Download Hemodynamic Compromise Associated with Air

Hemodynamic
Compromise
Associated
with Air Trapping
Following Coronary Artery Bypass
Surgery*
900C,
Davidj
(PCWP)
Dries, M.D.;t
Mali
M.D.;
Ramex
Salem,
Alvaro
Monto,as,
Mathru,
M.D.
Tadikonda
M.D.
induction
Treatment
included
bronchodilator
therapy
to reduce
air-
way obstruction,
limitation
of minute
ventilation,
and increasing
time available
for exhalation.
High inspiratory
flow
rates and expiratory
retard
may be beneficial.
(Chest 1990; 97:1002-03)
pressure;
PCWP
pulmonary
capil-
ardiac
mechanical
and
return,
A less
recognized
subsequent
and
cardiac
Hg
Hg
and
of 8 mm
Hg.
The
bypass
with
were
increased
titrated
to maintain
PCWP
the
chest,
bypass.
The
lungs
incision.
No
coronary
“air
diseases
including
resistance.#{176}-3
artery
of elastic
recoil
with
supported
exhalation
creating
compro-
with
pulmonary
or increased
airway
mechanical
ventilation
time (I:E)
peripheral
ratios, patients
air space units
air
progressive
trapping
and
and
Hemodynamic
consequences
cardiac
surgery
because
of the
pleura
on lung
of the
sternum
magnify
of
are
loss
exchange
air
at
expansion
risk
and
wall
operation.
parietal
Reapproximation
space
compromise
restriction
if this
may
process
is not
minutes
A 65-year-old
vessel
tive
pulmonary
woman
disease
function
of 55 percent
l)tllloUs
the
arterial
mm
disease.
blood
(PaCO),
fig;
*From
of
Departments
Reprint
South
1002
Professor.
requests:
Dr
First
Avenus’,
bronchitis
artery
Hg;
revealed
FEV,
x-ray
inspired
partial
and
Department
JL 60153
hemodynamically
of 32/20
was
100 mm
Hg.
mm
to initial
and
on
Upon
after
the
through
ECG
Secretion
and
Hg
levels
herniating
noted
airway
infusion
reopened.
returned
intact.
airway
taken:
I:E
ratio
monitors
output
tidal
was
plane
of anesthesia
these
measures,
pressure
was
volume
and
changed
was
the
decreased
stable
and
minimal
to
unchanged.
chest
was
to 30 cm
and
was
respiratory
prolong
closed
H20.
extubated
the
Twentywithout
The
the
patient
next
day.
DISCUSSION
hypotension
100 percent.
and
Medical
Masonic
318
After
Thoracic
Center,
Medical
2160
on sternal
cardiopulmonary
action
in addition
coronary
artery
bypass
secondary
mise
of the great
veins
returning
blood
volume
dian
degree
thoracic
incisions.
be
most
grafts,
The
trapping
and occurrence
pressure
in a group
with
normal
x
resistance),
trapping
and
lungs
and
time
constants
for
of
of
when
to
22
is
tidal volume,
system
(time
time
hyperinflation
to occur
in patients
with COPD
ventilation
for adequate
alveolar
greater
will
was increased
from
10
magnitude
of hyperinflation
compliance
Air
provides
than
other
of patients.
on several
factors.
These
include
time
constant
of the respiratory
=
likely
minute
group
patients
frequency
minute.
The
space
of hyperinflation
in this
paralyzed
expiration.
interKinking
malfunction,
of the pleural
hyperinflation
Bergman4
demonstrated
air
intrinsic
positive
end-expiratory
dependent
mechanical
valvular
consequences
pronounced
the
respiratory
breaths
per
following
in heart-lung
compromise.
to persistent
bleeding
and comprodue to adjacent
clot with inadequate
are prominent
considerations.
Me-
with opening
of pulmonary
sternotomy
a greater
reapproximation
bypass
can originate
to purely
vascular
tamponade
available
are
more
who require
high
ventilation.
COPD
complete
passive
exha-
lation.
