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Arena A, Miller E. Respiratory Acid-Base Disorders. Emerg Med Clin North Am 2023; 41:863-875. [PMID: 37758429 DOI: 10.1016/j.emc.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Respiratory acid-base disorders are often not thought of as frequently as their metabolic cousins, which occur more frequently in the emergency department. Although most respiratory and acid-base disturbances are driven by lung pathology, central nervous system and other organ systems can and do play a role as well. Although managing the airway and appropriate mechanical ventilation may be necessary, it is akin to placing a band-aid on a large wound. It is crucial for the emergency clinician to discover the etiology of the disturbance as management depends on treating the underlying etiology to prevent worsening acid-base status.
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Affiliation(s)
- Alexander Arena
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229-3900, USA.
| | - Emily Miller
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229-3900, USA
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Umeda A, Ishizaka M, Ikeda A, Miyagawa K, Mochida A, Takeda H, Takeda K, Fukushi I, Okada Y, Gozal D. Recent Insights into the Measurement of Carbon Dioxide Concentrations for Clinical Practice in Respiratory Medicine. SENSORS (BASEL, SWITZERLAND) 2021; 21:5636. [PMID: 34451079 PMCID: PMC8402333 DOI: 10.3390/s21165636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/06/2021] [Accepted: 08/16/2021] [Indexed: 12/28/2022]
Abstract
In the field of respiratory clinical practice, the importance of measuring carbon dioxide (CO2) concentrations cannot be overemphasized. Within the body, assessment of the arterial partial pressure of CO2 (PaCO2) has been the gold standard for many decades. Non-invasive assessments are usually predicated on the measurement of CO2 concentrations in the air, usually using an infrared analyzer, and these data are clearly important regarding climate changes as well as regulations of air quality in buildings to ascertain adequate ventilation. Measurements of CO2 production with oxygen consumption yield important indices such as the respiratory quotient and estimates of energy expenditure, which may be used for further investigation in the various fields of metabolism, obesity, sleep disorders, and lifestyle-related issues. Measures of PaCO2 are nowadays performed using the Severinghaus electrode in arterial blood or in arterialized capillary blood, while the same electrode system has been modified to enable relatively accurate non-invasive monitoring of the transcutaneous partial pressure of CO2 (PtcCO2). PtcCO2 monitoring during sleep can be helpful for evaluating sleep apnea syndrome, particularly in children. End-tidal PCO2 is inferior to PtcCO2 as far as accuracy, but it provides breath-by-breath estimates of respiratory gas exchange, while PtcCO2 reflects temporal trends in alveolar ventilation. The frequency of monitoring end-tidal PCO2 has markedly increased in light of its multiple applications (e.g., verify endotracheal intubation, anesthesia or mechanical ventilation, exercise testing, respiratory patterning during sleep, etc.).
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Affiliation(s)
- Akira Umeda
- Department of General Medicine, School of Medicine, IUHW Shioya Hospital, International University of Health and Welfare (IUHW), Yaita 329-2145, Japan
| | - Masahiro Ishizaka
- Department of Physical Therapy, School of Health Science, International University of Health and Welfare, Otawara 324-8501, Japan
| | - Akane Ikeda
- Department of Rehabilitation, IUHW Shioya Hospital, International University of Health and Welfare (IUHW), Yaita 329-2145, Japan
| | - Kazuya Miyagawa
- Department of Pharmacology, School of Pharmacy, International University of Health and Welfare, Otawara 324-8501, Japan
| | - Atsumi Mochida
- Department of Pharmacology, School of Pharmacy, International University of Health and Welfare, Otawara 324-8501, Japan
| | - Hiroshi Takeda
- Department of Pharmacology, School of Pharmacy, International University of Health and Welfare, Otawara 324-8501, Japan
- Department of Pharmacology, School of Pharmacy at Fukuoka, International University of Health and Welfare, Okawa 831-8501, Japan
| | - Kotaro Takeda
- Faculty of Rehabilitation, School of Healthcare, Fujita Health University, Toyoake 470-1192, Japan
| | - Isato Fukushi
- Faculty of Health Sciences, Uekusa Gakuen University, Chiba 264-0007, Japan
- Laboratory of Electrophysiology, Clinical Research Center, Murayama Medical Center, Musashimurayama 208-0011, Japan
| | - Yasumasa Okada
- Laboratory of Electrophysiology, Clinical Research Center, Murayama Medical Center, Musashimurayama 208-0011, Japan
