Respiratory and Hemodynamic Monitoring

นายแพทยอรรถวุฒิ ดีสมโชค
หนวยวิชาโรคระบบการหายใจและเวชบําบัดวิกฤต
ภาควิชาอายุรศาสตร คณะแพทยศาสตร มหาวิทยาลัยเชียงใหม

Symposium CRC-MV 2002 9/3/45

Monitoring
Q Goals :
– To continuously measure key indices that
ensure our understanding of underlying
pathophysiology, aid with diagnosis and guide
management
– To provide alarms that alert patient’s attendants
of a significant change in his/her condition
– To create trends that assist in assessing the
therapeutic response and predicting prognosis

1
Q Ideal information :
– EASILY obtained,
– CONTINUOUSLY available & reliable and
– the process of obtaining NOT harmful to the patient
Q Limitations :
– Clinical assessment alone - NOT predict accurately
– Non-invasive techniques - NOT continuous information
– Invasive techniques - ? Risk-benefit ratio
– Validity of the information - confounding factors

Clinical assessment
Q Bedside monitoring
– Vital signs : Respiratory rate, Heart rate,
Blood pressure
– Consciousness
– Cyanosis : central , peripheral
– Use of accessory muscles, abdominal paradox
(increased WOB)
– Urine output

2
Q Blood pressure
– Indirect BP : manual or automated
• Inaccurate in patients with marked peripheral
vasoconstriction and low stroke volume
• Not continuous monitoring of rapidly changing
hemodynamic status
– Direct invasive BP
• Continuous, beat-to-beat changes
• Detect pressures that Korotkoff sounds are absent
or inaccurate
• Decreased the need for multiple arterial punctures

Q Blood pressure (cont.)

– Pulse pressure = (Systolic - diastolic) pressure
– Mean arterial pressure = (Ps + 2Pd)/3
Q ECG monitoring :
– detect arrhythmia, ischemia
Q Arterial blood gases
– General assessment of respiratory function :
oxygenation & ventilation, acid-base
disturbance
– Require invasive procedure, not continuous
data

3
Q Arterial blood gases (cont.)
– Timing of sampling : after changing the ventilator
setting 10-30 min
– Alveolar-arterial oxygen difference : gas exchange
efficiency
• Normal (A-a)PO2 (room air) < 10 mmHg
• Hypoxemia with normal (A-a)PO2 : hypoventilation
• Estimate % shunt
– Arterial/Inspired FiO2 = PaO2/FiO2
• Normal = 550-600
• Differentiate acute lung injury from ARDS
• Estimate % shunt

Q Pulse oximetry
– Measure the saturation of Hb (oxyHb, reduced Hb) in
tissue during arterial & venous phases of pulsation
– Saturation = OxyHb x 100 %
OxyHb + reduced Hb
– Accuracy : within 2% of actual SaO2 (at SaO2 > 90%)
– Limitation
• Poor signal detection : probe malposition, motion,
hypothermia, no pulse, vasoconstriction,
hypotension
• Falsely low SO2 : nail polish, dark skin, methylene
blue, elevated serum lipid
• Falsely high SO2 : elevated COHb or
methemoglobin, hypothermia

4
Q Capnography
– Measure expired concentration of PCO2 (end tidal
PCO2)
– Normal end tidal PCO2 : less than PaCO2 < 5 mmHg
– Change in conditions with V/Q mismatch and absent in
esophageal intubation
– Calculate dead space = (PaCO2 -PetCO2)/PaCO2
– Detect airflow obstruction (A), air trapping (B)
A
PetCO2

Q Respiratory mechanics
– Respiratory muscle strength : Pimax
– Vital capacity (VC)
– Rapid shallow index (f/Vt)
• Pimax, VC, f/Vt : predict weaning outcome
– Thoracic compliance
• Static compliance = Vt/(Ppeak - PEEP)
• Dynamic compliance = Vt/(Pplateau - PEEP)
– Airway resistance = (Ppeak - Pplateau)/flow

5
Q Waveform : pressure-time, flow-time,
volume-time, pressure-volume

Auto-PEEP : expiratory
flow not return to zero

Air leak or air trapping :

volume in and out not equal

Central venous pressure

Q Measure right heart function and reflect preload & end
diastolic pressure and ability of right heart
Q Used to guide fluid therapy for both medical and surgical
patients
Q Inadequate for hemodynamic assessment and inaccurate
for estimation LV preload
Q ‘Zero’ point : catheter tip in right atrium (right 4th
intercostal space, midaxillary line)
Q Average CVP during normal inspiration and expiration :
between - 2 and + 6 mmHg (normal < 6 mmHg or 12
cmH2O)
Q Read at end-expiration

6
Fluid challenge test
CVP (cmH2O) PCWP (mmHg) Infusion
Start <8 < 10 200 mL/10 min
8-12 10-14 100 mL/10 min
> 12 > 14 50 mL/10 min
During infusion > 5 >7 Stop
After 10 min <2 <3 Continue
2< <5 3< <7 Wait 10 min
>5 >7 Stop
After waiting still > 2 still > 3 Stop
<2 <3 Repeat

Pulmonary artery (PA) catheter

Q Used to measure PA pressures and PCWP (assess LV
filling pressure)
– to diagnose circulatory deficiencies
– to differentiate acute heart failure from hypovolemia
or hypervolemia
Q PCWP closely parallels LA pressure & LVEDP, except in
mitral stenosis, increased PVR
Q Used with cardiac output and oxygen transport
measurement
Q Used to observe the progress of the disease and to titrate
various therapeutic interventions
Q Normal = 4-12 mmHg

7
Q PCWP that represents left heart filling pressure
– catheter tip in zone III : Pa > Pv > PA
– PADP > PCWP
– change in PCWP < 1/2 change in airway pressure
Q Effect of PEEP to PCWP
– PEEP < 10 cmH2O : limited effect on intrapleural pressure
– PEEP > 15 cmH2O : uncertain and altered by lung
compliance and venous return
• Real PCWP = measured PCWP - 1/2 PEEP
Q Measurement on and off PEEP :
– altered pressure gradient for venous return - autotransfusion
– deterioration of gas exchange, cardiac function
– NOT recommended