Discovering the Clinical Relevance of Heart-Lung Interactions.

In 1978, Dr. Pinsky's scientific career became firmly directed toward understanding the deeper meaning of heart-lung interactions. This would define his focus for the next 45 yr. At the time, he and colleagues studied the effects of changes in intrathoracic pressure on left ventricular performance in humans, documenting that the primary effect of large negative swings in intrathoracic pressure was to increase left ventricular transmural ejection pressure, and thus left ventricular afterload, selectively. They concluded that large intrathoracic pressure changes directly influence cardiac performance. This fundamental observation was followed by many additional observations in both highly invasive animal studies supported by less invasive clinical studies, which showed that intrathoracic pressure-induced changes in the gradients for venous return to the heart and left ventricular ejection from the heart disproportionately affected both right ventricular and left ventricular function. The direct clinical implications of these results form the rationale for use of continuous positive airway pressure as a primary treatment of acute cardiogenic pulmonary edema and immediate endotracheal intubation for acute upper airway obstruction. These findings subsequently led to the practical use of dynamic changes in left ventricular stroke volume and the associated arterial pulse pressure during positive-pressure ventilation to identify volume responsiveness and, thus, to personalize resuscitation efforts in the treatment of acute cardiovascular insufficiency.