Does Positive End-Expiratory Pressure Ventilation Improve Left Ventricular Function?

A Comparative Study by Transesophageal Echocardiography in Cardiac and Noncardiac Patients

¹ From the Respiratory Intensive Care Unit, Hôpital Ambroise Paré, University of Paris V, France
² From the Biostatistics Department, Hôpital Ambroise Paré, University of Paris V, France
³ From the Department of Cardiology, Hôpital Ambroise Paré, University of Paris V, France

Jean-Luc Fellahi, Département d'Anesthésie-Réanimation, Groupe Hospitalier Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75651 Paris Cedex 13, France

Study objectives: Positive end-expiratory pressure (PEEP) has been proposed to improve cardiac output in patients with left ventricular (LV) dysfunction. This study was designed to compare quantitative global and regional LV performance in response to PEEP in patients with normal and poor LV function.

Design: A prospective clinical trial.

Setting: Adult medical ICU in a university hospital.

Patients: Twelve critically ill patients requiring respiratory support and divided into two groups according to baseline transesophageal echocardiographic (TEE) measurements: normal LV dimensions and fractional area of contraction (FAC=61±5%) (n=7) and dilated cardiomyopathy with reduced FAC (21±1%) (n=5).

Measurements and results: All patients were studied when two successive levels of PEEP (best PEEP as the highest value of respiratory compliance and high PEEP as best PEEP+10 cm H₂O) were applied. Global systolic LV performance and quantitative regional wall motion analysis performed by the centerline method were assessed on the TEE transgastric short-axis view. End-systolic wall stress (ESWS) was used as a reliable indication of LV afterload. PEEP reduced LV dimensions asymmetrically in both groups of patients and septolateral diameter significantly decreased without affecting global LV systolic performance. Additionally, high PEEP produced a significant impairment in septal kinetics as evidenced by the centerline method. High PEEP also decreased ESWS for all patients (27% in normal group and 23% in cardiac group, p<0.05) without significant improvement in global systolic LV performance (FAC: +2% in normal group and +0% in cardiac group; not significant).

Conclusions: PEEP cannot be recommended routinely to improve LV performance in patients with severe dilated cardiomyopathy.

Key Words: cardiomyopathy • hemodynamics • PEEP ventilation • transesophageal echocardiography

Submitted on August 26, 1997
Accepted on January 26, 1998

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