A BEDSIDE INDEX ASSESSING THE RELIABILITY OF PULMONARY-ARTERY OCCLUSION PRESSURE MEASUREMENTS DURING MECHANICAL VENTILATION WITH POSITIVE END-EXPIRATORY PRESSURE

被引：61

作者：

TEBOUL, JL

BESBES, M

ANDRIVET, P

AXLER, O

DOUGUET, D

ZELTER, M

LEMAIRE, F

BRUNBUISSON, C

机构：

[1] Service de Reanimation Médicale, Hôpital Henri Mondor, Creted

[2] Laboratoire de Physiologie, Hôpital de Bicêtre, Université Paris Sud, Le Kremlin-Bicetre

来源：

JOURNAL OF CRITICAL CARE | 1992年 / 7卷 / 01期

关键词：

D O I：

10.1016/0883-9441(92)90005-R

中图分类号：

R4 [临床医学];

学科分类号：

1002 ; 100602 ;

摘要：

Pulmonary artery occlusion pressure (Ppao) represents the pressure in a pulmonary vein (Ppv) and reflects left atrial pressure (Pla) provided alveolar pressure (Palv) does not exceed the pressure existing at the venous end of the collapsible alveolar vessels. Three major factors may influence the relationships between Palv and Ppv: mechanical ventilation with positive end-expiratory pressure (PEEP), vertical location of the pulmonary artery catheter (PAC) tip relative to the left atrium, and volemia. In an experimental and clinical study, we assessed a simple means to ensure meaningful measurements of Ppao during mechanical ventilation with PEEP, based on the following reasoning: if Ppao reflects Palv and not Ppv, it will increase during positive pressure inspiration by an amount (ΔPpao) similar to Palv; thus, ΔPpao will widely exceed the increase in pulmonary arterial pressure (ΔPpa), which approximates the increase in pleural pressure. Conversely, when Ppao actually reflects Ppv, ΔPpao will be close to ΔPpa. A preliminary experimental study in an animal with a left atrial catheter and PAC in place showed that Ppao widely exceeded Pla when ΔPpao/ΔPpa widely exceeded 1 during mechanical ventilation with PEEP. After fluid infusion, Pla and Ppao were almost identical and ΔPpao/ΔPpa was now close to 1. In 12 patients ventilated for adult respiratory distress syndrome and with a left ventricular catheter and PAC in place, we verified at four levels of PEEP (0, 10, 15, and 20 cm H 2 O) that a Ppao close to left ventricular end-diastolic pressure was always associated with a ΔPpao/ΔPpa ratio close to 1 (38 measurements). In 34 additional patients ventilated for noncardiogenic pulmonary edema, we also tested the ΔPpao/ΔPpa ratio during the same incremental PEEP protocol and found that ΔPpao/ΔPpa was close to 1 at each level of PEEP in 30 of the patients (108 measurements). In five measurements in four hypovolemic patients, ΔPpao/ΔPpa widely exceeded 1; only one of these four patients was found to have a PAC tip located above the left atrium level on a lateral chest x-ray film. We conclude that the bedside determination of the ΔPpao/ΔPpa ratio should identify the cases in which Ppao measurements are not valid more reliably than lateral chest x-ray film, thus avoiding misleading interpretations of Ppao during PEEP ventilation. © 1992.

引用

页码：22 / 29

页数：8

共 17 条

[1]

West, Dollery, Naimark, Distribution of blood flow in isolated lung: Relation to vascular and alveolar pressures, J Appl Physiol, 19, pp. 713-724, (1964)

[2]

Lozman, Powers, Older, Et al., Correlation of pulmonary wedge and left atria] pressure: A study in the patient receiving positive end-expiratory pressure ventilation, Arch Surg, 109, pp. 270-277, (1974)

[3]

Jardin, Farcot, Boisante, Et al., Influence of positive end-expiratory pressure on left ventricular performance, N Engl J Med, 304, pp. 387-392, (1981)

[4]

Roy, Powers, Feustel, Et al., Pulmonary wedge catheterization during end-expiratory pressure ventilation in the dog, Anesthesiology, 46, pp. 385-390, (1977)

[5]

Tooker, Huseby, Butler, The effect of Swan-Ganz catheter height on the wedge pressure left atrial pressure relationship in edema during positive pressure ventilation, Am Rev Respir Dis, 117, pp. 721-725, (1978)

[6]

Hasan, Malanga, Braman, Et al., Lateral position improves wedge left atrial pressure correlation during positive pressure ventilation, Crit Care Med, 12, pp. 960-964, (1984)

[7]

Hotchkiss, Katsamouris, Lappas, Et al., Interpretation of pulmonary artery wedge pressure and pullback blood gas determinations during positive endexpiratory pressure ventilation and after exclusion of the bronchial circulation in the dog, Am Rev Respir Dis, 133, pp. 1019-1023, (1986)

[8]

Shasby, Dauber, Pfister, Et al., Swan-Ganz location and left atrial pressure determine the accuracy of the wedge pressure when positive end-expiratory is used, Chest, 80, pp. 666-670, (1981)

[9]

Rajacich, Burchard, Hasan, Et al., Central venous pressure and pulmonary capillary wedge pressure as estimates of left atrial pressure: Effects of positive endexpiratory pressure and catheter tip malposition, Crit Care Med, 17, pp. 7-11, (1989)

[10]

Teboul, Zapol, Brun-Buisson, Et al., A comparison of pulmonary artery occlusion pressure and left ventricular end-diastolic pressure during mechanical ventilation with PEEP in the patients with severe ARDS, Anesthesiology, 70, pp. 261-266, (1989)

← 1 2 →