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Spinelli E, Giani M, Slobod D, Pavlovsky B, di Pierro M, Crotti S, Lissoni A, Foti G, Grasselli G, Mauri T. Physiologic Effects of Extracorporeal Membrane Oxygenation in Patients with Severe Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 210:629-638. [PMID: 38526489 PMCID: PMC11389568 DOI: 10.1164/rccm.202309-1688oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 03/22/2024] [Indexed: 03/26/2024] Open
Abstract
Rationale: Blood flow rate affects mixed venous oxygenation (SvO2) during venovenous extracorporeal membrane oxygenation (ECMO), with possible effects on the pulmonary circulation and the right heart function. Objectives: To describe the physiologic effects of different levels of SvO2 obtained by changing ECMO blood flow in patients with severe acute respiratory distress syndrome receiving ECMO and controlled mechanical ventilation. Methods: Low (SvO2 target, 70-75%), intermediate (SvO2 target, 75-80%), and high (SvO2 target, >80%) ECMO blood flows were applied for 30 minutes in random order in 20 patients. Mechanical ventilation settings were left unchanged. The hemodynamic and pulmonary effects were assessed with pulmonary artery catheter and electrical impedance tomography. Measurements and Main Results: Cardiac output decreased from low to intermediate and to high blood flow/SvO2 (9.2 [6.2-10.9] vs. 8.3 [5.9-9.8] vs. 7.9 [6.5-9.1] L/min; P = 0.014), as well as mean pulmonary artery pressure (34 ± 6 vs. 31 ± 6 vs. 30 ± 5 mm Hg; P < 0.001) and right ventricular stroke work index (14.2 ± 4.4 vs. 12.2 ± 3.6 vs. 11.4 ± 3.2 g × m/beat/m2; P = 0.002). Cardiac output was inversely correlated with mixed venous and arterial Po2 values (R2 = 0.257; P = 0.031; and R2 = 0.324; P = 0.05). Pulmonary artery pressure was correlated with decreasing mixed venous Po2 (R2 = 0.29; P < 0.001) and with increasing cardiac output (R2 = 0.378; P < 0.007). Measures of [Formula: see text]/[Formula: see text] mismatch did not differ between the three steps. Conclusions: In patients with severe acute respiratory distress syndrome, increased ECMO blood flow rate resulting in higher SvO2 decreases pulmonary artery pressure, cardiac output, and right heart workload.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Institute for Scientific Research and Care Foundation Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - Marco Giani
- Department of Emergency and Intensive Care, Institute for Scientific Research and Care Foundation San Gerardo dei Tintori, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Bertrand Pavlovsky
- Medical Intensive Care Unit, University Hospital of Angers, Angers, France; and
| | - Michela di Pierro
- Department of Emergency and Intensive Care, Institute for Scientific Research and Care Foundation San Gerardo dei Tintori, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Stefania Crotti
- Department of Anesthesia, Critical Care and Emergency, Institute for Scientific Research and Care Foundation Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - Alfredo Lissoni
- Department of Anesthesia, Critical Care and Emergency, Institute for Scientific Research and Care Foundation Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Institute for Scientific Research and Care Foundation San Gerardo dei Tintori, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Institute for Scientific Research and Care Foundation Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Institute for Scientific Research and Care Foundation Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Wang L, Wang D, Zhang Y. Comparison of postoperative pulmonary complications and intraoperative safety in thoracoscopic surgery under non-intubated versus intubated anesthesia: a randomized, controlled, double-blind non-inferiority trial. Updates Surg 2024:10.1007/s13304-024-01935-y. [PMID: 39126533 DOI: 10.1007/s13304-024-01935-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 07/02/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE Traditional anesthesia for video-assisted thoracoscopy (VATS) such as double-lumen tracheal intubation (DLT) and one-lung ventilation (OLV), may lead to post-operative pulmonary complications (PPCs). Non-intubation VATS (NIVATS) is an anesthetic technique that avoided DLT and OLV, maybe avoiding the PPCs. So we hypothesized that NIVATS would non-inferiority to intubation VATS (IVATS) in the risk of developing PPCs and some safety indicators. METHODS This study is a randomised, controlled, double-blind, non-inferiority trial, 120 patients were randomly assigned to the NIVATS group and IVATS group according to 1:1. The primary outcome was the incidence of PPCs with a pre-defined non-inferiority margin of 10%. The second outcome was the safety indicators, including the incidence of cough/body movement, hypoxemia, malignant arrhythmia, regurgitation and aspiration, and transferring to endobronchial intubation intraoperatively (The malignant arrhythmia was defined as an arrhythmia that caused hemodynamic disturbances in a short period of time, resulting in persistent hypotension or even cardiac arrest in the patient). RESULTS There was no significant difference in demographic indicators such as gender and age between the two groups. The incidence of PPCs in the NIVATS group was non-inferior to that in the IVATS group (1.67% vs. 3.33%, absolute difference: - 1.67%; 95%CI - 7.25 to 3.91). In additionan, no significant differences were found between the two groups for the incidence of cough/body movement (10.00% vs. 11.67%, p = 0.77), the incidence of hypoxemia (25% vs. 18.33%, p = 0.38), the incidence of malignant arrhythmia (1.67% vs. 6.67%, p = 0.36), the incidence of regurgitation and aspiration (0% vs. 0%, p > 0.999) and the incidence of transferring to endobronchial intubation intraoperatively (0% vs. 0%, p > 0.999). CONCLUSION We conclude that when using the non-intubation anesthesia for VATS, the incidence of PPCs was not inferior to intubation anesthesia. Furthermore, NIVATS had little effect on perioperative safety.
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Affiliation(s)
- Lingfei Wang
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, 110042, Liaoning, China
| | - Dan Wang
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, 110042, Liaoning, China
| | - Yanmei Zhang
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, 110042, Liaoning, China.
