Arterial Pulse Pressure Variation with Mechanical Ventilation

Abstract

Fluid administration leads to a significant increase in cardiac output in only half of ICU patients. This has led to the concept of assessing fluid responsiveness before infusing fluid. Pulse pressure variation (PPV), which quantifies the changes in arterial pulse pressure during mechanical ventilation, is one of the dynamic variables that can predict fluid responsiveness. The underlying hypothesis is that large respiratory changes in left ventricular stroke volume, and thus pulse pressure, occur in cases of biventricular preload responsiveness. Several studies showed that PPV accurately predicts fluid responsiveness when patients are under controlled mechanical ventilation. Nevertheless, in many conditions encountered in the ICU, the interpretation of PPV is unreliable (spontaneous breathing, cardiac arrhythmias) or doubtful (low Vt). To overcome some of these limitations, researchers have proposed using simple tests such as the Vt challenge to evaluate the dynamic response of PPV. The applicability of PPV is higher in the operating room setting, where fluid strategies made on the basis of PPV improve postoperative outcomes. In medical critically ill patients, although no randomized controlled trial has compared PPV-based fluid management with standard care, the Surviving Sepsis Campaign guidelines recommend using fluid responsiveness indices, including PPV, whenever applicable. In conclusion, PPV is useful for managing fluid therapy under specific conditions where it is reliable. The kinetics of PPV during diagnostic or therapeutic tests is also helpful for fluid management.