Cardiopulmonary Monitoring: Basic Physiology, Tools, and Bedside Management for the Critically Ill

Description

This book offers a comprehensive overview of the basic physiology of the cardiac and pulmonary systems, tools for cardiopulmonary monitoring, and related issues in the management of specific conditions. The volume is divided into three main parts. The first part examines the functional basis of normal and abnormal physiology, organized into cardiac and pulmonary units and followed by a “combined” interactive component. The next section discusses cardiopulmonary monitoring tools and variables and is also divided into cardiac (e.g, echocardiography, heart rate, cardiac output), pulmonary (e.g, lung volume, pleural pressure, electrical impedance tomography), and combined tools such as radiology/MRI and tissue perfusion tests. The third section concerns the management and application of specific clinical problems such as pulmonary hypertension, cardiac shunts, cardiogenic shock, and ECMO with an emphasis on the physiological basics.  Acknowledgements Contents Contributors 1: Introduction: To the Love of Physiology Part I: Physiological Basics: Cardiovascular Basics 2: Volume and Regulation of Cardiac Output Pressure-Volume Relationship Capacitance Uniqueness of Volume-Pressure Relationship of the Cardiac Chambers Pressure-Flow Relationship Importance of Compliance for Blood Flow Flow from a Single Compliant Region Bathtub Concept Difference Between Hydraulic and Electrical Models of the Circulation Guyton’s Analysis Guyton’s, Graphical Approach Summary of Interaction of Cardiac and Return Functions Limits of the Cardiac and Return Functions Krogh’s Two-Compartment Model of the Circulation Summary References 3: Function of the Right Heart Introduction Origins of the Right Heart Differences Between RV and LV Right Ventricular Ejection Basic Principles Pressure-Volume Loops of the Right and Left Ventricles Role of Pulmonary Arterial Compliance Pressure Load vs. Volume Load Definitions of Right Ventricular Limitation, Dysfunction, Failure Right and Left Ventricular Interactions Is the Right Ventricle Necessary for Normal Aerobic Function? Importance of Right Coronary Blood Flow Why Is Presence of a Dysfunctional Right Ventricle Often Worse than No Right Ventricle? Conclusion References 4: Function of the Left Heart Basic Cardiac Muscle Characteristics Cardiac Muscle Tension-Length Relationships Ventricular Pressure-Volume Relationships The End-Systolic Pressure-Volume Relationship (ESPVR) and Emax Time-Varying Elastance and Maximum Elastance (Emax) Isovolumic Measures of Ventricular Contractility Ventricular Energetics Myocardial Oxygen Consumption Connection of Pressure-Volume Relationships with Ventricular Function Summary References 5: Pulmonary Vascular Resistance Introduction Definitions Nonlinearities in the Pulmonary Circulation Vascular Distensibility Starling Resistors Pulmonary Vascular Resistance in Presence of Starling Resistors Vascular Compliance Interpretation of Overall PVR Effect of Lung Inflation on PVR Summary References 6: Fluid Filtration in the Microcirculation Introduction The Revised Starling Principle: Basic Science Principles The Endothelial Glycocalyx: Primary Barrier to Circulating Plasma Proteins The Sub-Glycocalyx Space Classical Versus Revised Starling Principle Filtration Rate as a Function of Microvascular Pressure in the Revised Starling Principle Recap and a Textbook Figure to Forget Passive Coupling Ensures Epithelial-Endothelial Fluid Reabsorption Filtration and Reabsorption in the Kidney Filtration and Reabsorption in the Intestinal Mucosa Reabsorption in the Lymph Nodes Regulation of Microvascular and Tissue Pressures Microvascular Pressure Regulation of Interstitial Pressure Clinical Examples Blood Loss and Saline Infusion Lung Fluid Balance Further Considerations Monitoring the Stability of the Endothelial Glycocalyx Circulating Glycocalyx Components Optical Methods Measurement of Whole Body Glycocalyx Volume References 7: Physiology of Heart Rate Time Constants and Volume Constraints Cardiac Rhythmicity at the Cellular Level Sinoatrial Node Control Mechanisms of SAN Automaticity Membrane Clock