| | - David Gozal
- Department of Child Health and the Child Health Research Institute, MU Women's and Children's Hospital, University of Missouri, Columbia, MO 65201, USA
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Zhou Y, He H, Cui N, Wang H, Zhou X, Long Y. Acute hyperventilation increases oxygen consumption and decreases peripheral tissue perfusion in critically ill patients. J Crit Care 2021; 66:148-153. [PMID: 34364716 DOI: 10.1016/j.jcrc.2021.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/07/2021] [Accepted: 05/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aimed to evaluate the effects of acute hyperventilation on central venous-to-arterial carbon dioxide tension difference (Pv-aCO2), central venous oxygen saturation (ScvO2), central venous-to-arterial CO2 difference/arterial-central venous O2 difference ratio (CO2GAP-Ratio), and peripheral perfusion index (PI) in hemodynamically stable critically ill patients. METHODS Fifty-four mechanically ventilated patients were evaluated. The cardiac index, Pv-aCO2, ScvO2, CO2GAP-Ratio, PI, and arterial and venous blood gas parameters were measured in the first set of measurements. Then, alveolar ventilation was increased by raising the respiratory rate (10 breaths/min). After a 30 min hyperventilation period, the second set of measurements was recorded. RESULTS Acute hyperventilation induces an increase in Pv-aCO2 (from 3.87 ± 1.31 to 8.44 ± 1.81 mmHg, P < 0.001) and a decrease in ScvO2(from 71.78 ± 4.82 to 66.47 ± 5.74%, P < 0.001). The CO2GAP-Ratio was significantly increased(from 0.97 ± 0.40 to 1.74 ± 0.46, P < 0.001), and the PI showed a remarkable decrease caused by acute hyperventilation(from 1.82 ± 1.14 to 1.40 ± 0.99,P = 0.04). Hyperventilation-induced ∆_Pv-aCO2 was negatively correlated with ∆PaCO2(r = -0.572, P<0.001). The change in ∆_PaCO2 was correlated with ∆_ScvO2(r = 0.450, P<0.001). However, the left ventricular outflow tract velocity time integral (LVOT-VTI) remained unchanged during hyperventilation. CONCLUSIONS Acute hyperventilation induced an increase in oxygen consumption and decreased peripheral tissue perfusion in patients. For critical care patients, it is necessary to pay attention to the influence of hyperventilation on peripheral tissue perfusion indices and oxygen consumption indices.
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Affiliation(s)
- Yuankai Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Na Cui
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hao Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China.
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Umeda A, Ishizaka M, Tasaki M, Yamane T, Watanabe T, Inoue Y, Mochizuki T, Okada Y, Kesler S. Evaluation of time courses of agreement between minutely obtained transcutaneous blood gas data and the gold standard arterial data from spontaneously breathing Asian adults, and various subgroup analyses. BMC Pulm Med 2020; 20:151. [PMID: 32471394 PMCID: PMC7257137 DOI: 10.1186/s12890-020-01184-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Usual clinical practice for arterial blood gas analysis (BGA) in conscious patients involves a one-time arterial puncture to be performed after a resting period of 20-30 min. The aim of this study was to evaluate the use of transcutaneous BGA for estimating this gold standard arterial BGA. METHODS Spontaneously breathing Asian adults (healthy volunteers and respiratory patients) were enrolled (n = 295). Transcutaneous PO2 (PtcO2) and PCO2 (PtcCO2) were monitored using a transcutaneous monitor (TCM4, Radiometer Medical AsP, Denmark) with sensors placed on the chest, forearm, earlobe or forehead. Transcutaneous BGA at 1-min intervals was compared with arterial BGA at 30 min. Reasonable steps to find severe hypercapnia with PaCO2 > 50 mmHg were evaluated. RESULTS Sensors on the chest and forearm were equally preferred and used because of small biases (n = 272). The average PCO2 bias was close to 0 mmHg at 4 min, and was almost constant (4-5 mmHg) with PtcCO2 being higher than PaCO2 at ≥8 min. The limit of agreement for PCO2 narrowed over time: ± 13.6 mmHg at 4 min, ± 7.5 mmHg at 12-13 min, and ± 6.3 mmHg at 30 min. The limit of agreement for PO2 also narrowed over time (± 23.1 mmHg at 30 min). Subgroup analyses showed that the PaCO2 and PaO2 levels, gender, and younger age significantly affected the biases. All hypercapnia subjects with PaCO2 > 50 mmHg (n = 13) showed PtcCO2 ≥ 50 mmHg for until 12 min. CONCLUSIONS Although PtcCO2 is useful, it cannot completely replace PaCO2 because PCO2 occasionally showed large bias. On the other hand, the prediction of PaO2 using PtcO2 was unrealistic in Asian adults. PtcCO2 ≥ 50 mmHg for until 12 min can be used as a screening tool for severe hypercapnia with PaCO2 > 50 mmHg.
