Heart lung

interaction
Ubaidur Rahaman
Senior Resident,
CCM, SGPGMS,
Lucknow, ndia
Theprimaryfunctionof thecardiovascular- pulmonarysystemis
tolinkmetabolizingcellswithenergysourcesintheenvironment
MotherNatureisthemeanestmanagementGuru
intermsof costeffectiveness
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
P1 P2
P1> P2
Pressure gradient (P) = P1-P2
Relatonship between FLOW and PRESSURE
At a constant P flow depends upon
RESISTANCE
intra mural pressure
RESISTANCE
to that flow
(Poiseuille equation) Resistance
= viscosity of fluid, L= length of tube, r= radius of tube
Force driving flow (F) = P/ R
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Psur
Relatonship between FLOW and PRESSURE
TRANSMURAL PRESSURE
Radius (r) of any collapsible tube depends on
distending pressure
Transmural Pressure = intramural pressure surrounding pressure
(Ptm = Pim Psur)
Pim
Psur
Psur
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
In a collapsible tube if volume is not allowed to change
so that Ptm will remain unchanged
Change in Psur will bring about similar change in Pim
10
4
4
Ptm = 10-4=6
1
7
1
Ptm = 7-1=6
Volume will remain unchanged only when Ptm remains unchanged
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Analogous scenario
if lungvolumeisnotallowedtochange,
thentranspulmonarypressurewillnotchange
andrelationshipbetweenairwaypressureandpleuralpressure
willremainconstant
mullersmaneuverorvalsalvamaneuver
changeinpleuralpressure
willbringidenticalchangeinairwaypressure
sothatlungvolumeremainsconstant
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Surroundpressureforintrathoracicvascularstructures
outsidethealveoliandtheirvesselsis
JUXTACARDIACPLEURALPRESSURE
changesinITPwillbringaboutsimilarchangesinPimof vascularstructures
INTRATHORACICPRESSURE(ITP)
whichisdefinedas
changesinITPwillbringaboutsimilarchangesinPimof vascularstructures
(sothatPtmremainsconstant)
andthischange
willbemeasuredbydevice(whichmeasureitrelativetoPatm)
thisiseasilyappreciableinpatientswitharterialline
duringcoughing(causingincreasedITP)increasedarterialpressure
couldbeseenonmonitor
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
anotheranalogy
Shipinthewaterappearingtoriseandfall
asitisacteduponbypassivewaveswhenviewedfromshore.
Thesameship,howeverdoesnotchangeitsrelationshiptowater,
andasforastheshipisconcernedisquietstableinthesea,
andisnotforeversinkingandrisingagain
Cardiopulmonary interaction, Pinsky, Cardiopulmonary Critical Care, W.B. Saunders
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
ITP
ITP
Whatweroutinelymeasure
Pim
Arterial Pressure
Central venous pressure
Pim in relation to Patm
ITP
Measurement of Pleural pressure or pericardial pressure is difficult and tricky
Central venous pressure
Ppa/Ppao
For Transmural pressure
We need Pleural pressure or pericardial pressure
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
ForheartPsurispericardialpressure(Ppc)
Ttm=Pim Ppc
Pericardium
highextensibilityatlowlevelof stress
withanabrupttransitiontorelativeinextensibilityathigherstress
thereforeitexertsarestrainingeffectonvolumeof heart
Physiologic role of normal pericardium
Matthew W. Watkins, Martin M. LeWinter, annu. Rev. Med 993;44:171-180
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Whenheartisnotdistendedandpericardiumisnotdiseased
Ppc = Ppl
Ppc >> Ppl
heartisdistended
primarycardiacdiseaseorventricularinterdependence)
but
if
primarycardiacdiseaseorventricularinterdependence)
(pericardiumexertsrestrainingeffect)
pericardiumisdiseased
pericardialfluidordecreasedpericardialcompliance
overdistensionof lungormassivepleuraleffusionortensionpneumothorax
compressingheartincardiacfossa
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Allwetalkedaboutismechanicalfactors
but
thereareotherfactorswhichsimultaneouslyanddependently
playrole
Mural smooth muscle ( vascular, cardiac)
Neuro-humoral factors effecting these smooth muscles
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Transient effects: mechanical
Periodic changes induced by respiratory cycle (phasic effects)
or unsustained effects of various respiratory manoeuvres like
coughing, straining, recruitment manoeuvre coughing, straining, recruitment manoeuvre
Steady state effects: mechanical and neuro-humoral
Impact of sustained alterations of respiratory conditions:
PEEP, CPAP, weaning
