Cardiopulmonary Interactions with Dr. Bradley Fuhrman -- Part 1
Sep 4, 2023
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Dr. Bradley Fuhrman, a pediatrician and specialist in cardiology and neonatology, discusses clinically relevant cardiopulmonary interactions. Topics covered include cardiopulmonary dynamics, septic shock, fluid status assessment in pediatric patients, and the use of passive leg raise as a diagnostic tool.
The interactions between positive pressure ventilation and spontaneous breathing have significant implications for the management of critically ill patients.
In septic patients and those with respiratory distress, cardiopulmonary interactions are further complicated, requiring careful management to prevent cardiac arrest and optimize patient outcomes.
Deep dives
Importance of Cardiopulmonary Interactions in Patient Resuscitation
Understanding the interactions between the cardiovascular and respiratory systems is crucial during patient resuscitation. When resuscitating a patient, the circulation and breathing are closely connected, influencing each other. Positive pressure ventilation, such as during intubation, leads to increased intrathoracic pressure, which can impede venous return to the heart but support left ventricular ejection. Spontaneous breathing, on the other hand, promotes venous return but opposes left ventricular ejection. These interactions play a significant role in the management of critically ill patients.
Effects of Sepsis and Respiratory Distress on Cardiopulmonary Interactions
Sepsis and respiratory distress further complicate cardiopulmonary interactions. In septic patients, capillary leak leads to decreased mean systemic filling pressure, impaired left ventricular filling, and abnormalities in cardiac contractility and diastolic function. In respiratory distress, the increased inspiratory and expiratory forces create negative juxtapacardiac pressures, affecting ventricular filling and left ventricular afterload. Moreover, patients in respiratory distress have heightened oxygen consumption, placing an added strain on cardiac output. Managing these interactions becomes crucial in preventing cardiac arrest and optimizing patient outcomes.
Fluid Resuscitation and Physical Exam Findings in Cardiopulmonary Interactions
Fluid resuscitation is a key aspect of sepsis treatment and improving cardiopulmonary interactions. However, determining the optimal fluid status for a patient can be challenging. Physical exam findings, such as poor perfusion and signs of dehydration, can prompt the need for fluid administration. The passive leg raise test, where the legs are elevated briefly, can help identify patients who may respond favorably to fluid administration. However, predicting response to fluid therapy is complex, and individual patient factors need to be considered.
Conclusion
Understanding cardiopulmonary interactions is critical in the management of critically ill patients. The relationship between circulation and breathing plays a significant role in resuscitation and optimizing patient outcomes. Managing sepsis, respiratory distress, and fluid resuscitation requires careful consideration of the patient's condition and individual responses to interventions.
Bradley Fuhrman, MD completed his training in pediatrics followed by fellowships in cardiology and neonatology at the University of Minnesota where he went on to found the first PICU and serve as the Chief of critical care at that institution. He has also served as the associate director of the PICU at Children’s Hospital of Pittsburgh, Division Chief of Critical Care at Children’s Hospital Buffalo and Physician-in-Chief at El Paso Children’s Hospital. His career in pediatric critical care exceeds 40 years. He has many peer-reviewed publications with a research career that is focused in cardiac and respiratory physiology. He is also the co-author of Fuhrman and Zimmerman’s Pediatric Critical Care.
Learning Objectives:
By the end of listening to this 2-part series, learners should be able to discuss clinically relevant cardiopulmonary interactions and a fundamental clinical approach to optimizing cardiopulmonary mechanics in patients with:
Spontaneous (negative pressure) respirations with severe work of breathing
Septic shock
Mechanical (positive pressure) ventilation
Pulmonary hypertension with right ventricular systolic dysfunction
Left ventricular systolic dysfunction
Right ventricular diastolic dysfunction
Single ventricle Fontan circulation
References:
Bronicki RA, Penny DJ, Anas NG, Fuhrman B. Cardiopulmonary Interactions. Pediatr Crit Care Med. 2016 Aug;17(8 Suppl 1):S182-93. doi: 10.1097/PCC.0000000000000829. PMID: 27490598.
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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
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