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Respir Care. 2013 Nov;58(11):e138-43. doi: 10.4187/respcare.02437. Epub 2013 Apr 2.

Profound bradycardia with decreased PEEP.

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Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.


An athletic 21-year-old male was admitted to the surgical ICU after sustaining 2 stab wounds to his torso. He had an episode of left lung collapse early in his course, managed with suctioning and increased PEEP, to 15 cm H2O. He was bradycardic (heart rates 50-60 beats/min) throughout his ICU stay, but when the PEEP was lowered to 5 cm H2O in preparation for extubation, he developed sinus pauses and his heart rate dropped to 20 beats/min. After a thorough evaluation, the drop in his heart rate was determined to be due to increased vagal tone from increased cardiac output with the decreased PEEP. After premedication with glycopyrrolate, he was successfully extubated the following day, while his heart rate remained at his baseline of 50 beats/min. We review the physiologic mechanisms of bradycardia due to the removal of mechanical ventilation.


autonomic signaling; bradycardia; cardiovascular reflex; mechanical ventilation; vasovagal reflex

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