When
of carbon
(Pa02),
ofAnesthesiology,
The
following
produces
FVC
bypass,
pressure
University
Illinois
peak
than
immediately
were
were
and
remained
demonstrated
of oxygen
Anesthesiology,
with
Preopera-
percent
examination
(FIo),
Surgers;
Loyola
of Anesthesiology,
Mathru,
Maywood,
of3O
pressure
oxygen
of Surgery,
admitted
surgery.
cardiopulmonary
p11 7.32;
partial
was
bypass
to instituting
gas revealed:
and Cardiovascular
and the Department
Center,
Chicago.
tAssistant
Professor.
Professor.
§Associate
chronic
Chest
Prior
48 mm
fraction
the
tests
of predicted.
lung
dioxide
with
REPORT
for coronary
and
greater
pressure
were
When
bypass,
not appreciated.
Peak
for
triple
was
changes
cardiopulmoafter
occurred
PAP
artery
pressure
g/kg/min).
A norepinephnne
hyperinflated
measures
phase.
constant
corrected.
CASE
blood
from
15 minutes
pressure
chest
were
reduced
anesthetized,
hyperinflation
chest
pleural
po-
undergoing
dynamic
by
resumed
are
Patients
for
during
hemodynamic
and
embarrassment
trapping.
of restriction
with
the
recognized
gas
H20.
of ten
Arterial
wedge
(<5
chest
a rate
pulmonary
weaned
revealed
The
difficulty.
thus
hyperinflation.
tential
cm
systolic
grafts
following
were
of
descriptively
in patients
bradycardia
the
was
Acute
intrathoracic
phenomenon,
is seen
inspiratory/expiratory
disease
fail to empty
airway
during
loss
When
and standard
with
This
“
trapping,
and
ischemic
wheezing
was
the
under-
which
lungs
Hg.
with
capillary
dobutamine
measurements
of 22 mm
time
to close
the
opening
is mechan-
to high
patient
to 100
Hemodynamic
this
(Siemens
and
was 90 L/min.
rate
pulmonary
dose
hypotension
pressure
and
low
made
of 12 mI/kg
flow
at
technique,
a ventilator
tpt
patients
operations
due
hyperinflated
function.
termed,
in
cardiac
filling
by
in cardiac
hypotension
of ventricular
transmitted
misc
reduction
of
sternotomy
limitation
pressure
of ventricular
cause
median
ical
by
1 10/80
oxide/narcotic
using
inspiratory
mm
rate
extracardiac
filling,
decreased
hypotension
limitation
venous
going
causes
The
mm
exhalation
tamponade
volume
was
five
C
a tidal
of 20/10
The
PAP = pulmonary
artery
lary wedge
pressure
with
pressure
precipitous
Cardiovascular
collapse
due to pulmonary
hyperinflation
was noted in a patient
with chronic
obstructive
pulmonary
disease
following
median
sternotomy
for cardiac
surgery.
nitrous
instituted
pressure
attempts
, EC.C.P
using
was
per minute.
nary
and
anesthesia
ventilation
Sweden)
breaths
, F.C.C.P;t
Rao, M.D.;
of
mechanical
obstruction
creased
lation)
metabolism
functional
perinflation
may
worsens
follow
mechanical
ventilation,
tional ventilator
settings
rates
may
shorten
or
ventilation
or dead space,
residual
capacity
the
this
increase.
in patients
including
available
demonstrated
ical
secondary
tion
in
consequences
an
of the
open
chest
Hemodynamic
animal
Compromise
time
passive
convenand flow
leading
to
of the lungs.-’
heart
of dynamic
During
exhalation
(in-
hyperventiDynamic
hy-
with
COPD,
fixed I:E ratios
air trapping
and hyperinflation
Wallis and associates7
have
compression
increases
mechanical
increases.
direct
to lung
preparation.7-”
hyperinflation
Associated
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21610/ on 05/10/2017
mechanhyperinfla-
Hemodynamic
include
with Air Trapping
reduction
(Dr7es et a!)
in transmural
increase
pressure
in
and venous
intrathoracic
return
pressure
to the heart.
associated
The
PEEP
with
may spuriously
elevate
filling pressures
measured
with a
pulmonary
artery
catheter
(as in our patient).
