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    Interaksi Jantung Paru

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    Susilo Aja
    The document discusses the interaction between the heart and lungs and the effects of mechanical ventilation on cardiovascular function. It covers several key points: 1. Ventilation affects intrathoracic pressure, lung volume, and sympathetic tone, all of which impact preload, afterload, and cardiac output. 2. Positive pressure ventilation generally increases intrathoracic pressure more than spontaneous breathing, compressing the lungs and decreasing venous return. 3. These cardiovascular effects depend on the patient's cardiopulmonary status and compliance. In acute lung injury, increased airway pressures strongly correlate with increased intrathoracic pressures. 4. Low tidal volume modes like PC may cause fewer hemodynamic issues than VC in

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    © All Rights Reserved
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    Interaksi Jantung Paru

    Uploaded by

    Susilo Aja
    309 views29 pages
    The document discusses the interaction between the heart and lungs and the effects of mechanical ventilation on cardiovascular function. It covers several key points: 1. Ventilation affects intrathoracic pressure, lung volume, and sympathetic tone, all of which impact preload, afterload, and cardiac output. 2. Positive pressure ventilation generally increases intrathoracic pressure more than spontaneous breathing, compressing the lungs and decreasing venous return. 3. These cardiovascular effects depend on the patient's cardiopulmonary status and compliance. In acute lung injury, increased airway pressures strongly correlate with increased intrathoracic pressures. 4. Low tidal volume modes like PC may cause fewer hemodynamic issues than VC in

    Original Description:

    korelasi jantung dengan paru

    Original Title

    Interaksi jantung paru

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    The document discusses the interaction between the heart and lungs and the effects of mechanical ventilation on cardiovascular function. It covers several key points: 1. Ventilation affects intrathoracic pressure, lung volume, and sympathetic tone, all of which impact preload, afterload, and cardiac output. 2. Positive pressure ventilation generally increases intrathoracic pressure more than spontaneous breathing, compressing the lungs and decreasing venous return. 3. These cardiovascular effects depend on the patient's cardiopulmonary status and compliance. In acute lung injury, increased airway pressures strongly correlate with increased intrathoracic pressures. 4. Low tidal volume modes like PC may cause fewer hemodynamic issues than VC in

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    309 views29 pages

    Interaksi Jantung Paru

    Uploaded by

    Susilo Aja
    The document discusses the interaction between the heart and lungs and the effects of mechanical ventilation on cardiovascular function. It covers several key points: 1. Ventilation affects intrathoracic pressure, lung volume, and sympathetic tone, all of which impact preload, afterload, and cardiac output. 2. Positive pressure ventilation generally increases intrathoracic pressure more than spontaneous breathing, compressing the lungs and decreasing venous return. 3. These cardiovascular effects depend on the patient's cardiopulmonary status and compliance. In acute lung injury, increased airway pressures strongly correlate with increased intrathoracic pressures. 4. Low tidal volume modes like PC may cause fewer hemodynamic issues than VC in

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    INTERAKSI

    JANTUNG PARU

    INTRODUCTION
    UNIT KARDIORESPIRASI
    JANTUNG
    SISTIM PEMBULUH DARAH
    FUNGSI PARU

    VENTILASI
    LUNG VOLUME
    INTRATHORACIC PRESSURE
    SURROUNDING PRESSURE
    ENDOCRINOLOGIC RESPONSE

    MYOCARDIAL RESERVE

    CIRCULATING BLOOD VOLUME


    AUTONOMIC TONE
    BLOOD FLOW DISTRIBUTION

    FUNGSI KARDIOVASKULAR

    RESPONS KARDIOVASKULAR
    TERHADAP
    MANUVER VENTILASI MEKANIK

    BASELINE DARI FUNGSI SISTIM


    KARDIOVASKULAR PASIEN

    HUBUNGAN ANTARA AIRWAY PRESSURE,


    INTRATHORACIC PRESSURE, DAN LUNG VOLUME

    CONSEPT ~ HAS BEEN WIDELY ACCEPTED


    PPV - MELALUI AIRWAY PRESSURE
    LANGSUNG MEMPENGARUHI HEMODINAMIK
    Paw = Pleural Pressure and Lung Volume