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Affiliation(s)
- Akira Umeda
- Departments of Internal Medicine, International University of Health and Welfare (IUHW) Shioya Hospital, Tomita 77, Yaita-City, Tochigi, 329-2145, Japan.
| | - Masahiro Ishizaka
- Departments of Rehabilitation, International University of Health and Welfare (IUHW) Shioya Hospital, Yaita-City, Japan
| | - Masamichi Tasaki
- Departments of Rehabilitation, International University of Health and Welfare (IUHW) Shioya Hospital, Yaita-City, Japan
| | - Tateki Yamane
- Departments of Internal Medicine, International University of Health and Welfare (IUHW) Shioya Hospital, Tomita 77, Yaita-City, Tochigi, 329-2145, Japan
| | - Taiji Watanabe
- Departments of Internal Medicine, International University of Health and Welfare (IUHW) Shioya Hospital, Tomita 77, Yaita-City, Tochigi, 329-2145, Japan
| | - Yasushi Inoue
- Departments of Internal Medicine, International University of Health and Welfare (IUHW) Shioya Hospital, Tomita 77, Yaita-City, Tochigi, 329-2145, Japan
| | - Taichi Mochizuki
- Departments of Internal Medicine, International University of Health and Welfare (IUHW) Shioya Hospital, Tomita 77, Yaita-City, Tochigi, 329-2145, Japan
| | - Yasumasa Okada
- Department of Internal Medicine, National Hospital Organization Murayama Medical Center, Musashimurayama-City, Japan
| | - Sarah Kesler
- Intensive Care Unit, University of Minnesota, Minneapolis, MN, USA
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Nanjayya VB, McCracken P, Vallance S, Board J, Kelly PJ, Schneider HG, Pilcher D, Garner DJ. Arterio-VENouS Intra Subject agreement for blood gases within intensive care: The AVENSIS study. J Intensive Care Soc 2020; 21:64-71. [PMID: 32284720 DOI: 10.1177/1751143719840259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background In critically ill patients, who require multiple blood gas assessments, agreement between arterial and venous blood gas values for pH and partial pressure of carbon dioxide, is not clear. Good agreement would mean that venous values could be used to assess ventilation and metabolic status of patients in intensive care unit. Methods All adult patients admitted to Alfred intensive care unit, Melbourne, from February 2013 to January 2014, who were likely to have arterial and central venous lines for three days, were enrolled. Patients on extra-corporeal life support and pregnant women were excluded. After enrolment, near simultaneous arterial and central venous sampling and analysis were performed at least once per nursing shift till the lines were removed or the patient died. Bland-Altman analysis for repeated measures was performed to assess the agreement between arterio-venous pH and partial pressure of carbon dioxide. Results A total of 394 paired blood gas analyses were performed from 59 participants. The median (IQR) number of samples per patient was 6 (5-9) with the median (IQR) sampling interval 9.4 (5.2-18.5) h. The mean bias for pH was + 0.036 with 95% limits of agreement ranging from - 0.005 to + 0.078. For partial pressure of carbon dioxide, the values were -2.58 and -10.43 to + 5.27 mmHg, respectively. Conclusions The arterio-venous agreement for pH in intensive care unit patients appears to be acceptable. However, the agreement for partial pressure of carbon dioxide was poor.
