Author + information
- Received November 18, 1992
- Revision received October 18, 1993
- Accepted October 20, 1993
- Published online March 1, 1994.
- Otto A. Smiseth, MD, PhDa,∗,
- Christopher R. Thompson, MD∗,
- Hilton Ling, MD∗,
- Murray Robinson, MD∗ and
- Robert T. Miyagishima, MD∗
- ↵∗Address for correspondence: Dr. Otto A. Smiseth, Johan Castbergsv. 9, 0673 Oslo 6, Norway.
Objectives. This study was conducted to measure the cardiac constraining effect of the lungs during positive end-expiratory pressure and relate extracardiac pleural pressure (radial stress) to airway pressure, right atrial pressure and left ventricular filling.
Background. During positive end-expiratory pressure ventilation, the extracardiac pressure is elevated, and therefore intracavitary filling pressure does not reflect ventricular preload. Estimates of this pressure might be useful clinically to assess left ventricular preload.
Methods. In eight patients who had undergone coronary or valvular surgery and whose pericardium was left widely open, a flat pleural balloon transducer was placed over the anterolateral left ventricular wall. We recorded pulmonary capillary wedge pressure, right atrial pressure and left ventricular short-axis end-diastolic area by transesophageal echocardiography. Incremental positive end-expiratory pressure was applied.
Results. Extracardiac pleural pressure increased (p < 0.01) from 0.6 ± 1.8 (±SD) to 2.4 ± 1.8, 5.3 ± 1.5 and 8.2 ± 1.5 mm Hg at a positive end-expiratory pressure of 5, 10 and 15 cm H2O, respectively. The slope relating extracardiac pleural pressure to positive end-expiratory pressure (in mm Hg) was 0.70 ± 0.10, and the intercept was zero. Increasing extracardiac pleural pressure was associated with a progressive increase in pulmonary capillary wedge pressure and a decrease in left ventricular end-diastolic area. Consequently, although pulmonary capillary wedge pressure and left ventricular area changed in opposite directions, the value of pulmonary capillary wedge pressure minus extracardiac pleural pressure correlated positively with left ventricular area (r = 0.95, p < 0.001). Changes in right atrial pressure (Pra) correlated with changes in extracardiac pleural pressure (Ppleural): ΔPra = −0.3 + 0.56 · ΔPpleural (r = 0.89, p < 0.001).
Conclusions. In postoperative patients with open pericardium, pulmonary capillary wedge pressure minus extracardiac pleural pressure predicts left ventricular end-diastolic area during positive end-expiratory pressure. Further studies should be done to determine whether the observed relations between airway pressure and extracardiac pleural pressure and between right atrial pressure and extracardiac pleural pressure may give clinically useful estimates of left ventricular preload during positive end-expiratory pressure.
☆ This study was supported by a grant to Dr. Thompson from the Heart and Stroke Foundation of British Columbia and the Yukon, Vancouver and by a grant to Dr. Smiseth from the Nathalia and Knut Juul Christiansen's Foundation, Oslo, Norway.
- Received November 18, 1992.
- Revision received October 18, 1993.
- Accepted October 20, 1993.