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Autonomic tone
Respiratorysinusarrhythmia(normalautonomicresponsiveness)
LunginflationatVt>15ml/kgheartratebysympatheticwithdrawal
Reflexvasodilationwithlunghyperinflation
Humoralfactors
Sustainedhyperinflationinducesfluidretentionby
Changes In Lung Volume
Neuro-humoral interactions
Sustainedhyperinflationinducesfluidretentionby
plasmanorepinephrineandreninandAtrialnatriureticpeptide(ANP)
compressionof heartincardiacfossaby
juxtacardiacITPandLungVolume
PVR(byhyperinflation)
Mechanical interactions
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Primary difference in NPV and PPV
Negative pressure ventilation
primary change is in pleural pressure which leads to
change in airway pressure
Positive pressure ventilation
primary change is in airway pressure which leads to
change in pleural pressure
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Palv
Ppl Ppl
Patm
Patm
Ppc
Surrounding Pressures of Circulatory System
Ppl
Ppl
Pabd
Pabd
Patm
Patm= 0
Ppl= -2 to -5
Pabd = <5
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
PLEURALPRESSURE
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
50
75
100
Chest wall
Lung
Chest wall and Lung
( respiratory system)
V
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TLC
P-V curve of Lung, Chest wall and Respiratory system
0
25
50
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-20 20
FRC
RV
Pressure ( cm H2O)
Ppl, Pcw, Prs
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%
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
RestingVolumeofRespiratorysystem
At End Expiration
Elastic force of LUNG Elastic force of CHEST WALL
=
Negative pleural pressure
Functional Residual Capacity
(FRC)
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Pleural space is only a potential space
Pressure is difficult to measure
But can be estimated from distal esophageal pressure
( in posterior mediastinum where esophagus lies between two pleural recesses)
Pleural pressure is not uniform throughout the pleural space
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Effectofgravity
+
weightoflung
Vertical gradient
in in
Ppl and TTP
Dependent alveoli have lesser volume
than non dependent alveoli
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Thistruthremainstrue
whenlungvolumeisincreasing
Change in Pleural Pressure is
NOT UNIFORM
When lung is inflating
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Lateral chest wall moves outward
Less change in Ppl
Heart and great vessels
In cardiac fossa
TRAPPED AND COMPRESSED
Greater change in Ppl
Diaphragm most compliant
Least change in Ppl
Less change in Ppl
Pleural pressure change
juxta cardiac > lateral chest wall > diaphragm
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Obesity
compliance of lateral chest wall decreases
Greater change in Ppl
In different pathological states
Greater change in Ppl
Intra abdominal hypertension
compliance of diaphragmatic pleura decreases
Greater change in Ppl
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Change = +2
Change = +3
Cardiopulmonary interaction, Pinsky, Cardiopulmonary Critical Care, W.B. Saunders
Change = +5
Change = +10
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Pleural pressure has to be defined accordingly
Lung compliance
lateral chest wall pleural pressure
Hemodynamic
juxta cardiac pleural pressure
Diaphragmatic work
diaphragmatic pleural pressure
juxta cardiac pleural pressure
Eosophageal pressure estimates diaphragmatic pleural pressure
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Relationship between
PLEURAL PRESSURE, LUNG VOLUME and AIRWAY PRESSURE PLEURAL PRESSURE, LUNG VOLUME and AIRWAY PRESSURE
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
ITP / Palv = 1/(1+Ccw/CL )
In healthy subjects, Ccw=CL, during normal tidal volumes
ITP / Palv =
Relation betweenAlveolar pressure and Pleural pressure
Half of applied PEEP would be expected to be transmitted to
ITP
Decrease in CL will decrease the transmission
Clinical review: positive end expiratory pressure and cardiac output
Thomas Luecke, Palolo Pelosi. Crit Care 2005,9:607-621
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Relationshipbetween
PLEURALPRESSURE,LUNGVOLUMEandAIRWAYPRESSURE
innormalanddiseasedlung
control
ALI
control
Cardiopulmonary effect of positive pressure ventilation during acute lung injury.