Calcium Clock Extrinsic SAN Control Central Nervous System Circulating Factors Intrinsic SAN Control Intracardiac Nervous System Myogenic Peptides Tissue Stretch Determinants of the Heart Rate Dependence of the Length of the Action Potential Immediate Change in APD After a Sudden Decrease in HR or a Premature Excitation Transient Change in APD After a Decrease in HR APD at a New Steady State Intrinsic Heart Rate Normal Control of Heart Rate During Exercise Heart Rate, Beta Blockers, and Ejection Fraction Tachycardia and Hypovolemia Bainbridge Reflex Heart Rate and the Interaction of Venous Return and Cardiac Function in the Guyton Analysis Heart Rate and Diastolic Limitation Supply Demand of the Heart Conclusion References 8: Physiological Aspects of Arterial Blood Pressure Physical Principles Elastic Energy Kinetic Energy Gravitational Energy Why Is Mammalian Arterial Pressure Set So High Compared to Lower Species? Regional Distribution of Flow Critical Closing Pressure What Determines Pulse Pressure? Impedance Where Should Pressure Be Measured and Which Pressure? Conclusion References 9: Pulsatile Haemodynamics and Arterial Impedance Arterial Wall Properties and Pulsatile Haemodynamics Vascular Impedance Arterial Wave Reflections Changes of Waveforms in the Arterial System Non-invasive Assessment of Pulsatile Haemodynamics and Central Aortic Pressure Pulsatile Haemodynamics and Ventricular Arterial Coupling Conclusions References 10: Basics of Fluid Physiology Introduction What Is the Role of Water in Organisms? Volume and the Generation of Blood Flow Compartments Regulation of the Distribution of Body Water and Electrolytes What Are Osmoles? Extracellular Fluid Dynamics Movement and Distribution of Fluids Pure Water and Dextrose in Water Normal Saline Hypertonic Sodium Chloride Solutions Iso-oncotic Colloids Hyper-oncotic Solutions Sodium Bicarbonate Solution Summary References 11: Cerebral Hemodynamics Introduction to Intracranial Physiology Cerebral Blood Flow and Circulation CPP and Pressure Autoregulation Cerebral Perfusion Pressure Pressure Autoregulation Elevated ICP and Relationships/Targets of CPP Cerebral Metabolic Rate of Oxygen Cerebral Oxygenation and CO2 Reactivity Ischemia Mitochondria Carbon Dioxide and Hyperventilation Pharmacologic Regulation Osmotherapy Mannitol Hypertonic Saline Sedation Propofol Benzodiazepines Opioids Barbiturates Dexmedetomidine Neuromuscular Junction Blockers Conclusion References Part II: Physiological Basics: Pulmonary Basics 12: Stress, Strain, and the Inflation of the Lung Introduction Stress and Strain in 1D: Pressure and Volume More Complicated Models of Lung Inflation Prestress and the Shear Modulus Stress Transmission in the Lung Nonuniform Inflation: Stress Multipliers Barotrauma and Volutrauma Viscoelasticity, Respiratory Rate, and Mechanical Power Conclusion References 13: Physiology of PEEP and Auto-PEEP Introduction and Definitions Fundamental Concepts Transmural Pressure Regional Heterogeneity PEEP, Mean Airway Pressure, and Hemodynamics Interaction of the Venous Return and Starling Curves Influence of PEEP on the Determinants of Cardiac Output PEEP and Transmural Cardiac Pressures PEEP and Afterload Left Ventricular Afterload Right Ventricular Afterload PEEP Effects on Myocardial Contractility and Compliance “Braking” Effect of PEEP on Heart Rate PEEP and Lung Edema Spontaneous Vs. Passive Inflation and PEEP’s Cardiopulmonary Effects Selected Clinical Applications Hemodynamic Monitoring Dynamic Hyperinflation and Auto-PEEP PEEP on Auto-PEEP Conclusion References 14: Basics of Ventilation/Perfusion Abnormalities in Critically Ill Ventilated Patients Introduction General Considerations and Theoretical Basis of Gas Exchange Ventilation–Perfusion Relationships Shunt Bohr Dead Space The Alveolar-Arterial Difference (AaDO2) Assessing Matching with the Multiple Inert Gas Elimination Technique (MIGET) Clinical Assessment of Ventilation-Perfusion Matching Ventilation-Perfusion Matching in Healthy Young Subjects Effects of Gravity and Posture Effect of Aging Effect of Obesity Effect of Lung Disease Relationships in Acute Respiratory Distress Syndrome (ARDS) Effect of Positive Airway Pressure