Abstract
Mechanical ventilation in controlled mode has long been known to induce cyclic changes in systolic blood pressure. This occurrence was first described by Massumi et al. as an increase in systolic blood pressure related to lung inflation, followed by a decrease during expiration, and called “reverse pulsus paradoxus” [1] (Fig. 1). These changes stem from cyclic modifications in systemic venous return [2] and in right ventricular (RV) afterload [3] related to alterations in intrathoracic pressure and in transpulmonary pressure, respectively. Indirectly, this reflects cyclic changes in left ventricular (LV) stroke volume induced by positive-pressure ventilation. Such a phenomenon is always present but is limited in a patient with a normal hemodynamic status. Coyle et al. were probably the first to use these variations to detect hypovolemia [4]. Using the baseline value of systolic blood pressure observed at end-expiration, they also separated systolic blood pressure variations into two components, delta Up (dUp) and delta Down (dDown) (4) (Fig. 1), the latter being closely correlated with the level of induced hemorrhage in dogs 5 and with fluid responsiveness in septic patients [6].
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References
Massumi R, Mason D, Zauddin V, Zelis R, Otero J, Amsterdam E (1976) Reversed pulsus paradoxus. N Engl J Med 289:1272–1275
Guyton A, Linsdsey A, Abernathy B, Richardson T (1957) Venous return at various right atrial pressures and the normal venous return curve. Am J Physiol 189:609–615
Jardin F, Delorme G, Hardy A, Auvert B, Beauchet A, Bourdarias JP (1990) Reevaluation of hemodynamic consequences of positive pressure ventilation: emphasis on cyclic right ventricular afterloading by mechanical lung inflation. Anesthesiology 72:966–970
Coyle JP, Teplick RS, Long MC, Davison JK (1983) Respiratory variations in systemic arterial pressure as an indicator of volume status. Anesthesiology 59:A53 (abst)
Perel A, Pizov R, Cotev S (1987) Systolic blood pressure variation is a sensitive indicator of hypovolemia in ventilated dogs subjected to graded hemorrhage. Anesthesiology 67:498–502
Tavernier B, Makhotine O, Lebuffe G, Dupont J, Scherpereel P (1998) Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Anesthesiology 89:1313–1321
Denault A, Gasior T, Gorcsan J, Mandarino W, Deneault L, Pinsky M (1999) Determinants of aortic pressure variation during positive-pressure ventilation in man. Chest 116:178–186
Michard F, Boussat S, Chemla D, et al (2000) Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med 162:134–138
Jardin F, Farcot JC, Gueret P, Prost JF, Ozier Y, Bourdarias JP (1983) Cyclic changes in arterial pulse during respiratory support. Circulation 68:266–274
Vieillard-Baron A, Chergui K, Rabiller A, et al (2004) Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med 30:1734–1739
Versprille A (1990) The pulmonary circulation during mechanical ventilation. Acta Anaesthesiol Scand 34(Suppl 94):51–62
Vieillard-Baron A, Chergui K, Augarde R, et al (2003) Cyclic changes in arterial pulse during respiratory support revisited by Doppler echocardiography. Am J Respir Crit Care Med 168:671–676
Vieillard-Baron A, Loubières Y, Schmitt JM, Page B, Dubourg O, Jardin F (1999) Cyclic changes in right ventricular outflow impedance during mechanical ventilation. J Appl Physiol 87:1644–1650
Vieillard-Baron A, Schmitt JM, Augarde R, et al (2001) Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis. Crit Care Med 29:1551–1555
Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F (2002) Echo-Doppler demonstration of acute cor pulmonale at the bedside in the medical intensive care unit. Am J Respir Crit Care Med 166:1310–1319
Magder S (2004) Clinical usefulness of respiratory variations in arterial pulse. Am J Respir Crit Care Med 169:151–155
De Backer D, Heenen S, Piagnerelli M, Koch M, Vincent JL (2005) Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med 31:517–523
Teboul JL, Vieillard-Baron A (2005) Clinical value of pulse pressure variations in ARDS. Still an unresolved issue? Intensive Care Med 31:499–500
Reuter D, Felbinger T, Schmidt C, et al (2002) Stroke volume variations for assessment of cardiac responsiveness to volume loading in mechanically ventilated patients after cardiac surgery. Intensive Care Med 28:392–398
Gattinoni L, Pelosi P, Suter P, Pedoto A, Vercesi P, Lissoni A (1998) Acute respiratory distress syndrome caused by pulmonary and extra-pulmonary disease. Different syndromes? Am J Respir Crit Care Med 156:3–11
The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308
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Vieillard-Baron, A. (2006). Pulse Pressure Variations in Managing Fluid Requirement: Beware the Pitfalls!. In: Vincent, JL. (eds) Intensive Care Medicine. Springer, New York, NY. https://doi.org/10.1007/0-387-35096-9_18
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DOI: https://doi.org/10.1007/0-387-35096-9_18
Publisher Name: Springer, New York, NY
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