    wrong assumption

    SEBETULNYA
    Paw SANGAT TERGANTUNG PADA:
    POLA VENTILASI
    AIRWAY RESISTANCE
    LUNG COMPLIANCE

    Paw TIDAK MEREFLEKSIKAN Ppc


    (= Transmural LV Pressure)
    SECARA AKURAT

    LUNG VOLUME
    INTRATHORACIC PRESSURE

    RESPON HEMODINAMIK
    TERHADAP VENTILASI

    HEMODYNAMIC EFFECTS OF
    VENTILATION
    ADA 3 KONSEP DASAR YG HRS DIPAHAMI
    1. BERNAFAS = EXERCISE, KEBUTUHAN O2 DAN
    ELIMINASI CO2
    2. INSPIRASI : INTRAPLEURAL PRESSURE

    LUNG VOLUME
    3. BERNAFAS SPONTAN : ITP
    , SEDANGKAN
    VENTILASI TEKANAN POSITIF /PPV: ITP

    EFEK HEMODINAMIK AKIBAT


    PERUBAHAN PADA VOLUME PARU
    PERUBAHAN PADA VOLUME PARU
    MENYEBABKAN EFEK PADA:
    TONUS SIMPATIS OTONOM
    RESISTENSI PEMBULUH DARAH PARU /
    Pulmonary Vascular Resistance

    TONUS SIMPATIS OTONOM


    RESP SINUS ARRHYTHMIA
    Inspiration-associated cardioacceleration
    Vagally mediated reflex arcs
    lung inflation to normal TV <10 cc/kg
    heart rate

    the

    ADH INDUCED FLUID RETENTION

    MECHANICAL VENTILATION-INDUCED CHANGES IN


    PULMONARY VASCULAR RESISTANCE (PVR)

    PVR

    Alveolar
    compression

    Total PVR

    Alveolar Vessels

    Hypoxic pulmonary
    vasoconstriction

    Extra-alveolar
    vessels

    RV

    FRC

    LUNG VOLUME

    TLC

    VENTRICULAR INTERDEPENDENCE
    50

    35

    20

    LV Pressure (mmHg)

    20

    10

    0
    0

    10

    20

    30

    40

    LV VOLUME (ml)
    The effect of increasing right ventricular (RV) volumes on the left
    ventricular (LV) diastolic pressure-volume (filling) relationship.
    Increase on RV volume decrease LV diastolic compliance

    HEMODYNAMIC EFFECTS OF CHANGES IN


    INTRATHORACIC PRESSURE ON THE LV FILLING AND
    EJECTION PRESSURE
    Increasing ITP decreases the
    pressure gradient for venous
    return and LV gradient

    ITP
    VENOUS
    RETURN

    THORAX

    LV
    EJECTION

    ITP
    Decreasing ITP increases the
    pressure gradients for venous
    return and LV gradient

    Decrease in ITP that decrease Pra to below zero relative to atm pressure
    increase venous return by only a limited amount; increases in ITP
    progressively decrease venous return to a complete circulatory standstill

    Blood Flow (L/m)

    6
    5

    ITP

    ITP

    3
    2

    Venous return
    curve

    1
    -5

    0
    5
    Right Arterial Pressure (mmHg)

    10

    HEMODYNAMIC EFFECTS OF VENTILATION


    BASED ON CARDIOPULMONARY STATUS
    Should be clear that:
    Spont and PPV have profound hemodynamic
    consequences and might even have opposite
    effects on the cardiovascular stability in the
    different populations of patients
    Different modes of mechanical ventilatory
    support, by varying degree of the patients
    effort and thus changes in WoB and ITP as well
    as the level of lung volume, also alter the
    hemodynamic response.

