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Madotto F, Rezoagli E, McNicholas BA, Pham T, Slutsky AS, Bellani G, Laffey JG. Patterns and Impact of Arterial CO 2 Management in Patients With Acute Respiratory Distress Syndrome: Insights From the LUNG SAFE Study. Chest 2020; 158:1967-1982. [PMID: 32589951 DOI: 10.1016/j.chest.2020.05.605] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/08/2020] [Accepted: 05/29/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Considerable variability exists regarding CO2 management in early ARDS, with the impact of arterial CO2 tension on management and outcomes poorly understood. RESEARCH QUESTION To determine the prevalence and impact of hypocapnia and hypercapnia on the management and outcomes of patients with early ARDS enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study, an international multicenter observational study. STUDY DESIGN AND METHODS Our primary objective was to examine the prevalence of day 1 and sustained (day 1 and 2) hypocapnia (Paco2 < 35 mm Hg), normocapnia (Paco2 35-45 mm Hg), and hypercapnia (Paco2 > 45 mm Hg) in patients with ARDS. Secondary objectives included elucidating the effect of CO2 tension on ventilatory management and examining the relationship with ARDS outcome. RESULTS Of 2,813 patients analyzed, 551 (19.6%; 95%CI, 18.1-21.1) were hypocapnic, 1,018 (36.2%; 95% CI, 34.4-38.0) were normocapnic, and 1,214 (43.2%; 95% CI, 41.3-45.0) were hypercapnic, on day 1. Sustained hypocapnia was seen in 252 (9.3%; 95% CI, 8.2-10.4), sustained normocapnia in 544 (19.3%; 95% CI, 17.9-20.8), and sustained hypercapnia in 654 (24.1%; 95% CI, 22.5-25.7) patients. Hypocapnia was more frequent and severe in patients receiving noninvasive ventilation but also was observed in patients on controlled mechanical ventilation. Sustained hypocapnia was more frequent in middle-income countries, whereas sustained hypercapnia was more frequent in Europe. ARDS severity profile was highest in sustained hypercapnia, and these patients received more protective ventilation. No independent association was seen between arterial CO2 and outcome. In propensity-matched analyses, the hospital mortality rate was 36% in both sustained normocapnic and hypercapnic patients (P = 1.0). ICU mortality was higher in patients with mild to moderate ARDS receiving sustained hypocapnia (38.1%) compared with normocapnia (27.1%). INTERPRETATION No evidence was found for benefit or harm with hypercapnia. Of concern, ICU mortality was higher with sustained hypocapnia in mild to moderate ARDS.
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Affiliation(s)
- Fabiana Madotto
- IRCCS MultiMedica, Value-based healthcare unit, Sesto San Giovanni (Milan), Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Bairbre A McNicholas
- School of Medicine, National University of Ireland Galway, Galway, Ireland; Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland
| | - Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Service de médecine intensive-réanimation, AP-HP, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France; Keenan Research Center at the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Arthur S Slutsky
- Keenan Research Center at the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, and the Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - John G Laffey
- School of Medicine, National University of Ireland Galway, Galway, Ireland; Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland; Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland.
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