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Kipp S, Arn SR, Leahy MG, Guenette JA, Sheel AW. The metabolic cost of breathing for exercise ventilations: effects of age and sex. J Appl Physiol (1985) 2024; 137:329-342. [PMID: 38841757 DOI: 10.1152/japplphysiol.00282.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 06/07/2024] Open
Abstract
Given that there are both sex-based structural differences in the respiratory system and age-associated declines in pulmonary function, the purpose of this study was to assess the effects of age and sex on the metabolic cost of breathing (V̇o2RM) for exercise ventilations in healthy younger and older males and females. Forty healthy participants (10 young males 24 ± 3 yr; 10 young females 24 ± 3 yr; 10 older males 63 ± 3 yr, 10 older females 63 ± 6 yr) mimicked their exercise breathing patterns (voluntary hyperpnea) in the absence of exercise across a range of exercise intensities. At peak exercise, V̇o2RM represented a significantly greater fraction of peak oxygen consumption (V̇o2peak) in young females, 12.7 ± 4.0%, compared with young males, 10.7 ± 3.0% (P = 0.027), whereas V̇o2RM represented 13.5 ± 2.3% of V̇o2peak in older females and 13.2 ± 3.3% in older males. At relative ventilations, there was a main effect of age, with older males consuming a significantly greater fraction of V̇o2RM (6.6 ± 1.9%) than the younger males (4.4 ± 1.3%; P = 0.012), and older females consuming a significantly greater fraction of V̇o2RM (6.9 ± 2.5%) than the younger females (5.1 ± 1.4%; P = 0.004) at 65% V̇emax. Furthermore, both younger and older males had significantly better respiratory muscle efficiency than their female counterparts at peak exercise (P = 0.011; P = 0.015). Similarly, younger participants were significantly more efficient than older participants (6.5 ± 1.5% vs. 5.5 ± 2.0%; P = 0.001). Normal age-related changes in respiratory function, in addition to sex-based differences in airway anatomy, appear to influence the ventilatory responses and the cost incurred to breathe during exercise.NEW & NOTEWORTHY Here we show that at moderate and high-intensity exercise, older individuals incur a higher cost to breathe than their younger counterparts. However, as individuals age, the sex difference in the cost of breathing narrows. Collectively, our findings suggest that the normative age-related changes in respiratory structure and function, and sex differences in airway anatomy, appear to influence the ventilatory responses to exercise and the oxygen cost to breathe.
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Affiliation(s)
- Shalaya Kipp
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sierra R Arn
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael G Leahy
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan A Guenette
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, Providence Research, The University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - A William Sheel
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, Providence Research, The University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
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Magnusdottir SO, Simonsen C, Karbing DS, Rasmussen BS, Kjaergaard B. Hypoxia in the pulmonary vein increases pulmonary vascular resistance independently of oxygen in the pulmonary artery. Animal Model Exp Med 2024; 7:156-165. [PMID: 38506157 PMCID: PMC11079156 DOI: 10.1002/ame2.12402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/10/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Hypoxic pulmonary vasoconstriction (HPV) can be a challenging clinical problem. It is not fully elucidated where in the circulation the regulation of resistance takes place. It is often referred to as if it is in the arteries, but we hypothesized that it is in the venous side of the pulmonary circulation. METHODS In an open thorax model, pigs were treated with a veno-venous extra corporeal membrane oxygenator to either oxygenate or deoxygenate blood passing through the pulmonary vessels. At the same time the lungs were ventilated with extreme variations of inspired air from 5% to 100% oxygen, making it possible to make combinations of high and low oxygen content through the pulmonary circulation. A flow probe was inserted around the main pulmonary artery and catheters in the pulmonary artery and in the left atrium were used for pressure monitoring and blood tests. Under different combinations of oxygenation, pulmonary vascular resistance (PVR) was calculated. RESULTS With unchanged level of oxygen in the pulmonary artery and reduced inspired oxygen fraction lowering oxygen tension from 29 to 6.7 kPa in the pulmonary vein, PVR was doubled. With more extreme hypoxia PVR suddenly decreased. Combinations with low oxygenation in the pulmonary artery did not systematic influence PVR if there was enough oxygen in the inspired air and in the pulmonary veins. DISCUSSION The impact of hypoxia occurs from the alveolar level and forward with the blood flow. The experiments indicated that the regulation of PVR is mediated from the venous side.
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Affiliation(s)
- Sigridur Olga Magnusdottir
- Biomedical Research LaboratoryAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Carsten Simonsen
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of Cardiothoracic SurgeryAalborg University HospitalAalborgDenmark
| | | | - Bodil Steen Rasmussen
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of Anesthesia and Intensive CareAalborg University HospitalAalborgDenmark
| | - Benedict Kjaergaard
- Biomedical Research LaboratoryAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of Cardiothoracic SurgeryAalborg University HospitalAalborgDenmark
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Gaulton TG, Martin K, Xin Y, Victor M, Ribeiro De Santis Santiago R, Britto Passos Amato M, Berra L, Cereda M. Regional lung perfusion using different indicators in electrical impedance tomography. J Appl Physiol (1985) 2023; 135:500-507. [PMID: 37439236 PMCID: PMC10538981 DOI: 10.1152/japplphysiol.00130.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/19/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023] Open
Abstract
Management of acute respiratory distress syndrome (ARDS) is classically guided by protecting the injured lung and mitigating damage from mechanical ventilation. Yet the natural history of ARDS is also dictated by disruption in lung perfusion. Unfortunately, diagnosis and treatment are hampered by the lack of bedside perfusion monitoring. Electrical impedance tomography is a portable imaging technique that can estimate regional lung perfusion in experimental settings from the kinetic analysis of a bolus of an indicator with high conductivity. Hypertonic sodium chloride has been the standard indicator. However, hypertonic sodium chloride is often inaccessible in the hospital, limiting practical adoption. We investigated whether regional lung perfusion measured using electrical impedance tomography is comparable between indicators. Using a swine lung injury model, we determined regional lung perfusion (% of total perfusion) in five pigs, comparing 12% sodium chloride to 8.4% sodium bicarbonate across stages of lung injury and experimental conditions (body position, positive end-expiratory pressure). Regional lung perfusion for four lung regions was determined from maximum slope analysis of the indicator-based impedance signal. Estimates of regional lung perfusion between indicators were compared in the lung overall and within four lung regions. Regional lung perfusion estimated with a sodium bicarbonate indicator agreed with a hypertonic sodium chloride indicator overall (mean bias 0%, limits of agreement -8.43%, 8.43%) and within lung quadrants. The difference in regional lung perfusion between indicators did not change across experimental conditions. Sodium bicarbonate may be a comparable indicator to estimate regional lung perfusion using electrical impedance tomography.NEW & NOTEWORTHY Electrical impedance tomography is an emerging tool to measure regional lung perfusion using kinetic analysis of a conductive indicator. Hypertonic sodium chloride is the standard agent used. We measured regional lung perfusion using another indicator, comparing hypertonic sodium chloride to sodium bicarbonate in an experimental swine lung injury model. We found strong agreement between the two indicators. Sodium bicarbonate may be a comparable indicator to measure regional lung perfusion with electrical impedance tomography.
