Assist-control mechanical ventilation attenuates ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 2004, 170:1241-1248.
• [19]Wilkerson DK, Rosen AL, Gould SA, Sehgal LR, Sehgal HL, Moss GS: Oxygen extraction ratio: a valid indicator of myocardial metabolism in anemia. J Surg Res 1987, 42:629-634.
• [20]Levy PS, Chavez RP, Crystal GJ, Kim SJ, Eckel PK, Sehgal LR, Sehgal HL, Salem MR, Gould SA: Oxygen extraction ratio: a valid indicator of transfusion need in limited coronary vascular reserve? J Trauma 1992, 132:769-773.
• [21]Spence RK, Costabile JP, Young GS, Norcross ED, Alexander JB, Pello MJ, Atabek UM, Camishion RC: Is hemoglobin level alone a reliable predictor of outcome in the severely anemic surgical patient? Am Surg 1992, 58:92-95.
• [22]Sakr Y, Vincent JL, Reinhart K, Groeneveld J, Michalopoulos A, Sprung CL, Artigas A, Ranieri VM: High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury. Chest 2005, 128:3098-3108.
• [23]Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF, Hite RD, Harabin AL: Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006, 354:2564-2575.
• [24]Mas A, Saura P, Joseph D, Blanch L, Baigorri F, Artigas A, Fernández R: Effect of acute moderate changes in PaCO2 on global hemodynamics and gastric perfusion. Crit Care Med 2000, 28:360-365.
• [25]Kallet RH, Campbell AR, Dicker RA, Katz JA, Mackersie RC: Effects of tidal volume on work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome. Crit Care Med 2006, 34:1241-1248.
• [26]Melot C: Ventilation-perfusion relationships in acute respiratory failure. Thorax 1994, 49:1241-1248.
• [27]Bigatello LM, Davignon KR, Stelfox HT: Respiratory mechanics and ventilator waveforms in the patient with acute lung injury. Respiratory Care 2005, 50:1241-1248.
• [28]Pinsky MR: Effect of mechanical ventilation on heart-lung interactions. In Ventilator management strategies for critical care. Edited by Hill NS, Levy MM. New York, NY: Marcek Dekker Inc; 2001:655-692.
• [29]Kregenow DA, Swenson ER: The lung and carbon dioxide: implications for permissive and therapeutic hypercapnia. Eur Respir J 2002, 20:1241-1248.
• [30]Curley G, Laffey JG, Kavanagh BP: Bench-to-bedside review: Carbon dioxide. Crit Care 2010, 14:220. BioMed Central Full Text
• [31]Szold A, Pizov R, Segal E, Perel A: The effect of tidal volume and intravascular volume state on systolic pressure variation in ventilated dogs. Intensive Care Med 1989, 15:1241-1248.
• [32]Cabrera MR, Nakamura GE, Montague DA, Cole RP: Effect of airway pressure on pericardial pressure. Am Rev Respir Dis 1989, 140:659-667.
• [33]Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, Kairalla RA, Deheinzelin D, Munoz C, Oliveira R, Takagaki TY, Carvalho CR: Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Eng J Med 1998, 338:347-354.
• [34]Villar J, Kacmarek RM, Pérez-Méndez L, Aguirre-Jaime A: A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Crit Care Med 2006, 34:1241-1248.
• [35]Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, Slutsky AS, Pullenayegum E, Zhou Q, Cook D, Brochard L, Richard JC, Lamontagne F, Bhatnagar N, Stewart TE, Guyatt G: Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 2010, 303:865-873.