Tidal Volume, Ventilation Mode, and Cardiac Output References 15: Control of Breathing Control of Breathing Respiratory Rhythm Generation Modulation: Chemoreflex, Mechanoreflex, and Negative Feedback Efferent Pathways: CNS-Processed Signal Targeting Effector Respiratory Muscles Ventilatory Response to Arterial PO2, PCO2, and pH Central Chemoreceptors Arterial Chemoreceptors Reflexes from the Lungs and Airways Nose and Upper Airways Lungs and Lower Airways Pulmonary Stretch Receptors Bronchial C-Fibers Juxtacapillary Receptors Autonomic Nervous System in the Lungs Patients in the Intensive Care Unit Clinical Implications References 16: Respiratory Muscle Blood Flow and Heart–Lung Interactions Introduction The Respiratory Muscles Anatomy Energetics and Mechanics Normal Resting Respiratory Muscle Blood Flow and the System at Peak Effort Role of Afferent Fibers Conclusion References 17: Surfactant Activity and the Pressure-Volume Curve of the Respiratory System Introduction Surface Tension Pressure-Volume Behavior, Recruitment, and Static Surface Tension Recruitment and the Origin of Crackles Surfactant Composition Surfactant Activity Surfactant Secretion and the Subphase Alveolar Collapse and Phase Transitions in Surfactant Lipid Layers Current View of Surfactant Function Surfactant Function and Replacement in Acute Respiratory Distress Syndrome (ARDS) Conclusion References Part III: Physiological Basics: Interactions 18: Heart-Lung Interactions Introduction Guyton’s Graphical Analysis of the Regulation of Cardiac Output Changes in Ppl Fall in Ppl: Spontaneous Breath Effect of Decrease in Ppl on the LV Rise in Ppl: PEEP and Mechanical Ventilation Effect of Increase in Ppl on the LV Effect of Transpulmonary Pressure Effect of Lung Inflation Respiratory Variations in Heart Rate RV-LV Interactions During Ventilation Pulsus Paradoxus Inverse Pulsus Paradoxus HJR Active Expiration Kussmaul’s Sign Mueller Maneuver Valsalva Summary References Part IV: The Tools: Cardiovascular 19: Evaluation of Devices for Measurement of Blood Pressure Introduction Invasive Arterial Blood Pressure Measurement (Arterial Catheter) Intermittent Non-invasive Arterial Blood Pressure Measurement Non-invasive Continuous Arterial Blood Pressure Measurement The Future of Arterial Blood Pressure Measurement Conclusion References 20: Measurement of Cardiac Output Cardiac Output and Clinical Decision-Making Normalization of Cardiac Output Measurement The Fick Principle General Theory Sources of Error Using the Fick Principle Errors of Sampling and Analysis Errors due to Changes in Cardiac Output Errors due to Changes in Respiration Continuous Cardiac Output BT the Fick Method Indicator Dilution Methods Thermodilution Technique General Theory Sources of Variability Errors Related to the Injectate Errors Related to Physiologic and Pathophysiologic Factors Analytical Problems Reliability Continuous Thermodilution Technique Use of Expired Gases and the Fick Principle to Measure Cardiac Output Rebreathing Technique Potential Problems Single-Breath Technique Foreign Gas Method Pulse Contour Analysis Vigileo™-FloTrac System LiDCO plus® System PiCCO System Esophageal Doppler Echocardiographic Techniques Transthoracic Echocardiography Transesophageal Echocardiography Methods that Assess Changes in Thoracic Volume Thoracic Electrical Bioimpedance Thoracocardiography Conclusions and Future Directions References 21: Evaluations of Devices for Measurement of Cardiac Output Quality Criteria Common to Measurements and Devices Specific Quality Criteria for Devices Procedures for the Device Validation Conclusion References 22: Basics of Hemodynamic Measurements Volume Versus Pressure Measurements Importance of Understanding Pressure Measurements How to Measure a Pressure Transmural Pressure Where on the Tracing Do You Make the Measurement? Frequency Response Use of CVP Use of Ppao Pulmonary Artery Pressure Conclusion References 23: Cerebral Hemodynamic Monitoring Techniques Introduction Background Intracranial Pressure Anatomy and Physiology History Waveform Analysis and Trends Modes of Measurement Clinical Application Indications Cerebral Perfusion Pressure Cerebral Oxygenation Cerebral