This may
falsely assure adequate
preload
and misguide
hemodynamic
management
in COPD
patients.
Our patient
demonstrated
hypotension
and
elevation
of filling pressures
when
an
attempt
was made to close the sternum
On opening
the
chest,
blood
pressure
and filling pressures
returned
to
A Case of Delayed
Cardiac Tamponade
Echocardiographic
Catherine
M. Otto,
M.D.;
B.S.,
RterPMcKeown,M.B.,
Alan
Postoperative
with Unusual
Findings*
S. Pearlrnan,
and
FC.C.P;t
M.D.
.
normal.
Once
should
air trapping
is recognized,
be aimed
at controlling
dynamic
hyperinflation.’
therapeutic
measures
factors
contributing
to
These
include
bronchodilator
therapy
to relieve airway
obstruction,
reduction
in minute
ventilation,
and maximizing
time available
for exhalation.
Minute
ventilation
should he reduced
to the minimum
that
will
maintain
adequate
pH.
trapping
and improve
rates and expiratory
thought
due to localized
in a 64-year-old
man
after aortic valve replacement
and repair of an ascending
aortic
dissection.
The clinical
findings
were subtle and the
echocardiographic
findings
were unusual.
Color
Doppler
flow imaging
assisted
in making
the diagnosis
of localized
measures
flow
include
These
retard.2b0
to reduce
air
of high
flow
are
use
ventilation/perfusion
techniques
relationships
atrial
pulmonary
be considered
hypotension
occurring
following
coronary
have a greater
hyperinflation
and
in the differential
artery
chest
bypass
in
and
embarrassment
of
Braunwald
Braunwald
E, ed.
E.
heart
Diseases
disease.
of
Smith
secondary
to
DE,
Graybar
airtrapping
GB,
WB.
treated
Kirby
with
RR.
3 Kimball
and
1984;
WR,
with
A 64-year-old
valve
In:
Saunders,
man
requiring
disease.
Am
4 Bergman
DE,
Robins
Rev
NE.
AG.
flow
Dynamic
in chronic
aortic
warfarin
sodium
the
Respir
Dis
1982;
Intrapulmonary
(25
with
retard.
right
at rapid
J,
5 Milic-Emili
intrinsic
PEEP
failure.
In:
frequencies.
A.
its ramifications
Vincent
emergency
SB, Rossi
Gottfried
and
Anesthesiology
JL,
medicine.
ed.
New
York:
in
with
respiratory
intensive
Springer-Verlag,
and
was
flow
1987:192-98
JF.
Applied
Butterworths
7 Wallis
Publishers,
interaction
Physiol
1983;
physiology,
2nd
ed.
Boston:
imaging
right
Compean
with
the
R, Kindred
positive
MK.
end-expiratory
Mechanical
J
pressure.
peak
was
ventricle.
1 and
through
There
and left ventricular
systolic
function
was
were
normal,
the
with
were
inflow
a loculated
seen
severe
apical
Ofl
right
atrial
diastolic
1 .8 mIs).
the
filling
Color
Doppler
compressed
atrium
flow
right
respiratory
atrium
from
into
the
variation
in right
curves.
Left ventricular
prosthetic
aortic
valve
size and
and graft
Doppler
fl()
mIs)
by demonstrating
no apparent
inflow
velocity
normal.