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Affiliation(s)
- Timothy G Gaulton
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Kevin Martin
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Yi Xin
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Marcus Victor
- Pulmonary Division, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
- Medical Electrical Devices Laboratory (LabMed), Electronics Engineering, Aeronautics Institute of Technology, Sao Jose dos Campos, Brazil
| | - Roberta Ribeiro De Santis Santiago
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | | | - Lorenzo Berra
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Li Q, Zhao M, Wu D, Guo X, Wu J. Adverse outcomes of artificial pneumothorax under right bronchial occlusion for patients with thoracoscopic-assisted oesophagectomy in the prone position versus the semiprone position. Front Oncol 2022; 12:919910. [PMID: 36016610 PMCID: PMC9395967 DOI: 10.3389/fonc.2022.919910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThere are few studies on the impact of body position on variations in circulation and breathing, and it has not been confirmed whether body position changes can reduce the pulmonary complications of thoracoscopic-assisted oesophagectomy.MethodsA single-center retrospective study included patients undergoing thoracoscopic-assisted oesophagectomy in the prone position or semiprone position between 1 July 2020, and 30 June 2021, at the Shanghai Chest Hospital. There were 103 patients with thoracoscopic-assisted oesophagectomy in the final analysis, including 43 patients undergoing thoracoscopic-assisted oesophagectomy in the prone position. Postoperative pulmonary complication (PPC) incidence was the primary endpoint. The incidence of cardiovascular and other complications was the secondary endpoint. Chest tube duration, patient-controlled anaesthesia (PCA) pressing frequency within 24 h, ICU stay, and the postoperative hospital length of stay (LOS) were also collected.ResultsCompared with the semiprone position, the prone position decreased the incidence of atelectasis (12% vs. 30%, P = 0.032). Nevertheless, there were no considerable differences in the rates of cardiovascular and other complications, ICU stay, or LOS (P >0.05). Multivariable logistic regression analysis showed that the prone position (OR = 0.196, P = 0.011), no smoking (OR = 0.103, P <0.001), preoperative DLCO% ≥90% (OR = 0.230, P = 0.003), and an operative time <180 min (OR = 0.268, P = 0.006) were associated with less atelectasis.ConclusionsOur study shows that artificial pneumothorax under right bronchial occlusion one-lung ventilation for patients with thoracoscopic-assisted oesophagectomy in the prone position can decrease postoperative atelectasis compared with the semiprone position.
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Affiliation(s)
- Qiongzhen Li
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Mingye Zhao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Dongjin Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
- *Correspondence: Jingxiang Wu, ; Xufeng Guo, ; Dongjin Wu,
| | - Xufeng Guo
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
- *Correspondence: Jingxiang Wu, ; Xufeng Guo, ; Dongjin Wu,
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
- *Correspondence: Jingxiang Wu, ; Xufeng Guo, ; Dongjin Wu,
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Kitajima T, Marumo S, Amimoto H, Shiraishi Y, Yamaki H, Shirata M, Inoue D, Fukui M. Relationship Between Episodic Nocturnal Hypercapnia and History of Exacerbations in Patients with Advanced Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2022; 17:1553-1563. [PMID: 35832833 PMCID: PMC9273152 DOI: 10.2147/copd.s361914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/25/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose An episodic increase in transcutaneous carbon dioxide pressure (PtcCO2) is often recognized in patients with advanced chronic obstructive pulmonary disease (COPD) by overnight PtcCO2 monitoring. This phenomenon, called episodic nocturnal hypercapnia (eNH), mainly corresponds to rapid eye movement (REM) sleep-related hypoventilation. However, it is unclear whether eNH is associated with the frequency of COPD exacerbation. We aimed to investigate whether a relationship exists between COPD exacerbation and eNH. Patients and Methods We enrolled consecutive patients with stable, severe, or very severe COPD with a daytime arterial carbon dioxide pressure (PaCO2) <55.0 mmHg who underwent overnight PtcCO2 monitoring from April 2013 to January 2017. We retrospectively analyzed the prevalence of eNH and sleep-associated hypoventilation (SH) as defined by the American Academy of Sleep Medicine. Moreover, we compared the relationship between the frequency of COPD exacerbations in the previous year and eNH or SH. Results Twenty-four patients were included in this study. The study patients had a mean daytime PaCO2 and nocturnal PtcCO2 of 43.3 ± 6.8 mmHg and 42.9 ± 9.6 mmHg, respectively. Six (25.0%) and 11 (45.9%) of the 24 patients met the SH and eNH criteria, respectively. The odds ratios of SH and eNH for at least one annual exacerbation were 1.0 [95% confidence interval (CI): 0.16–6.00] and 11.1 [95% CI: 1.39–87.7], respectively. The odds ratios of SH and eNH for at least two annual exacerbations were 0.3 [95% CI: 0.04–2.64] and 6.6 [95% CI: 1.06–39.4], respectively. Conclusion In patients with advanced COPD and a daytime PaCO2 <55.0 mmHg, eNH may be associated with a history of more frequent exacerbations than SH. Further studies are required to validate these findings.