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Affiliation(s)
- Vinodh B Nanjayya
- The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Shirley Vallance
- The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Patrick J Kelly
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | | | - David Pilcher
- The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Daniel J Garner
- The Alfred Hospital, Melbourne, Australia.,Hawkes bay District Health Board, Hastings, New Zealand
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Mallat J, Mohammad U, Lemyze M, Meddour M, Jonard M, Pepy F, Gasan G, Barrailler S, Temime J, Vangrunderbeeck N, Tronchon L, Thevenin D. Acute hyperventilation increases the central venous-to-arterial PCO 2 difference in stable septic shock patients. Ann Intensive Care 2017; 7:31. [PMID: 28321801 PMCID: PMC5359263 DOI: 10.1186/s13613-017-0258-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/11/2017] [Indexed: 01/16/2023] Open
Abstract
Background To evaluate the effects of acute hyperventilation on the central venous-to-arterial carbon dioxide tension difference (∆PCO2) in hemodynamically stable septic shock patients. Methods Eighteen mechanically ventilated septic shock patients were prospectively included in the study. We measured cardiac index (CI), ∆PCO2, oxygen consumption (VO2), central venous oxygen saturation (ScvO2), and blood gas parameters, before and 30 min after an increase in alveolar ventilation (increased respiratory rate by 10 breaths/min). Results Arterial pH increased significantly (from 7.35 ± 0.07 to 7.42 ± 0.09, p < 0.001) and arterial carbon dioxide tension decreased significantly (from 44.5 [41–48] to 34 [30–38] mmHg, p < 0.001) when respiratory rate was increased. A statistically significant increase in VO2 (from 93 [76–105] to 112 [95–134] mL/min/m2, p = 0.002) was observed in parallel with the increase in alveolar ventilation. While CI remained unchanged, acute hyperventilation led to a significant increase in ∆PCO2 (from 4.7 ± 1.0 to 7.0 ± 2.6 mmHg, p < 0.001) and a significant decrease in ScvO2 (from 73 ± 6 to 67 ± 8%, p < 0.001). A good correlation was found between changes in arterial pH and changes in VO2 (r = 0.67, p = 0.002). Interestingly, we found a strong association between the increase in VO2 and the increase in ∆PCO2 (r = 0.70, p = 0.001). Conclusions Acute hyperventilation provoked a significant increase in ∆PCO2, which was the result of a significant increase in VO2 induced by hyperventilation. The clinician should be aware of the effects of acute elevation of alveolar ventilation on ∆PCO2. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0258-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jihad Mallat
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France. .,Intensive Care Unit, Centre Hospitalier d'Arras, Boulevard Georges Besnier, 62022, Arras Cedex, France.
| | - Usman Mohammad
- Intensive Care Unit, Centre Hospitalier d'Arras, Boulevard Georges Besnier, 62022, Arras Cedex, France
| | - Malcolm Lemyze
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France.,Intensive Care Unit, Centre Hospitalier d'Arras, Boulevard Georges Besnier, 62022, Arras Cedex, France
| | - Mehdi Meddour
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France
| | - Marie Jonard
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France.,Intensive Care Unit, Centre Hospitalier d'Arras, Boulevard Georges Besnier, 62022, Arras Cedex, France
| | - Florent Pepy
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France
| | - Gaelle Gasan
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France
| | - Stephanie Barrailler
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France
| | - Johanna Temime
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France
| | - Nicolas Vangrunderbeeck
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France
| | - Laurent Tronchon
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France
| | - Didier Thevenin
- Department of Anesthesiology and Critical Care Medicine, Service de Réanimation polyvalente, Centre Hospitalier du Dr. Schaffner, 99 route de La Bassée, 62307, Lens Cedex, France.,Intensive Care Unit, Centre Hospitalier d'Arras, Boulevard Georges Besnier, 62022, Arras Cedex, France
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Morel J, Gergelé L, Dominé A, Molliex S, Perrot JL, Labeille B, Costes F. The venous–arterial difference in CO2 should be interpreted with caution in case of respiratory alkalosis in healthy volunteers. J Clin Monit Comput 2016; 31:701-707. [DOI: 10.1007/s10877-016-9897-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 06/06/2016] [Indexed: 11/24/2022]
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Morel J, Gergele L, Verveche D, Costes F, Auboyer C, Molliex S. Do fluctuations of PaCO2 impact on the venous-arterial carbon dioxide gradient? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:456. [PMID: 22115122 PMCID: PMC3388629 DOI: 10.1186/cc10528] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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