Romand JA, Shi W, Pinsky MR. Chest 1995;108:1041-1048
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
control
ALI
Relationshipbetween
PLEURALPRESSURE,LUNGVOLUMEandAIRWAYPRESSURE
innormalanddiseasedlung
Cardiopulmonary effect of positive pressure ventilation during acute lung injury.
Romand JA, Shi W, Pinsky MR. Chest 1995;108:1041-1048
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Primary determinant of increases in Pleural Pressure during PPV is
change in LUNG VOLUME,
not change in airway pressure
If tidal volume is kept constant, pleural pressure will increase equally,
independent of the mechanical properties of lung
Decreased compliance/ higher airway resistance
higher Paw required to generate similar tidal volume
Heart lung interactions.
Pinsky MR, Textbook of Critical Care, 5
th
edition, Elsvier Saunders
Presumably pericardial pressure does not increase as much as ITP
because increasing lung volume reduces filling of ventricles,
decreasing their size inside cardiac fossa
It is difficult to estimate changes in pleural pressure or pericardial pressure
that will occur in patient as PEEP is increased.
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
LV RA
Patm
Patm
Ptm = Pim - Patm
Ppl Ppl
Ptm = Pim - Ppl
Surrounding Pressures of Circulatory System
LA
LV RA
RV
Ptm = Pim - Ppl
Ppl
Ppl
Ppl
Ppl
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
ChangesinPtmwillbesimilarwithanychangeinITP
forallintrathoracicstructures
Nochange in
RVafterload
gradienttoflowinPulmonarycirculation
LVpreload
Change in ITP independent of change in lung volume
Except
thosecontinuingasextrathoracicstructure-
Aortaandgreatveins
Gradienttoflow
Venousreturnandcardiacejection
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
VR and ITP VR and ITP
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
IncreasedITP
IncreasedMSFP
IncreasedResistancetoVR
VR and ITP
increasedPimof RA
DecreasedVR
DecreasedPimof RA
DecreasedPtmof RA
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Trendrecordingof
RApressure,juxtacardiacPleuralpressureandRAtransmuralpressure
Cardiopulmonary interaction, Pinsky, Cardiopulmonary Critical Care, W.B. Saunders
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
LV afterload and ITP LV afterload and ITP
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
increaseITP---- increasePimAorta
Intrathoracic aorta
Ptmunchanged(Ptm=Pim ITP)
Extrathoracic aorta
Ptmincreased(Ptm=Pim- Patm)
sensedbycarotidbaroreceptors
vasodialation
DecreasedPim
Intrathoracicaorta
LV afterload and ITP
vasodialation Intrathoracicaorta
DecreasedPim
Ptm
cametobaselinevalue
DecreasedPtmof intrathoracicaorta
LVPtmrequiredtoopenAValsodecreased
DecreasedLVwallstress DecreasedLVafterload
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Reflexvasodilatation Reflexvasoconstriction
Cardiopulmonary interaction, Pinsky, Cardiopulmonary Critical Care, W.B. Saunders
Reflexvasodilatation Reflexvasoconstriction
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
ConceptofAFTERLOAD
Walltension=Transmuralpressure radiusofcurvature/wallthickness
T=Ptm r/h
(LaplacesLaw)
Of anygivenvolume,geometricalshape,withsmallestradiusof curvatureis
SPHERE
Moststablegeometricalshape,of anyvolume
Airbubblesacquiresphericalshape
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
LVejectsbloodintoAortawhenAVopens
AVopenswhenLVPtmexceedsAorticPtm
LVPtmisgenerated(isovolumetriccontraction)
TogeneratethisPtm,tensionisgeneratedinmusclefibre(isometriccontraction)
ThisTensiongenerationrequiresATP
WORKOFPUMPING
IncreasedITP
AorticPtmisdecreased
LVPtmrequired,toopenAV,alsodecreased
Tensiongeneratedinmusclefibrealsodecreased
