1. 4 - Cardio-Pulmonary System

2. Ready

3. Cardio-Pulmonary System James H. Philip, M.E.(E.), M.D. Anesthesiologist and Director of Technology Assessment Brigham and Women's Hospital Medical Liaison, Department of Biomedical Engineering Partners HealthCare System Associate Professor of Anaesthesia Harvard Medical School I have a financial interest in Gas Man ® and Med Man Simulations, Inc. I have performed research on some of the drugs or devices described © 1998 - 2003, James H Philip, all rights reserved.

4. Objectives - Cardio-pulmonary System Why we need it What it is What it does How it does it How we measure it now How we will measure it

5. Why Oxygen is inhaled by the lungs Oxygen (and sugar) are transported to tissues, cells, and then mitochondria Mitochondria O 2 + 2 CHO -> H 2 O + 2CO 2 + Energy Carbon dioxide is transported from mitochondria, cells, tissues to lungs Carbon dioxide is exhaled by the lungs

6. Cardio-Pulmonary system Lungs Tissues

7. Why did I lump systems? Cardiac Vascular Pulmonary Three systems Combine to allow life All are necessary Monitoring often involves them all

8. What it is (Cardio-Pulmonary system) Heart is a pump Lungs bring oxygen from air into blood Circulation transports: lungs tissues Oxygen to tissues Carbon dioxide from tissues Lungs bring carbon dioxide from blood into air

9. Heart, opened for clarity

10. Heart, schematized for more clarity

11. Heart Chambers RA RV LA LV

12. Heart Chambers RA RV LA LV Right Atrium Left Atrium Left Ventricle Right Ventricle

13. Venous return from tissues RA RV LA LV

14. SVC Superior Vena Cava RA RV LA LV IVC Inferior Vena Cava

15. RA -> RV RA RV LA LV

16. PA Pulmonary artery RA RV LA LV

17. Lungs RA RV LA LV

18. Heart, opened for clarity

19. RA RV

20. Heart, opened for clarity RA RV Tricusped Valve

21. Heart, opened for clarity RA RV Tricusped Valve Pulmonic Valve

22. Heart, opened for clarity

23. LA LV

24. Heart, opened for clarity LA LV Mitral valve (2 cusps)

25. Heart, opened for clarity LV Aorta

26. Heart, opened for clarity LV Aorta Aortic valve

27. Lungs

28. Trachea

29. Lungs Trachea Mainstem bronchi

30. Lungs Trachea Mainstem bronchi R L

31. Lungs Trachea Mainstem bronchi R L Smaller Bronchi Bronchioles Alveoli

32. Alveolus

33. Pulomnary artery blood Pulmonary vein blood

34. Alveolus Pulomnary artery blood Pulmonary vein blood High CO 2 Low O 2

35. Alveolus Pulomnary artery blood Pulmonary vein blood High CO 2 Low O 2 loses CO 2 gains O 2

36. Alveolus Pulomnary artery blood Pulmonary vein blood High CO 2 Low O 2 Low CO 2 High O 2

37. Alveolus Oxygen diffuses into blood

38. Alveolus Carbon dioxide diffuses out of blood

39. Nomenclature Mostly jargon Not done to intentionally convuse But usually does so, anyway Start with COCardiac Output

40. Cardiac Output How much blood the heart pumps in one minute must equal blood which returned from tissues Paradox Return or Pumping capability can limit! Useful physiologic variable Ocasionally doesn’t give the whole answer

41. Abbreviations BSABody Surface Area IndexParameter / BSA CICardiac Index (= CO / BSA) COCardiac Output MAPMean Arterial Pressure MPAPMean Pulmonary Artery Pressure PCWPPulmonary Capillary Wedge Pressure LVEDPLeft Ventricular End-Diastolic Pressure LAPLeft Atrial Pressure PVRPulmonary Vascular Resistance RAPRight Atrial Pressure R/L VSWIRight / Left Ventricular Stroke Work Index R/L CWRight / Left Cardiac Work SVStroke Volume SVIStroke Volume Index (=SV/BSA) SVRSystemic Vascular Resistance

42. Filling Pressures

43. Pulmonary Vessels LA LV Lungs PA PC Pulmonary Capillaries

44. Pulmonary Artery Pressure PAP LA

45. Pulmonary Capillary Wedge Pressure PCWP

46. Pulmonary Capillary Wedge Pressure PCWP ≈ PA diastolic pressure

47. Schematic View

48. Central Circulation LA LVAo PVPA RA RV SVC IVC PC

49. Right Ventricle LA LVAo PVPA RA RV SVC IVC PC RVEDP = Right Ventricular End-Diastolic Pressure

50. Right Ventricle LA LVAo PVPA RA RV SVC IVC PC RVEDP = Right Ventricular End-Diastolic Pressure = Pressure in RV before it contracts = Starting pressure = pre-lad