Microdialysis Electrophysiology Take-Home Points References 24: Transthoracic Echocardiography for Monitoring Cardiopulmonary Interactions Introduction TTE Imaging Left Heart Function Right Heart Function Pericardium Valves Classical Hemodynamical Parameters Cardiac Output and Stroke Volume Pulmonary Artery Pressures Pulmonary Artery Occlusive Pressure (PAOP) Clinical Conditions General Assessment of Patients with Shock Findings in Specific Shocks Septic Shock Cardiogenic Shock Respiratory Failure Other Clinical Situations Pitfalls and Limitations of Echocardiography Practical Problems (Monitoring, Number of Echo Machines, Price, Quality of the Machines, Time Constraints) Education Echocardiography a Continuous Monitoring Technique? Conclusion References 25: Transesophageal Echocardiography for Monitoring Cardiopulmonary Interactions Introduction Monitoring Cardiac Flows by Doppler Monitoring Transmural Cardiac Pressures by 2-D TEE Clinical Applications Conclusion References 26: Extra-cardiac Doppler Hemodynamic Assessment Using Point-of-Care Ultrasound Introduction Principles of Doppler Ultrasound The Arterial Doppler Waveform The Venous Doppler Waveform The Portal Doppler Waveform Clinical Application of Doppler Ultrasound in Critically Ill Patients Differential Diagnosis of Undifferentiated Shock Assessment of Fluid Responsiveness, Fluid Status, and Hemodynamic Management Evaluation of Organ Injury Conclusions References 27: Measurements of Fluid Requirements with Cardiovascular Challenges Introduction Static Indices of Cardiac Preload Fluid Challenge Standard Fluid Challenge Mini Fluid Challenge Pulse Pressure Variation, Stroke Volume Variation Principle Demonstration Limitations Variability of the Diameter of Vena Cava Principle Measurement Method Limitations Passive Leg Raising Test Principle Reliability Cardiac Output Measurement Technique Other Practical Aspects Limitations Respiratory Occlusion Tests Principle End-Expiratory Occlusion Test Association of End-Inspiratory and End-Expiratory Occlusions Limitations Other Tests Using Heart–Lung Interactions Nobody Is Perfect! Conclusion References 28: CO2-Derived Indices to Guide Resuscitation in Critically Ill Patients Introduction The Meaning of PCO2 Gap What Is the PCO2 Gap? CO2 Production How Is CO2 Transported? How Is CO2 Eliminated? What Is the Relationship Between CCO2 and PCO2? What Are the Determinants of the PCO2 Gap? What Is the Place of the PCO2 Gap in Clinical Practice? How to Interpret the PCO2 Gap in Practice? Combination of ΔPCO2 and Oxygen-Derived Variables vs. PCO2-Derived Indices Errors and Pitfalls of the PCO2 Gap Conclusion References 29: Microcirculatory Monitoring to Assess Cardiopulmonary Status Introduction Microcirculation and Tissue Oxygenation Microcirculatory Monitoring Techniques Assessment of Microcirculatory Perfusion Videomicroscopic Techniques Capillaroscopy Handheld Vital Microscopes (HVM) Laser-based Techniques Laser Doppler Techniques Laser Doppler Flowmetry (LDF) Laser Doppler Perfusion Imaging (LDPI) Laser Speckle Contrast Imaging (LSCI) Assessment of Microcirculatory Function Oxygen Electrodes and Optode Sensors Near-infrared Spectroscopy (NIRS) Conclusion References 30: Clinical Assessment and Monitoring of Peripheral Circulation During Shock and Resuscitation Introduction Skin Blood Flow Regulation Rationale for Monitoring Peripheral Perfusion During Shock Assessment of Peripheral Perfusion Clinical Assessment of Peripheral Perfusion Subjective Assessment and Skin Temperature Gradients Skin Mottling Capillary Refill Time (CRT) Optical Methods Peripheral Perfusion Index Pleth Variability Index NearInfrared Spectroscopy (NIRS) of the Thenar Eminence Peripheral Perfusion Indexes During Shock and Resuscitation Correlation of Peripheral Perfusion Indexes with Perfusion of Internal Organs Peripheral Perfusion Indexed During Resuscitation Peripheral Perfusion Indexes as a Target of Resuscitation Limitations Summary and Conclusions References 31: Optimizing Oxygen Delivery in Clinical Practice Introduction Oxygen Delivery Equation Optimizing Cardiac Output Fluid Administration Vasoactive Medications Mechanical Ventilation Optimizing Arterial Oxygen Content