AFTERLOADISDECREASED
STROKEVOLUMEISINCREASED
DEREASESD WORK OF PUMPING
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
c
d
LVESPVR
100
150
C-AVO
d-AVC
a-MVO
b-MVC
LV PRESSURE VOLUME CURVE
LV volume
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Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
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End systolic length
CARDIAC MUSLCE LENGTH TENSION CURVE
Muscle length
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End diastolic length
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
LVESPVR
100
150
LV PRESSURE VOLUME CURVE
Afterload = 90 mm Hg
SV = 80 ml
Afterload = 70 mm Hg
SV = 105 ml
LV volume
50
130
50
LVESDVR
L
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SV = 105 ml
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
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CARDIAC MUSLCE LENGTH TENSION CURVE
Peak isometric tension
Muscle length
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Resting tension
Decreased muscle tension
Decreased wall stress
Decreased work
Decreased oxygen requirement
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Clinical implications
This increase or decrease in afterload will have marked
effect in
LV dysfunction LV dysfunction
poor frank starling curve
Marked variation in pleural pressure esp negative
lung airway and parenchymal disease
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
RV afterload, Pulmonary circulation,
LV preload LV preload
&
Lung volume
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
lung volume and PVR (RV afterload)
(bimodalrelation)
P
V
R

P
V
R

Lung volume
RV TLC FRC
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
West zones of pulmonary
circulation
PA >Pa >Pv
Pa=Pulmonary arterial pressu
PA=Alveolar pressure
Pv=Pulmonary venous pressu
Pa >Pv >PA
Pa >PA >Pv
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Ventricular Ventricular
Interdependence
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
LV RV
pericardium
LV RV
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
ForheartPsurispericardialpressure(Ppc)
Ttm=Pim Ppc
Pericardium
highextensibilityatlowlevelof stress
withanabrupttransitiontorelativeinextensibilityathigherstress
thereforeitexertsarestrainingeffectonvolumeof heart
Physiologic role of normal pericardium
Matthew W. Watkins, Martin M. LeWinter, annu. Rev. Med 993;44:171-180
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
commonseptum&circumferentialfibres
expansionof bothventriclesconstrainedbyacommonpericardium
(pericardialconstraint)
RV & LV mechanically coupled
Diastolicfillingofoneventriclehastobeatthecostofanother
diastolicfillingofoneventriclewillaffectthegeometryandstiffnessofanother
PARELLEL INTERDEPENDENCE
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
0 50 35 20
L
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RV end diastolic volume
10
20
Changes in RVEDV, changed LV diastolic compliance
10 20 30
LV end diastolic volume (ml)
L
V

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(
m
m
H
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)
40
5
Heart lung interactions.
Pinsky MR, Textbook of Critical Care, 5
th
edition, Elsvier Saunders
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Outputof RVispreloadof LV
SERIES INTERDEPENDENCE
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Myocardialcontractilityisnot Myocardialcontractilityisnot
significantlyaffectedbyITP
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
So
This was heart. .lung interaction
Is our interaction still preserved?
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
..ThankYou