Valsalva Maneuver
1707- Italian anatomist Valsalva discribed this maneuver. The subject closes the mouth and nose, expires forcibly and thereby increases the pressure inside the pharynx and the lung passages. Today this is used to asses the autonomic responsiveness to circulatory changes. Increased intrathoracic pressure red. VR red.C.O. red. BP
Procedure
The subject expires against a 40 mm Hg resistance for 15 sec. Sudden inc. ITP. / intra abd. Pressure /CSF pressure The peripheral venous valves shutthe blood accumulate in peri. Veins aortic flow drops to about 50% of control.
IPPV
1543-Vesalius animal research 18th century - human research 1952 - >200 cases of poliomyalitis treated with IPPV Tremendous use in anaesthetic practice and management of critically ill But ass. with disturbances in normal physiological mechanisms
IPPV ctd.
Normal breathing negative pressure in the intrapleural space during insp. IPPV positive pressure in the upper airways pushes gas in. This positive intrathoracic pressure is responsible for most of the physiological disturbances.
Systems Affected
1. Res.system CVS 3. Renal Brain 6. Endocrine 7. Metabolic 2. 4. 5. GIT
Res. System
1. 2. 3. 4. 5 6. Red. FRC Altered distribution of vent. Inc. shunt effect Inc. dead space Barotrauma Redistribution of extravascular lung water
FRC
FRC vol.of gas in the lungs at the end of normal exp. FRC is reduced by about 17% in the adult with anaes. and muscle relaxation The most likely reason is cephalad displacement of the diaphragm and alteration of thoracic geometry . Red. FRC encroachment of closing capacity areas of atelectasis inc. shunt [ diagram] Abd. Distension and prone position marked red. FRC
Distribution of Vent.
In the normal person compliance is greatest in the most dependent parts of the lungs due to the variation in the resting volume of different lung units.[diagram]
In the supine patient expansion of most dependent part of the lung is opposed by the pressure of the abd. contents. But in spon.breathing pt.inc. contractility of those parts of the diaphragm compressed by the abd. Contents counteracts this. During IPPV this does not happen. Therefore insp. gases preferentially distributed to uppermost lung units. Prone position dorsal part, lat. Position -uppermost
Barotrauma
Large TV and excessive inflation pressures increases the risk of barotrauma.
Peak airway pressure > 30 cm H2O pul.interstitial emphysema. Peak awp. > 60 cm pneumothorax More common in nonuniform lung diseases - obs. airways disease - broncho pul. dysplasia -hypovolaemia
Other effects Absent cough - Absent sigh effect - Impaired clearence of secretions Redistribution of lung water IPPV inc. pul. Cap. P inc. p. gradient inc. fluid This is not clinically significant. In pul. oedema IPPV redistribution of lung water, recruitment of alveoli and reopening of airways improved gas exchange
Cardiovascular System
The main effect is red. CO (10 20%) This is due to 1. red. VR 2. inc. pul. Vas. resistance 3. red. LV compliance 4. cardiac tamponade effect 5. Release of a negative inotropic factor
Venous Return
Spon. Insp. red. ITP inc. VR keeps the atria open
IPPV inc. ITP during insp. red. VR In a poorly compliant lung inc. airway p.is not transmitted to intrapleural space and red. CO is less. The effect of anaes. and sedative drugs further compromise the BP.
LV Compliance
Inc. pul. vas. resistance inc. RV afterload red. RV output dilatation of RV deviation of interventricular septum to the left red. LV size red. CO Inc. RV afterload red. LA filling red. LV output Elderly and hypovolaemic patients have a higher risk. cardiac tamponade effect and negative inotropic effect demonstrated in animals.
Renal System
IPPV red. UOP Na retention This may be due to 1. red. CO 2. hormonal changes Red. CO red. Renal perfusion p. Red. VR inc. renal venous p. Red. A-V p.gradient red. perfusion. Hormonal changes 1. red. Anti Natriuretic Factor 2. inc. renin activity 3. inc. ADH
Brain Red. VR inc. ICP Hypervent. red. Paco2 constriction of cerebral bld. vessels red. ICP. GIT Paralytic ileus lasting for about 48 hrs. May be due to red. gut perfusion or altered autonomic activity. Metabolic functions IPPV might have an effect on the hormone synthesis and met. which take place in the lungs. PEEP and CPAP exaggerates all above physiological effects.