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Effect of Positive End-Expiratory Pressure on Cardiac Index and Right Ventricular Performance in Ventilated Children
Jan-Christoph Clausen1,2, Michael Emeis1,2, Richard Hollander3
1Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center of the Charité (DHZC), Berlin, Germany.
Insights
Higher positive end-expiratory pressure (PEEP) improved cardiac index and right ventricular (RV) function in children after congenital heart disease (CHD) surgery. This suggests PEEP can optimize lung volume and cardiopulmonary interactions post-operatively.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular physiology
- Respiratory mechanics
Background:
- Lower positive end-expiratory pressure (PEEP) is often recommended for patients with congenital heart disease (CHD) to avoid hemodynamic compromise.
- The impact of varying PEEP levels on cardiac index, lung mechanics, and right ventricular (RV) function in post-cardiac surgery pediatric patients remains incompletely understood.
Purpose of the Study:
- To investigate the effects of different PEEP levels on cardiac index, lung mechanics, and RV function in pediatric patients following cardiac surgery for CHD.
- To determine if higher PEEP levels can optimize cardiopulmonary interactions and lung recruitment in this vulnerable population.
Main Methods:
- A prospective, single-center physiological study was conducted in a tertiary pediatric cardiac intensive care unit.
- Fifty-eight pediatric subjects (<5 years) undergoing cardiac surgery for CHD were enrolled.
- Measurements of cardiac index, RV function, static compliance (Cstat), dynamic compliance, and transpulmonary pressures were taken at four PEEP levels: baseline, high PEEP (+4 cm H2O), low PEEP (-4 cm H2O), and return to baseline.
Main Results:
- Cardiac index and RV performance significantly improved at higher PEEP levels (PEEPhigh) (p < 0.01).
- A decrease in cardiac index was observed in a minority of patients (12% at PEEPhigh, 31% at PEEPlow).
- Changes in RV performance and Cstat were concordant, improving or worsening together with PEEP manipulation, irrespective of underlying lesion or surgical factors like cardiopulmonary bypass (CPB).
Conclusions:
- In children with CHD undergoing biventricular repair, higher PEEP levels generally enhanced cardiac index, RV function, and Cstat, suggesting pulmonary recruitment benefits.
- The close relationship between cardiac performance and Cstat changes with PEEP manipulation highlights their interconnectedness.
- Findings support the use of PEEP to optimize lung volume and cardiopulmonary interactions in pediatric patients post-cardiac surgery.
Objective:
Lower positive end-expiratory pressure (PEEP) is commonly suggested in congenital heart disease (CHD) patients to prevent hemodynamic impairment and right ventricular (RV) dysfunction. We sought to study the effect of different levels of PEEP on cardiac index, lung mechanics, and RV function in subjects after cardiac surgery.
Design:
Prospective, single-center physiology study conducted in a tertiary pediatric cardiac ICU between November 2023 and July 2024.
Setting:
Operating room (OR) and cardiac ICU (CICU).
Patients:
Subjects younger than 5 years post-cardiac surgery for CHD.
Interventions:
Four consecutive PEEP levels: baseline (PEEPstart), high PEEP (baseline plus 4 cm H 2 O; PEEPhigh), low PEEP (baseline minus 4 cm H 2 O; PEEPlow), and return to baseline (PEEPend).
Measurements:
In 58 subjects, cardiac index and RV function, static (Cstat) and dynamic compliance, and transpulmonary pressures were measured at each PEEP level and with constant driving pressure. Of these subjects, 81.0% underwent surgery with cardiopulmonary bypass (CPB). The median age was 4.9 months, and 55% of subjects were male. The mean baseline PEEP was 6.2 cm H₂O ( sd 1.4), the mean PEEPhigh was 10.2 cm H₂O ( sd 1.4), and the mean PEEPlow was 3.3 cm H₂O ( sd 0.7).
Main Results:
Overall, cardiac index and RV performance increased significantly with PEEPhigh ( p < 0.01). Cardiac index decreased in 7 of 58 patients (12%)with PEEPhigh and in 18 of 58 patients (31%) with PEEPlow. Directional change in measures of RV performance and Cstat over time was generally concordant; with manipulation of PEEP, both improved or worsened together, independent of the underlying lesion. Sensitivity analyses showed that the results remained consistent regardless of the location of the measurement (OR vs. CICU), whether inhaled nitric oxide or milrinone was used, whether RV outflow tract obstruction was present, and whether CPB was used.
Conclusions:
In children with CHD who underwent biventricular repair, cardiac index, RV function, and Cstat generally improved with higher PEEP, indicating pulmonary recruitment. Changes in cardiac performance and Cstat were closely related, with both improving or worsening together with manipulation of PEEP. This study supports the use of PEEP to optimize lung volume and cardiopulmonary interactions after cardiac surgery.
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