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Affiliation(s)
- Takamasa Kitajima
- Respiratory Disease Center, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Satoshi Marumo
- Respiratory Disease Center, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Hisanori Amimoto
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Japan
| | - Yusuke Shiraishi
- Department of Respiratory Medicine, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Haruka Yamaki
- Department of Respiratory Medicine, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Masahiro Shirata
- Department of Respiratory Medicine, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Daiki Inoue
- Respiratory Disease Center, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Motonari Fukui
- Respiratory Disease Center, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
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Park CG, Jung WS, Park HY, Kim HW, Kwak HJ, Jo YY. Comparison of the Effects of Normocapnia and Mild Hypercapnia on the Optic Nerve Sheath Diameter and Regional Cerebral Oxygen Saturation in Patients Undergoing Gynecological Laparoscopy with Total Intravenous Anesthesia. J Clin Med 2021; 10:jcm10204707. [PMID: 34682830 PMCID: PMC8540822 DOI: 10.3390/jcm10204707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Cerebral hemodynamics may be altered by hypercapnia during a lung-protective ventilation (LPV), CO2 pneumoperitoneum, and Trendelenburg position during general anesthesia. The purpose of this study was to compare the effects of normocapnia and mild hypercapnia on the optic nerve sheath diameter (ONSD), regional cerebral oxygen saturation (rSO2), and intraoperative respiratory mechanics in patients undergoing gynecological laparoscopy under total intravenous anesthesia (TIVA). Sixty patients (aged between 19 and 65 years) scheduled for laparoscopic gynecological surgery in the Trendelenburg position. Patients under propofol/remifentanil total intravenous anesthesia were randomly assigned to either the normocapnia group (target PaCO2 = 35 mmHg, n = 30) or the hypercapnia group (target PaCO2 = 50 mmHg, n = 30). The ONSD, rSO2, and respiratory and hemodynamic parameters were measured at 5 min after anesthetic induction (Tind) in the supine position, and at 10 min and 40 min after pneumoperitoneum (Tpp10 and Tpp40, respectively) in the Trendelenburg position. There was no significant intergroup difference in change over time in the ONSD (p = 0.318). The ONSD increased significantly at Tpp40 when compared to Tind in both normocapnia and hypercapnia groups (p = 0.02 and 0.002, respectively). There was a significant intergroup difference in changes over time in the rSO2 (p < 0.001). The rSO2 decreased significantly in the normocapnia group (p = 0.01), whereas it increased significantly in the hypercapnia group at Tpp40 compared with Tind (p = 0.002). Alveolar dead space was significantly higher in the normocapnia group than in the hypercapnia group at Tpp40 (p = 0.001). In conclusion, mild hypercapnia during the LPV might not aggravate the increase in the ONSD during CO2 pneumoperitoneum in the Trendelenburg position and could improve rSO2 compared to normocapnia in patients undergoing gynecological laparoscopy with TIVA.
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Affiliation(s)
| | | | | | | | - Hyun-Jeong Kwak
- Correspondence: (H.-J.K.); (Y.-Y.J.); Tel.: +82-322-460-3637 (H.-J.K.); +82-322-460-3651 (Y.-Y.J.); Fax: 82-32-469-6319 (H.-J.K. & Y.-Y.J.)
| | - Youn-Yi Jo
- Correspondence: (H.-J.K.); (Y.-Y.J.); Tel.: +82-322-460-3637 (H.-J.K.); +82-322-460-3651 (Y.-Y.J.); Fax: 82-32-469-6319 (H.-J.K. & Y.-Y.J.)
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Gierhardt M, Pak O, Walmrath D, Seeger W, Grimminger F, Ghofrani HA, Weissmann N, Hecker M, Sommer N. Impairment of hypoxic pulmonary vasoconstriction in acute respiratory distress syndrome. Eur Respir Rev 2021; 30:30/161/210059. [PMID: 34526314 DOI: 10.1183/16000617.0059-2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/05/2021] [Indexed: 12/29/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a serious complication of severe systemic or local pulmonary inflammation, such as caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. ARDS is characterised by diffuse alveolar damage that leads to protein-rich pulmonary oedema, local alveolar hypoventilation and atelectasis. Inadequate perfusion of these areas is the main cause of hypoxaemia in ARDS. High perfusion in relation to ventilation (V/Q<1) and shunting (V/Q=0) is not only caused by impaired hypoxic pulmonary vasoconstriction but also redistribution of perfusion from obstructed lung vessels. Rebalancing the pulmonary vascular tone is a therapeutic challenge. Previous clinical trials on inhaled vasodilators (nitric oxide and prostacyclin) to enhance perfusion to high V/Q areas showed beneficial effects on hypoxaemia but not on mortality. However, specific patient populations with pulmonary hypertension may profit from treatment with inhaled vasodilators. Novel treatment targets to decrease perfusion in low V/Q areas include epoxyeicosatrienoic acids and specific leukotriene receptors. Still, lung protective ventilation and prone positioning are the best available standard of care. This review focuses on disturbed perfusion in ARDS and aims to provide basic scientists and clinicians with an overview of the vascular alterations and mechanisms of V/Q mismatch, current therapeutic strategies, and experimental approaches.