Oxygen Delivery to Tissues Relative Effects of DO2 Variables on Oxygen Delivery Maximizing Oxygen Delivery in the Critically Ill Summary and Conclusions References Part V: The Tools: Respiratory 32: Measuring Volume, Flow, and Pressure in the Clinical Setting Introduction Spirometry Body Plethysmography Resistance and Elastance Oscillometry and Impedance Clinical Applications Summary References 33: Measurement of Pleural Pressure Esophageal Pressure as an Estimate of Pleural Pressure Positioning of the Esophageal Balloon Calibration Technical Pitfalls Clinically Relevant Measures Transpulmonary Pressure Patient’s Effort When the Respiratory Muscles Are Active Patient-Ventilator Interaction References 34: Ultrasound Assessment of the Lung Introduction Principles Basic Physics of Ultrasound Ultrasound Systems Lung Ultrasound Findings Normal Lung Ultrasound (Figs. 34.2 and 34.3; Table 34.1) Interstitial Syndrome (Fig. 34.4 and Table 34.1) Alveolar Syndrome (Fig. 34.5 and Table 34.1) Lung Ultrasound for the Diagnosis and Monitoring of Lung Pathologies Pneumothorax. (Fig. 34.6; Tables 34.1 and 34.2) Pleural Effusion (Fig. 34.7; Tables 34.1 and 34.2) Diffuse Lung Diseases Focal Lung Diseases (Table 34.2) Diagnostic Approach Training Future Directions Conclusion References 35: Diaphragm Ultrasound: Physiology and Applications Introduction Physiological Basis of Diaphragm Ultrasound Basic Functional Anatomy of the Diaphragm Basic Mechanics of Diaphragm Contraction Sonographic Correlates of Diaphragm Structure and Function Structure Motion Shortening Diaphragm Thickening: Relation to Inspiratory Volume Diaphragm Thickening: Relation to Inspiratory Pressure Diaphragm Strain Technical Approach to Diaphragm Ultrasound Diaphragm Excursion Diaphragm Thickness and Thickening Diaphragm Echodensity Diaphragm Speckle Tracking Clinical and Research Applications of Diaphragm Ultrasound Detecting Structural Changes in the Diaphragm Facilitating Nerve Conduction and Electromyography Studies Evaluating Diaphragm Function Predicting Weaning Outcomes References 36: Monitoring Respiratory Muscle Function Clinical Assessment Pulmonary Function Testing Respiratory Muscle Pressure Output Respiratory Muscle Pressure Output: Strength Voluntary Maneuvers: Airway Pressures Voluntary Maneuvers: Transdiaphragmatic Pressure Mueller Maneuver Mueller-Expulsive Maneuver Sniff Pdi Pressure Relaxation Rate Voluntary Maneuvers: Cough Pga Voluntary Maneuvers: Clinical Usefulness of Transdiaphragmatic Pressure Measurements Evoked Maneuvers Evoked Maneuvers: Phrenic Nerve Stimulation Electrical Stimulation Magnetic Stimulation Comparison of Electrical and Magnetic Stimulation Twitch Pressure: Airway Twitch Pressure Twitch Interpolation Technique: General Concepts Twitch Interpolation Technique: Central Fatigue Evoked Maneuvers: Pgatw Respiratory Muscle Pressure Output: Effort Work of Breathing Pressure–Time Product Tension–Time Index of the Diaphragm Esophageal and Gastric Pressure Tracings Pleural Pressure–Abdominal Pressure Diagram Ratio of Change in Gastric-to-Esophageal Pressure Ratio of Change in Gastric-to-Transdiaphragmatic Pressure Electromyography Analysis of EMG Signals Frequency-Domain Analysis Time-Domain Analysis Neuromechanical Coupling Neuromuscular Coupling Neuroventilatory Coupling Clinical Applications of Electromyography Imaging Chest X-ray and Fluoroscopy Computed Tomography Magnetic Resonance Imaging Diaphragm Ultrasonography Ultrasound Measurement of Diaphragm Thickness (Zone of Apposition) Ultrasound Estimation of Diaphragm Strength and Recruitment (Zone of Apposition) Diaphragm Thickening Two-Dimensional Speckle Tracking Imaging Shear-Wave Elastography Ultrasound Measurement of Diaphragm Motion (Dome) Assessment of Muscle Fiber Vibration Surface Phonomyography Surface Mechanomyography Conclusion References 37: Basics of Electrical Impedance Tomography and Its Application Introduction Basics of Bioimpedance EIT Measurements and Image Reconstruction Functional Imaging and EIT Waveform Analysis Ventilation Monitoring Using EIT Validation of EIT Measurements Global Ventilation Global Changes in End-Expiratory Lung Volume (EELV) and Impedance (EELI) Regional