    Fundamental of cardiopulmonary
    interaction
    SPONT VENT LUNG VOLUME
    ITP
    IPPV
    LUNG VOLUME
    ITP
    Most hemodynamic differences between spont
    ventilation and IPPV reflex differences in ITP and
    energy to create this swings
    Changes in both lung volume and ITP need to be
    considered when assessing the hemodynamic
    effects of either spont ventilation or IPPV

    The effects of changes in ITP on the LV pressure-volume


    relation (ESPVR) when cardiac contractility is normal

    LV Pressure

    ESPVR
    ITP

    Decreased
    LV Ejection
    Pressure

    Increased LV
    ejection Pressure

    Increased LV Preload

    ITP
    Decreased
    LV Preload

    Diastolic compliance

    LV Volume

    ITP

    = EDV

    , ESV

    SV

    ITP

    = EDV

    , ESV

    SV

    The effects of changes in ITP on the LV pressure-volume


    relation (ESPVR) when cardiac contractility is impaired and
    volume status is expanded

    LV Pressure

    ESPVR
    Increased LV
    ejection Pressure

    Decreased
    LV Ejection
    Pressure

    Decreased
    LV Preload

    ITP

    ITP

    Increased LV Preload
    Diastolic compliance

    LV Volume

    ITP

    = EDV

    , ESV

    SV

    ITP

    = EDV

    , ESV

    SV

    ACUTE LUNG INJURY


    PEEP sangat diperlukan untuk
    mempertahankan distensi alveolus sehingga
    oksigenasi arteri lebih baik.
    Pada prinsipnya peningkatan tekanan jalan
    nafas tidak merefleksikan peningkatan ITP,
    namun khusus pada pasien dgn ALI dimana
    terjadi penurunan compliance paru dan
    dinding dada, maka setiap peningkatan
    volume paru oleh ventilasi mekanik akan
    meningkatkan ITP.

    SINGER AND COWORKERS;

    Hyperinflation determine the decrease


    in CO, not Paw.
    Hyperinflation can be counterbalanced,
    in part, by fluid rescucitation that restore
    the ITBV to the pre-PEEP level.

    Lessard and coworkers:

    Compare VC, PC and PC-IRV in 9


    ARDS
    Because PEEP and TV consistent, the ITP
    were similar
    Arterial pressure was slightly lower with
    PC-IRV compare to VC and PC
    But no significant hemodynamic effects
    were seen.

    Chan and Abraham:

    Similar results in 10 ARDS patients


    macth for comparable TV and total
    PEEP

    Abraham and Yoshihara, Poelaert and


    colleagues;

    Membandingkan mode PC (TV kecil)


    dgn VC
    Kesimpulan bahwa insiden penurunan
    CO lebih sedikit pada pasien yg
    menggunakan PC

    Christian and coworkers;


    APRV (BIPAP) dapat meningkatkan performa
    jantung pada pasien dengan ALI/ARDS
    Dengan mode APRV maka peak pressure dan
    Mean Paw akan lebih rendah sehingga
    transmisi ITP akan lebih kecil juga.
    Dengan turunnya ITP maka venous return
    akan meningkat, selanjutnya performa jantung
    juga akan lebih baik, sehingga mengurangi
    insiden pemakaian vasopresor untuk
    menunjang MAP dan DO2.

    COPD
    Masalah utama hemodinamik sangat
    berhubungan dengan dynamic hyperinflation
    Dynamic hyperinflation akan menyebabkan
    timbulnya auto/intrinsic PEEP
    Auto PEEP + PPV akan meningkatkan
    overdistensi alveolar
    Ppl
    venous return
    Asmatic attact/acute on COPD decreased
    ITP (mean 30 cmH2O) pulmonary edema
    (from PPV to spont)

    Intrinsic plus extrinsic PEEP ~


    alters hemodynamic function,
    except the ext PEEP is delivered
    below the intrinsic level of PEEP

    Weaning of patients with COPD


    Severe COPD may experience
    cardiogenic pulmonary edema
    during weaning
    The cause probably combined
    volume overload and increased LV
    failure due to decrease LV-EF, and
    after diuresis many of these
    patients can be subsequently
    weaned.

    MOHSENIFAR AND COLLEAGUES;

    Patients who could not weaned had a


    gastric pHi that was substantially
    reduced from 7.36 during IPPV to 7.09
    during weaning.
    Patients who succesfully weaned show
    little change in pHi (7.45 to 7.46).
    Thus, occult cardiovascular insuffisiency
    may play a major role in failure to wean
    in critical ill patients

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