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Affiliation(s)
- Mareike Gierhardt
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) - CONICET - Partner Institute of the Max Planck Society, Buenos Aires, Argentina.,Department of Lung Development and Remodeling, Max Planck Institute for Heart and Lung Research, Member of the German Center for Lung Research (DZL), Member of the Cardio-Pulmonary Institute (CPI) Bad Nauheim, Germany
| | - Oleg Pak
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Dieter Walmrath
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany
| | - Werner Seeger
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) - CONICET - Partner Institute of the Max Planck Society, Buenos Aires, Argentina.,Institute for Lung Health (ILH), Giessen, Germany
| | - Friedrich Grimminger
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Hossein A Ghofrani
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - Norbert Weissmann
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Matthias Hecker
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Both authors contributed equally
| | - Natascha Sommer
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Both authors contributed equally
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10
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Wittenstein J, Scharffenberg M, Ran X, Zhang Y, Keller D, Tauer S, Theilen R, Chai Y, Ferreira J, Müller S, Bluth T, Kiss T, Schultz MJ, Rocco PRM, Pelosi P, Gama de Abreu M, Huhle R. Effects of Body Position and Hypovolemia on the Regional Distribution of Pulmonary Perfusion During One-Lung Ventilation in Endotoxemic Pigs. Front Physiol 2021; 12:717269. [PMID: 34566683 PMCID: PMC8461176 DOI: 10.3389/fphys.2021.717269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/10/2021] [Indexed: 01/28/2023] Open
Abstract
Background: The incidence of hypoxemia during one-lung ventilation (OLV) is as high as 10%. It is also partially determined by the distribution of perfusion. During thoracic surgery, different body positions are used, such as the supine, semilateral, lateral, and prone positions, with such positions potentially influencing the distribution of perfusion. Furthermore, hypovolemia can impair hypoxic vasoconstriction. However, the effects of body position and hypovolemia on the distribution of perfusion remain poorly defined. We hypothesized that, during OLV, the relative perfusion of the ventilated lung is higher in the lateral decubitus position and that hypovolemia impairs the redistribution of pulmonary blood flow. Methods: Sixteen juvenile pigs were anesthetized, mechanically ventilated, submitted to a right-sided thoracotomy, and randomly assigned to one of two groups: (1) intravascular normovolemia or (2) intravascular hypovolemia, as achieved by drawing ~25% of the estimated blood volume (n = 8/group). Furthermore, to mimic thoracic surgery inflammatory conditions, Escherichia coli lipopolysaccharide was continuously infused at 0.5 μg kg-1 h-1. Under left-sided OLV conditions, the animals were further randomized to one of the four sequences of supine, left semilateral, left lateral, and prone positioning. Measurements of pulmonary perfusion distribution with fluorescence-marked microspheres, ventilation distribution by electrical impedance tomography, and gas exchange were then performed during two-lung ventilation in a supine position and after 30 min in each position and intravascular volume status during OLV. Results: During one-lung ventilation, the relative perfusion of the ventilated lung was higher in the lateral than the supine position. The relative perfusion of the non-ventilated lung was lower in the lateral than the supine and prone positions and in semilateral compared with the prone position. During OLV, the highest arterial partial pressure of oxygen/inspiratory fraction of oxygen (PaO2/F I O 2) was achieved in the lateral position as compared with all the other positions. The distribution of perfusion, ventilation, and oxygenation did not differ significantly between normovolemia and hypovolemia. Conclusions: During one-lung ventilation in endotoxemic pigs, the relative perfusion of the ventilated lung and oxygenation were higher in the lateral than in the supine position and not impaired by hypovolemia.
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Affiliation(s)
- Jakob Wittenstein
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Martin Scharffenberg
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Xi Ran
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany.,Department of Intensive Care, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Yingying Zhang
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany.,Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Diana Keller
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Sebastian Tauer
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Raphael Theilen
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Yusen Chai
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Jorge Ferreira
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Sabine Müller
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany.,Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany.,Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States.,Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Robert Huhle
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
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11
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Asadi AK, Sá RC, Arai TJ, Theilmann RJ, Hopkins SR, Buxton RB, Prisk GK. Regional pulmonary perfusion patterns in humans are not significantly altered by inspiratory hypercapnia. J Appl Physiol (1985) 2019; 127:365-375. [PMID: 31169470 DOI: 10.1152/japplphysiol.00254.2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary vascular tone is known to be sensitive to both local alveolar Po2 and Pco2. Although the effects of hypoxia are well studied, the hypercapnic response is relatively less understood. We assessed changes in regional pulmonary blood flow in humans in response to hypercapnia using previously developed MRI techniques. Dynamic measures of blood flow were made in a single slice of the right lung of seven healthy volunteers following a block-stimulus paradigm (baseline, challenge, recovery), with CO2 added to inspired gas during the challenge block to effect a 7-Torr increase in end-tidal CO2. Effects of hypercapnia on blood flow were evaluated based on changes in spatiotemporal variability (fluctuation dispersion, FD) and in regional perfusion patterns in comparison to hypoxic effects previously studied. Hypercapnia increased FD 2.5% from baseline (relative to control), which was not statistically significant (P = 0.07). Regional perfusion patterns were not significantly changed as a result of increased FICO2 (P = 0.90). Reanalysis of previously collected data using a similar protocol but with the physiological challenge replaced by decreased FIO2 (FIO2 = 0.125) showed marked flow redistribution (P = 0.01) with the suggestion of a gravitational pattern, demonstrating hypoxia has the ability to affect regional change with a global stimulus. Taken together, these data indicate that hypercapnia of this magnitude does not lead to appreciable changes in the distribution of pulmonary perfusion, and that this may represent an interesting distinction between the hypoxic and hypercapnic regulatory response.NEW & NOTEWORTHY Although it is well known that the pulmonary circulation responds to local alveolar hypoxia, and that this mechanism may facilitate ventilation-perfusion matching, the relative role of CO2 is not well appreciated. This study demonstrates that an inspiratory hypercapnic stimulus is significantly less effective at inducing changes in pulmonary perfusion patterns than inspiratory hypoxia, suggesting that in these circumstances hypercapnia is not sufficient to induce substantial integrated feedback control of ventilation-perfusion mismatch across the lung.