Changes in Lung Ventilation or Volume EIT Measures for Analyzing Spatial Distribution of Ventilation Subtracting fEIT Images Impedance Ratio Regional Respiratory System Compliance (CRS) Regional Pressure–Volume (P/V) Curves Alveolar Overdistension and Collapse (ODCL) Center of Ventilation (CoV) Global Inhomogeneity Index (GI Index) EIT Measures for Analyzing Temporal Distribution of Ventilation Regional Ventilation Delay (RVD): Regional Ventilation Delay Index (RVDI) Intratidal Gas Distribution (ITV) Clinical Application Estimation of Lung Collapse and Overdistension Pneumothorax Detection Monitoring Lung Volumes During Endotracheal Suctioning Monitoring Positioning of Endotracheal Tubes Monitoring Ventilatory Dyssynchrony Perfusion Monitoring Using EIT Measurement Principle Perfusion Monitoring Using Cardiac Activity Perfusion Monitoring Using Contrast Agents Conclusion References 38: Clinical Monitoring by Volumetric Capnography Time-Based and Volume-Based Capnography Respiratory Monitoring Monitoring ventilation by VCap Monitoring Gas Exchange by VCap Hemodynamic Monitoring Preload Assessment by VCap Summary References 39: MRI in the Assessment of Cardiopulmonary Interaction Introduction Techniques for Mapping Cardiopulmonary Interaction Dynamic Contrast Enhanced (DCE) MRI Proton Imaging Oxygen Enhanced MRI Hyperpolarized Gases Fluorine Gas MRI Applications of MR Imaging in Cardiopulmonary Interactions Pulmonary Perfusion Lung Parenchyma (Diffuse Lung Disease) Ventilation (Gas Exchange) Heart Disease Imaging of Lung Mechanics Summary References Part VI: The Tools: Interaction 40: Respiratory Function of Hemoglobin: From Origin to Human Physiology and Pathophysiology Introduction Anaerobic Origin of Hemoproteins Hemoglobin as Oxygen Carrier Erythrocytes as Hemoglobin Carrier Bohr and Haldane Effects 2,3-Bisphosphoglycerate Effects of Temperature Erythrocyte as a Source of Bioactive NO Antioxidation Adaptation of Erythrocytes for Oxygen Transport Size Shape Distribution Production, Storage and Release Adaptation to Life Without Hemoglobin Clinical Physiology and Pathophysiology Increased Metabolic Demand Adaptation to Ambient Hypoxia Hemoglobinopathy Unstable Hemoglobins Hemoglobin Variants with Altered O2 Affinity Carboxyhemoglobinemia Methemoglobinemia Post-translational Modification of Hemoglobin Conclusions References 41: Acid-Base and Hydrogen Ion Introduction Importance of Water Importance of Strong Ions Importance of CO2 Importance of Albumin Approach to Identifying the Cause of a Disturbance of Blood [H+] (pH) Base Excess: Direct Estimation of Metabolic Derangements in Acid–Base Status BE Approach to Evaluation of Acid–Base Disorders (Table 41.1) How Are the “Water” (i.e., Dilutional Effects), [Cl-] Effects, and [Albumin] Evaluated? Water Effect Chlorideeffect Proteineffect “Other Effects” Summary Case Examples Case 1 Case 2 References Part VII: Applications 42: Use of Maintenance and Resuscitation Fluids Introduction Volume and the Generation of Blood Flow Clinical Administration of Fluids Assessment of Hydration, Na+ Balance, and Vascular Volume Maintenance and Daily Needs Use of Fluids for Resuscitation Goals What Types of Fluids? Crystalloid Solutions Colloids Managing Hydration Status Summary References 43: Identifying and Applying Best PEEP in Ventilated Critically Ill Patients Introduction Classical Methods to Set PEEP: Compliance and PEEP-FiO2 Tables The Best Respiratory System Compliance PEEP-FiO2 Tables and EXPRESS Approach Airway Closure: A Major Confounding Factor Esophageal Manometry Estimating Transpulmonary Pressure with Esophageal Pressure Guiding PEEP with Esophageal Pressure Electrical Impedance Tomography Guiding PEEP with EIT Decremental PEEP Steps Center of Ventilation Direct Assessment of Lung Recruitability Rationale CT Scan Pressure-Volume Curves, Lung Volume, and a Simplified Method Global Integrative Clinical Approach References 44: Cardiopulmonary Monitoring in the Prone Patient Introduction Prone Position and Hemodynamics Prone Position and the Lung Prone Position Maneuver Monitoring in Prone Position Summary References 45: Cardiopulmonary Interactions in the Management of Acute Obstructive Disease