51. Right Atrium LA LVAo PVPA RA RV SVC IVC PC RAP = RVEDP

52. Right Atrium LA LVAo PVPA RA RV SVC IVC PC RAP = RVEDP End of diastole, the A-V valves are open Pressures are equal =

53. Right Atrium LA LVAo PVPA RA RV SVC IVC PC CVP = RAP Central Venous Pressure = Right Atrial Pressure

54. CVP = RAP = RH Filling Pressure LA LVAo PVPA RA RV SVC IVC PC CVP = RAP Central Venous Pressure = Right Atrial Pressure = Right Heart Filling Pressure

55. R Heart Filling Pressure is Easy to measure LA LVAo PVPA RA RV SVC IVC PC CVP = RAP Central Venous Pressure = Right Atrial Pressure = Right Heart Filling Pressure

56. R Heart Filling Pressure is Easy to measure LA LVAo PVPA RA RV SVC IVC PC CVP = RAP Central Venous Pressure = Right Atrial Pressure = Right Heart Filling Pressure Neck vein (internal jugular IJ)

57. L Heart Filling Pressure LA LVAo PVPA RA RV SVC IVC PC Neck vein (internal jugular IJ) Can’t get there from here

58. L Heart Filling Pressure LA LVAo PVPA RA RV SVC IVC PC Neck vein (internal jugular IJ) Can’t get there from anywhere

59. L Heart Filling Pressure LA LVAo PA RA RV SVC IVC PC Neck vein (internal jugular IJ) PV Wedge a balloon in the a capillary

60. L Heart Filling Pressure LA LVAo PA RA RV SVC IVC PC Neck vein (internal jugular IJ) PV Wedge a balloon in the a capillary Produce Pulmonary Capillary Wedge Pressure PCWP

61. L Heart Filling Pressure LA LVAo PA RA RV SVC IVC PC Neck vein (internal jugular IJ) PV Wedge a balloon in the a capillary Produce Pulmonary Capillary Wedge Pressure PCWP = LAP

62. PCWP = L Heart Filling Pressure LA LVAo PA RA RV SVC IVC PC Neck vein (internal jugular IJ) PV Wedge a balloon in the a capillary Produce Pulmonary Capillary Wedge Pressure PCWP = LAP

63. By-the-stroke analysis Cardiac Output = (Heart Rate) x (Stroke Volume) CO = HR x SV Units: Cardiac Output = [strokes/min] x [mL / stroke] = mL / min CO = HR x SV —> SV = CO / HR Example CO = 5 L / min = 5,000 mL / min; HR = 50 / min SV = [ 5,000 mL / min ] / [ 50 / min ] = 100 mL

64. Cardiac Work Stroke Work = (Pressure rise) x (Stroke Volume) Stroke Work = ∆ P x ∆ V ∆ P = pressure after chamber - pressure before chamber LV: MAP - LVEDP = MAP - PCWP

65. Some Cardiovascular Parameters Cardiac Output = (Heart Rate) x (Stroke Volume) Units: Cardiac Output = strokes/min x mL / stroke = mL / min = flow rate Left Ventricular Stroke Work = LVSW = SV (MAP - PCWP) Left Ventricular Stroke Work IndexLVSWI = SV (MAP-PCWP)/BSA Right Ventricular Stroke Work IndexRVSWI = SV (MPAP-RAP)/BSA Left Cardiac WorkLCW = CO MAP / BSA Right Cardiac WorkRCW = CO MPAP / BSA

66. Pressure - Flow relationship V (voltage) = I (current) x R (resistance) P (pressure) = F (flow or CO) x R (resistance) P = F x R; R = P / F = ∆ P / F Pulmonary Vascular Resistance PVR = (MPAP-PAWP) / CO Systemic Vascular Resistance SVR = (MAP-RAP) / CO

67. Pressure - Flow relationship V (voltage) = I (current) x R (resistance) P (pressure) = F (flow or CO) x R (resistance) P = F x R; R = P / F = ∆ P / F Pulmonary Vascular Resistance PVR = (MPAP-PAWP) / CO Systemic Vascular Resistance SVR = (MAP-RAP) / CO

68. Stop