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Affiliation(s)
- Amran K Asadi
- Department of Anesthesiology, Stanford University, Stanford, California
| | - Rui Carlos Sá
- Department of Medicine, University of California, San Diego, La Jolla, California
| | - Tatsuya J Arai
- Department of Medicine, University of California, San Diego, La Jolla, California
| | - Rebecca J Theilmann
- Department of Radiology, University of California, San Diego, La Jolla, California
| | - Susan R Hopkins
- Department of Medicine, University of California, San Diego, La Jolla, California.,Department of Radiology, University of California, San Diego, La Jolla, California
| | - Richard B Buxton
- Department of Radiology, University of California, San Diego, La Jolla, California
| | - G Kim Prisk
- Department of Medicine, University of California, San Diego, La Jolla, California.,Department of Radiology, University of California, San Diego, La Jolla, California
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12
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Dorrington KL, Talbot NP, Robbins PA. Hypercapnic Pulmonary Vasoconstriction Contributes to Regional Perfusion Distribution: Relevance to Asthma. Am J Respir Crit Care Med 2019; 197:682-683. [PMID: 29072845 DOI: 10.1164/rccm.201707-1510le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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13
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14
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Zuoyou L, Shiota S, Morio Y, Sugiyama A, Sekiya M, Iwakami SI, Ienaga H, Fukuchi Y, Takahashi K. Borderline pulmonary hypertension associated with chronic hypercapnia in chronic pulmonary disease. Respir Physiol Neurobiol 2019; 262:20-25. [PMID: 30660859 DOI: 10.1016/j.resp.2019.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 12/20/2022]
Abstract
Pulmonary hypertension (PH) due to lung diseases is classified as group 3 by the Dana Point classification. Given the basic pathophysiological conditions of group 3 lung diseases and the previously well-known concept of hypercapnic pulmonary vasoconstriction, chronic hypercapnia besides alveolar hypoxia might be another causative factor to increase mean pulmonary arterial pressure (PAm). Two hundred twenty-five subjects with chronic pulmonary diseases were assessed by a right heart catheterization and blood gas parameters. The subjects were classified into the following 4 groups: Hypercapnic Hypoxia (HCHX), Hypercapnic Normoxia (HCnx), Normocapnic Hypoxia (ncHX), and Normocapnic Normoxia (ncnx). Compared with ncnx, the HCHX, HCnx and ncHX groups all showed significantly higher PAm and met the criteria of borderline PH. Multiple regression analysis showed that PaCO2, as well as SaO2, was an independent variable for PAm. Given the poor prognosis with borderline PH, the elimination of excess pulmonary carbon dioxide in hypercapnia could be a considerable treatment strategy in chronic pulmonary disease.
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Affiliation(s)
- Liu Zuoyou
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Satomi Shiota
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan.
| | - Yoshiteru Morio
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan; Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Ai Sugiyama
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Mitsuaki Sekiya
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan; Saiseikai Kawaguchi General Hospital, Saitama, Japan
| | - Shin-Ichiro Iwakami
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan; Department of Respiratory Medicine, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Hiroki Ienaga
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan; Department of Respiratory Medicine, Koshigaya Municipal Hospital, Saitama, Japan
| | - Yoshinosuke Fukuchi
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
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15
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Pulmonary hemodynamics responses to hypoxia and/or CO 2 inhalation during moderate exercise in humans. Pflugers Arch 2018; 470:1035-1045. [PMID: 29502264 DOI: 10.1007/s00424-018-2127-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 02/07/2018] [Accepted: 02/19/2018] [Indexed: 02/06/2023]
Abstract
In this study, we hypothesized that adding CO2 to an inhaled hypoxic gas mixture will limit the rise of pulmonary artery pressure (PAP) induced by a moderate exercise. Eight 20-year-old males performed four constant-load exercise tests on cycle at 40% of maximal oxygen consumption in four conditions: ambient air, normobaric hypoxia (12.5% O2), inhaled CO2 (4.5% CO2), and combination of hypoxia and inhaled CO2. Doppler echocardiography was used to measure systolic (s)PAP, cardiac output (CO). Total pulmonary resistance (TPR) was calculated. Arterialized blood pH was 7.40 at exercise in ambient and hypoxia conditions, whereas CO2 inhalation and combined conditions showed acidosis. sPAP increases from rest in ambient air to exercise ranged as follows: ambient + 110%, CO2 inhalation + 135%, combined + 184%, hypoxia + 217% (p < 0.001). CO was higher when inhaling O2-poor gas mixtures with or without CO2 (~ 17 L min-1) than in the other conditions (~ 14 L min-1, p < 0.001). Exercise induced a significant decrease in TPR in the four conditions (p < 0.05) but less marked in hypoxia (- 19% of the resting value in ambient air) than in ambient (- 33%) and in both CO2 inhalation and combined condition (- 29%). We conclude that (1) acute CO2 inhalation did not significantly modify pulmonary hemodynamics during moderate exercise. (2) CO2 adjunction to hypoxic gas mixture did not modify CO, despite a higher CaO2 in combined condition than in hypoxia. (3) TPR was lower in combined than in hypoxia condition, limiting sPAP increase in combined condition.
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16
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Thurnheer R, Ulrich S, Bloch KE. Precapillary Pulmonary Hypertension and Sleep-Disordered Breathing: Is There a Link? Respiration 2016; 93:65-77. [PMID: 27884004 DOI: 10.1159/000452957] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/28/2016] [Indexed: 12/19/2022] Open
Abstract
Among patients with sleep apnea the reported prevalence of precapillary pulmonary hypertension (PH) has varied largely, depending on patient selection, disease definition, and associated conditions, in particular chronic pulmonary disease. However, in the absence of comorbidities, PH seems to be rare in patients with sleep apnea. Conversely, sleep-related breathing disorders have been commonly found in patients with PH and they have been associated with an impaired quality of life. Since sleep-related breathing disorders may affect the pulmonary circulation and vice versa, patients with sleep-related breathing disorders should be evaluated for risk factors, symptoms and clinical signs of PH and right ventricular heart failure and patients with PH should be evaluated for sleep apnea. Therapeutic options for patients with sleep apnea and PH may include supplemental oxygen, drugs and positive pressure ventilation. Both nocturnal oxygen administration and acetazolamide have been shown to improve sleep apnea in patients with PH. In addition, oxygen therapy also improved exercise performance. Further studies are needed to corroborate the efficacy of these and other treatments.