Introduction Normal Respiratory Mechanics Airflow Limitation in Obstructive Lung Diseases Heart-Lung Interaction in Health Pleural Pressure and the Right Heart Pleural Pressure and the Left Heart Intra-pulmonary Vessels Heart-Lung Interaction in Obstructive Disease – The Spontaneously Breathing Patient Auto-PEEP and Hyperinflation Pulsus Paradoxus Heart-Lung Interaction in Severe Obstructive Disease – The Mechanically Ventilated Patient Therapeutic Strategy Conclusion References 46: Evaluation and Management of Ventilator-Patient Dyssynchrony Introduction Classification Over-Assistance (Low Respiratory Drive) Ineffective Efforts Delayed or Prolonged Cycling Insufficient Assistance (High Respiratory Drive) Flow Starvation Short or Premature Cycling Double Trigger and Breath Stacking The Entrainment Phenomenon: Reverse Triggering Assessment of Asynchronies Management – A Clinical Approach Clinical Consequences Conclusion References 47: Cardiopulmonary Monitoring in the Patient with an Inflamed Lung ARDS as an Inflammatory Disease Pathophysiology of ARDS Exudative Phase Proliferative Phase Fibrotic Phase ARDS Phenotypes: The “Hyperinflammation” Ventilator-Induced Lung Injury and Inflammation Evolving Definitions and Pathophysiology of VILI: From “Barotrauma” to “Ergotrauma” Mechanotransduction and Ventilator-Induced Lung Injury Biotrauma and Inflammation VILI, Inflammation and Fibrosis Biological Modulation of the Inflamed Lung Future Perspectives References 48: Ventilation During Veno-Venous Extracorporeal Membrane Oxygenation Introduction Principles of Gas Exchange During VV-ECMO in Acute Respiratory Failure Mechanical Ventilation Strategies During VV-ECMO Ventilatory Strategy During the Early Phase of VV-ECMO Assisted Mechanical Ventilation During VV-ECMO References 49: Vasopressor Support for Patients with Cardiopulmonary Failure Introduction Differences Between Various Agents Adrenergic Vasopressor Agents Non-adrenergic Vasopressor Agents Vasopressin Derivatives Angiotensin II Impact on Outcome Effects of Vasopressors on Left Ventricular Function Effects of Vasopressors in Right Heart Failure: (Fig. 49.1) Conclusions References 50: Cardiogenic Shock Part 1: Epidemiology, Classification, Clinical Presentation, Physiological Process, and Nonmechanical Treatments Definition Cardiogenic Shock with Acute Coronary Syndromes Cardiogenic Shock Without an Acute Coronary Syndrome Presentation of Shock Congestive Component Distributive Component Physiology and Pathophysiology Limitation to Filling Clinical Consequences of the Above Analysis Management Monitoring Diagnostic value of PA catheter Management value of PA catheter Volume Pharmacological Approaches Epinephrine (Epi) Norepinephrine (NE) Epi versus NE Dobutamine Dopamine Milrinone Sodium bicarbonate (NaHCO3) Role of Ventilation in Cardiogenic Shock Summary References 51: Cardiogenic Shock Part 2: Mechanical Devices for Cardiogenic Shock Introduction IABP Devices that Support Ventricular Outflow General Principles LV Off-loading by Percutaneous Micro-axial Trans-aortic Devices (Impella®) Physiological Considerations with Micro-axial LVAD Support Surgically Implantable Devices for LV Decompression Left Atrial Decompression of the LV: TandemHeart® p-VAD Physiological Considerations Related to Devices Based on LA Drainage Comparison of Hemodynamic Profile of TandemHeart Versus Impella® Extracorporeal Membrane Oxygenation (ECMO) Physiological Considerations with ECMO Right Ventricular Failure Right Heart Support Summary References 52: Pathophysiology of Sepsis and Heart-Lung Interactions: Part 1, Presentation and Mechanisms Introduction Definition Clinical Presentation Epidemiology Presentation in Experimental Inflammatory Syndromes Human Data Animal Data Vascular Mechanics Required for the High Cardiac Output State Coronary Blood Flow and Myocardial Ischemia Basic Cellular Mechanisms Triggering the Process: Cytokine Cascade Drivers of the Clinical Manifestations Vascular Failure in Sepsis Mechanisms of Vascular Dysfunction Role of Potassium ATP Channel Nitric Oxide and Superoxide Mitochondrial Dysfunction Intracellular Calcium Regulation Permeable Barriers Synthesis of Mechanisms References 53: Pathophysiology of Sepsis and Heart-Lung Interactions: Part 2, Treatment Treatments Management of O2 Delivery Role of Volume Synthesis of the Defects Norepinephrine Phenylephrine Vasopressin Epinephrine Dobutamine Milrinone Miscellaneous Therapies Heart-Lung Component Summary References 54: Cardiopulmonary Monitoring of Patients with Pulmonary Hypertension and Right Ventricular Failure Introduction Pulmonary Pathophysiology Cardiopulmonary Hemodynamics Normal Pulmonary Circulation Pulmonary Hypertension (PH) Other Pulmonary Vascular Physiologic Parameters Introduction Pulmonary Vascular Compliance Pulmonary Artery Elastance Pulmonary Artery Impedance Pulmonary Hypertension Introduction Relationship Between Pulmonary Vascular Physiologic Parameters Clinical Significance of Altered Pulmonary Vascular Physiology Other Aspects of Pulmonary Physiology Pulmonary Gas Exchange Pulmonary Diffusing Capacity (DLco) Airway Function Pulmonary Compliance/Volumes Pathophysiology of RV Failure in PAH Normal RV Function Introduction RV Failure Introduction RV Failure: RV-PA Coupling Versus Decoupling RV Failure: RV Ischemia RV Failure: Ventricular Interdependence Cardiopulmonary Monitoring of the PAH Patient Introduction Cardiopulmonary Monitoring of the PAH Patient: Clinical Parameters Symptomatic/Functional Classification Recommendations for Clinical Practice Health-Related Quality of Life (HRQoL) Recommendations for Clinical Practice Physical Examination Recommendations for Clinical Practice Cardiopulmonary Monitoring of the PAH Patient: Exercise Capacity Introduction 6-Minute Walk Test (6MWT) Introduction Effects of PH on 6MWT Effects of PH-Targeted Therapy on 6MWT Prognostic Value of 6MWT in PH Cardiopulmonary Exercise Test (CPET) Introduction CPET Patterns in PAH Correlation of CPET Parameters with Severity of PAH Prognostic Value of CPET Parameters in PAH Summary Recommendations for Clinical Practice Diagnosis of PH Assessment of PH Severity/Prognosis Cardiopulmonary Monitoring of the PAH Patient: Invasive Hemodynamics Right Heart Catheterization (RHC) Introduction RHC in PH Patients Clinical Importance of Pulmonary Hemodynamics in PH Recommendations for Clinical Practice Cardiopulmonary Monitoring of the PAH Patient: Echocardiography Introduction Echocardiography in PH Overall Approach 2-D Evaluation Doppler Examination Right-Heart Chamber Evaluation Recommendations for Clinical Practice Cardiopulmonary Monitoring of the PAH Patient: Cardiac MR Introduction Cardiac MR in PH Recommendations for Clinical Practice Cardiopulmonary Monitoring of the PAH Patient: Biomarkers Introduction: PAH Vascular Biology Biomarkers Which Reflect the Pathobiology of PAH Natriuretic Peptides (ANP, BNP, NT-proBNP) Introduction Prognostic Role of BNP and NT-proBNP Recommendations for Clinical Practice Cardiopulmonary Monitoring of the PAH Patient: Summary References 55: Monitoring and Management of Acute Pulmonary Embolism Introduction Pathophysiology Vasoconstrictive Mediators The Role of the Right Ventricle Categorization of Pulmonary Embolism Diagnosis of Acute PE Laboratory Testing Transthoracic Echocardiography Computed Tomography Angiography (CTA) Management Anticoagulation and Thrombolytics Vasoactive Medications Airway Management in PE Conclusion References 56: Clinical Neurologic Issues in Cerebrovascular Monitoring References 57: Delirium in the Critically Ill Patient Introduction: ICU Delirium and its Consequences Delirium Definition and Epidemiology Delirium Pathophysiology Delirium Identification Risk Factors Delirium Prevention and Treatment PADIS Guidelines and the ABCDEF Bundle Nonpharmacological Interventions Environment Early Rehabilitation and Mobilization Sleep Pharmacological Interventions Drugs for Delirium Prophylaxis and Treatment Analgesia and Sedation Management Conclusion References 58: Obesity in Critically Ill Patients Introduction Changes in Baseline Physiology Obesity and the Abdomen Obesity Control of Breathing/OSA/ OHS Obesity as a Risk Factor for Critical Illness Airway Management Ventilator Management in Obese Patients Additional Considerations Obesity and Outcomes Conclusion References Part VIII: Epilogue 59: The Future References Index