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Highly Accessed Review

Clinical review: Positive end-expiratory pressure and cardiac output

Thomas Luecke1* and Paolo Pelosi2

Author Affiliations

1 Section Head, Critical Care, Department of Anesthesiology and Critical Care Medicine, University Hospital of Mannheim, Germany

2 Associate Professor in Anaesthesia and Intensive Care, Dipartimento di Scienze Cliniche e Biologiche, Università degli Studi dell'Insubria, Varese, Italy

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Critical Care 2005, 9:607-621  doi:10.1186/cc3877

Published: 18 October 2005

Abstract

In patients with acute lung injury, high levels of positive end-expiratory pressure (PEEP) may be necessary to maintain or restore oxygenation, despite the fact that 'aggressive' mechanical ventilation can markedly affect cardiac function in a complex and often unpredictable fashion. As heart rate usually does not change with PEEP, the entire fall in cardiac output is a consequence of a reduction in left ventricular stroke volume (SV). PEEP-induced changes in cardiac output are analyzed, therefore, in terms of changes in SV and its determinants (preload, afterload, contractility and ventricular compliance). Mechanical ventilation with PEEP, like any other active or passive ventilatory maneuver, primarily affects cardiac function by changing lung volume and intrathoracic pressure. In order to describe the direct cardiocirculatory consequences of respiratory failure necessitating mechanical ventilation and PEEP, this review will focus on the effects of changes in lung volume, factors controlling venous return, the diastolic interactions between the ventricles and the effects of intrathoracic pressure on cardiac function, specifically left ventricular function. Finally, the hemodynamic consequences of PEEP in patients with heart failure, chronic obstructive pulmonary disease and acute respiratory distress syndrome are discussed.