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Affiliation(s)
- Robert Thurnheer
- Department of Internal Medicine, Pulmonary Division and Sleep Disorders Center, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
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17
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Prone position in thoracoscopic esophagectomy improves postoperative oxygenation and reduces pulmonary complications. Surg Endosc 2016; 31:1136-1141. [PMID: 27387180 DOI: 10.1007/s00464-016-5081-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND While thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest. METHODS A total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis. RESULTS Two patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO2/FiO2 ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P. CONCLUSION The findings of this study demonstrate that thoracoscopic esophagectomy in the prone position improves postoperative oxygenation and is therefore a potentially superior surgical approach.
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18
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Sleep Transcutaneous vs. End-Tidal CO2 Monitoring for Patients with Neuromuscular Disease. Am J Phys Med Rehabil 2016; 95:91-5. [DOI: 10.1097/phm.0000000000000345] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Swenson ER. Hypoxia and Its Acid-Base Consequences: From Mountains to Malignancy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 903:301-23. [PMID: 27343105 DOI: 10.1007/978-1-4899-7678-9_21] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hypoxia, depending upon its magnitude and circumstances, evokes a spectrum of mild to severe acid-base changes ranging from alkalosis to acidosis, which can alter many responses to hypoxia at both non-genomic and genomic levels, in part via altered hypoxia-inducible factor (HIF) metabolism. Healthy people at high altitude and persons hyperventilating to non-hypoxic stimuli can become alkalotic and alkalemic with arterial pH acutely rising as high as 7.7. Hypoxia-mediated respiratory alkalosis reduces sympathetic tone, blunts hypoxic pulmonary vasoconstriction and hypoxic cerebral vasodilation, and increases hemoglobin oxygen affinity. These effects and others can be salutary or counterproductive to tissue oxygen delivery and utilization, based upon magnitude of each effect and summation. With severe hypoxia either in the setting of profound arterial hemoglobin desaturation and reduced O2 content or poor perfusion (ischemia) at the global or local level, metabolic and hypercapnic acidosis develop along with considerable lactate formation and pH falling to below 6.8. Although conventionally considered to be injurious and deleterious to cell function and survival, both acidoses may be cytoprotective by various anti-inflammatory, antioxidant, and anti-apoptotic mechanisms which limit total hypoxic or ischemic-reperfusion injury. Attempts to correct acidosis by giving bicarbonate or other alkaline agents under these circumstances ahead of or concurrent with reoxygenation efforts may be ill advised. Better understanding of this so-called "pH paradox" or permissive acidosis may offer therapeutic possibilities. Rapidly growing cancers often outstrip their vascular supply compromising both oxygen and nutrient delivery and metabolic waste disposal, thus limiting their growth and metastatic potential. However, their excessive glycolysis and lactate formation may not necessarily represent oxygen insufficiency, but rather the Warburg effect-an attempt to provide a large amount of small carbon intermediates to supply the many synthetic pathways of proliferative cell growth. In either case, there is expression and upregulation of many genes involved in acid-base homeostasis, in part by HIF-1 signaling. These include a unique isoform of carbonic anhydrase (CA-IX) and numerous membrane acid-base transporters engaged to maintain an optimal intracellular and extracellular pH for maximal growth. Inhibition of these proteins or gene suppression may have important therapeutic application in cancer chemotherapy.
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Affiliation(s)
- Erik R Swenson
- Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA, USA. .,Department of Physiology and Biophysics, University of Washington, Seattle, WA, USA. .,VA Puget Sound Health Care System, University of Washington, Seattle, WA, USA.
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20
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Balanos GM, Pugh K, Frise MC, Dorrington KL. Exaggerated pulmonary vascular response to acute hypoxia in older men. Exp Physiol 2015; 100:1187-98. [DOI: 10.1113/ep085403] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 08/03/2015] [Indexed: 12/16/2022]
Affiliation(s)
- George M. Balanos
- School of Sport, Exercise and Rehabilitation Sciences; University of Birmingham; Edgbaston Birmingham UK
| | - Keith Pugh
- School of Sport, Exercise and Rehabilitation Sciences; University of Birmingham; Edgbaston Birmingham UK
| | - Matthew C. Frise
- Department of Physiology, Anatomy & Genetics; University of Oxford; Oxford UK
| | - Keith L. Dorrington
- Department of Physiology, Anatomy & Genetics; University of Oxford; Oxford UK
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21
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Abstract
Hypoxic pulmonary vasoconstriction (HPV) represents a fundamental difference between the pulmonary and systemic circulations. HPV is active in utero, reducing pulmonary blood flow, and in adults helps to match regional ventilation and perfusion although it has little effect in healthy lungs. Many factors affect HPV including pH or PCO2, cardiac output, and several drugs, including antihypertensives. In patients with lung pathology and any patient having one-lung ventilation, HPV contributes to maintaining oxygenation, so anesthesiologists should be aware of the effects of anesthesia on this protective reflex. Intravenous anesthetic drugs have little effect on HPV, but it is attenuated by inhaled anesthetics, although less so with newer agents. The reflex is biphasic, and once the second phase becomes active after about an hour of hypoxia, this pulmonary vasoconstriction takes hours to reverse when normoxia returns. This has significant clinical implications for repeated periods of one-lung ventilation.