The
(1 .4
(best
compressed
slit-like
ventricular
ventricular
effusion
pos-
1). Increased
addition,
with
in distinguishing
pericardial
cava
In
velocit;
inflow
(Fig
left
the
of both
as a small
views
atrium
2),
No
on
a 4-cm
velocities
of right
early
helpful
vena
appeared
54:103947
Fig
suspected.
wa-s seen
appeared
right
a large
compression
functional
the
impairment
adjacent
the inferior
1977:63-93
RobothamJL,
TW,
heart-lung
AppI
respiratory
and
ventricular
from
6 Nunn
views,
was
on apical
later
The
was
demonstrated
flow
days
complaints
swallowing.
accumulation
compression.
around
four
and
There
causing
in the
to atrial
hut
tamp()nade
atrium
Doppler
a decrease
subcostal
(right
and
left
transmitral
present
control).
views
confirmed
secondary
difficulty
effusion
The
da);
with
was discharged
fibrillation
and
fluid
parasternal
atria.
s. lie
times
cardiac
findingwas
with
compression
care
and
pericardial
of a woven
anticoagulated
of22
atrial
aortic
of aortic
insertion
was
time
s (2.37
ascending
consisting
and
pcstoperative
pericardial
left
early
effusion
hyperinflation:
in patients
Update
37:626-33
29.8
but
consistent
mechanical
1972;
Dynamic
findings
acute
repair
he
anorexia,
was
effusion
This
an
Duromedics)
recurrent
dyspnea,
and
with
1 ith
with
loculated
orifice
ventilation
usually
postoperative
REPORT
a prothrombin
anterior
orifice.
pulmonary
during
outcome.
of late
surgical
mm
on the
time
pleural
peak
trapping
recognition
catheterization
Postoperatively;
readmitted
significant
26:991-95
gas
compli-
Early
echocardiographic
presented
graft.
hospital
he was
left
hyperinfiation
obstructive
uncommon
A case
unusual
97:1003-04)
satisfactory
heart
emergency
replacement
Dacron
of orthopnea,
Hypotension
expiratory
for
right
diagnosis.
tamponade
terior
dependence
essential
1990;
follows.
dissection
60:350-53
Leith
ventilator
surgery.
are
echocardiogram,
Anesthesiology
is an
cardiac
and
prothromhin
yr,
tamponade
following
CASE
1980:1517-82
2 Weng
cardiac
patients
pericardium.
Philadelphia:
(Chest
patients
COPD
the
occurred
a definitive
cardiac
from
JR.
tamponade
atria
management
provide
REFERENCES
1 Darsee
cardiac
the
Echocardiography
propensity
for developing
air trapping.
Failure
air trapping
as a cause
for hemodynamic
may lead to hemodynamic
mismanagement.
recognize
elayed
cation
in the
consequent
diagnosis
closure
surgery.
of
compression.
D
inhomogeniety.
In conclusion,
PEEP
should
undergoing
Other
gas exchange
to improve
face of alveolar
to
Postoperative
compression
evidence
for
prosthetic
valve
dysfunction.
8 Lloyd
TC.
cardiac
Respiratory
9 Pepe
PE,
mechanically
Rev
Respir
ventilated
Respir
10 Connors
rate
system
J Appl Physiol
Marini
JJ. Occult
fossa.
on
Dis
AF,
gas
Dis
1982;
exchange
as
seen
from
the
53:57-62
positive
patients
end-expiratory
with
air
On
right
equalization
flow
pressure
obstruction.
in
Am
of
pressure,
Hg;
heart
19 mm
and
catheterization,
diastolic
pulmonary
Hg;
there
intracardiac
pulmonary
artery
capillary
wedge
was
central
diastolic
pressure.
pressure,
toward
a trend
pressures:
20
mm
venous
21 mm
11g.
The
126:166-70
McCaffree
1981;
compliance
1982;
DR.
during
124:537-43
Gray
BA. Effect
mechanical
ofinspiratory
ventilation.
flow
Am
Rev
*From
the
tDepartment
Reprint
Surgery,
Division
of Cardiolog;
of Surger)
Department
University
requests:
Dr. McKeown,
12901
Bruce
B. Downs
Cardiovascuhir
Building,
Tampa
CHEST
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21610/ on 05/10/2017
of Medicine,
of \Vashington,
and
Seattle.
and
Thoracic
33612
I 97 I 4 I APRIL,
1990
1003