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22
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Frise MC, Robbins PA. Iron, oxygen, and the pulmonary circulation. J Appl Physiol (1985) 2015; 119:1421-31. [PMID: 26066825 PMCID: PMC4683351 DOI: 10.1152/japplphysiol.00179.2015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 06/05/2015] [Indexed: 12/24/2022] Open
Abstract
The human pulmonary vasculature vasoconstricts in response to a reduction in alveolar oxygen tension, a phenomenon termed hypoxic pulmonary vasoconstriction (HPV). This review describes the time course of this behavior, which occurs in distinct phases, and then explores the importance for HPV of the hypoxia-inducible factor (HIF) pathway. Next, the HIF-hydroxylase enzymes that act as molecular oxygen sensors within the HIF pathway are discussed. These enzymes are particularly sensitive to intracellular iron availability, which confers iron-sensing properties on the HIF pathway. Human studies of iron chelation and supplementation are then reviewed. These demonstrate that the iron sensitivity of the HIF pathway evident from in vitro experiments is relevant to human pulmonary vascular physiology. Next, the importance of iron status in high-altitude illness and chronic cardiopulmonary disease is explored, and the therapeutic potential of intravenous iron discussed. The review concludes by highlighting some further complexities that arise from interactions between the HIF pathway and other intracellular iron-sensing mechanisms.
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Affiliation(s)
- Matthew C Frise
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Peter A Robbins
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
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23
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Tremblay JC, Lovering AT, Ainslie PN, Stembridge M, Burgess KR, Bakker A, Donnelly J, Lucas SJE, Lewis NCS, Dominelli PB, Henderson WR, Dominelli GS, Sheel AW, Foster GE. Hypoxia, not pulmonary vascular pressure, induces blood flow through intrapulmonary arteriovenous anastomoses. J Physiol 2014; 593:723-37. [PMID: 25416621 DOI: 10.1113/jphysiol.2014.282962] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/10/2014] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) is increased by acute hypoxia during rest by unknown mechanisms. Oral administration of acetazolamide blunts the pulmonary vascular pressure response to acute hypoxia, thus permitting the observation of IPAVA blood flow with minimal pulmonary pressure change. Hypoxic pulmonary vasoconstriction was attenuated in humans following acetazolamide administration and partially restored with bicarbonate infusion, indicating that the effects of acetazolamide on hypoxic pulmonary vasoconstriction may involve an interaction between arterial pH and PCO2. We observed that IPAVA blood flow during hypoxia was similar before and after acetazolamide administration, even after acid-base status correction, indicating that pulmonary pressure, pH and PCO2 are unlikely regulators of IPAVA blood flow. ABSTRACT Blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) is increased with exposure to acute hypoxia and has been associated with pulmonary artery systolic pressure (PASP). We aimed to determine the direct relationship between blood flow through IPAVA and PASP in 10 participants with no detectable intracardiac shunt by comparing: (1) isocapnic hypoxia (control); (2) isocapnic hypoxia with oral administration of acetazolamide (AZ; 250 mg, three times a day for 48 h) to prevent increases in PASP; and (3) isocapnic hypoxia with AZ and 8.4% NaHCO3 infusion (AZ + HCO3 (-) ) to control for AZ-induced acidosis. Isocapnic hypoxia (20 min) was maintained by end-tidal forcing, blood flow through IPAVA was determined by agitated saline contrast echocardiography and PASP was estimated by Doppler ultrasound. Arterial blood samples were collected at rest before each isocapnic-hypoxia condition to determine pH, [HCO3(-)] and Pa,CO2. AZ decreased pH (-0.08 ± 0.01), [HCO3(-)] (-7.1 ± 0.7 mmol l(-1)) and Pa,CO2 (-4.5 ± 1.4 mmHg; P < 0.01), while intravenous NaHCO3 restored arterial blood gas parameters to control levels. Although PASP increased from baseline in all three hypoxic conditions (P < 0.05), a main effect of condition expressed an 11 ± 2% reduction in PASP from control (P < 0.001) following AZ administration while intravenous NaHCO3 partially restored the PASP response to isocapnic hypoxia. Blood flow through IPAVA increased during exposure to isocapnic hypoxia (P < 0.01) and was unrelated to PASP, cardiac output and pulmonary vascular resistance for all conditions. In conclusion, isocapnic hypoxia induces blood flow through IPAVA independent of changes in PASP and the influence of AZ on the PASP response to isocapnic hypoxia is dependent upon the H(+) concentration or Pa,CO2.
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Affiliation(s)
- Joshua C Tremblay
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
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Dominelli PB, Render JN, Molgat-Seon Y, Foster GE, Sheel AW. Precise mimicking of exercise hyperpnea to investigate the oxygen cost of breathing. Respir Physiol Neurobiol 2014; 201:15-23. [PMID: 24981705 DOI: 10.1016/j.resp.2014.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 06/13/2014] [Accepted: 06/17/2014] [Indexed: 11/25/2022]
Abstract
The oxygen cost of exercise hyperpnea (V˙(O2 RM)) has been quantified using a variety of techniques with inconsistent findings. Between-study variation relates to poor control of breathing patterns and lung mechanics. We developed a methodology allowing precise matching of exercising WOB in order to estimate V˙(O2 RM). Thirteen healthy young subjects (7 male) completed an incremental cycle exercise test, familiarization and experimental days where exercise hyperpnea was mimicked. On experimental days, feedback of exercise flow, volume and the respiratory pressures were provided while end-tidal CO2 was kept at exercise levels during each 5-min trial. Minute ventilation levels between 50 and 100% maximum were mimicked 3-5 times. The r(2) between exercise and mimic trails was 0.99 for frequency, tidal volume and minute ventilation; 0.86 for esophageal pressure swings and 0.93 for WOB. The coefficient of variation for (V˙(O2) averaged 4.3, 4.4 and 5.7% for 50, 75 and 100% ventilation trials. When WOB and other respiratory parameters are tightly controlled, the V˙(O2 RM) can be consistently estimated.
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Affiliation(s)
- P B Dominelli
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada.
| | - J N Render
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
| | - Y Molgat-Seon
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
| | - G E Foster
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - A W Sheel
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
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Abstract
Hypoxic pulmonary vasoconstriction (HPV) continues to fascinate cardiopulmonary physiologists and clinicians since its definitive description in 1946. Hypoxic vasoconstriction exists in all vertebrate gas exchanging organs. This fundamental response of the pulmonary vasculature in air breathing animals has relevance to successful fetal transition to air breathing at birth and as a mechanism of ventilation-perfusion matching in health and disease. It is a complex process intrinsic to the vascular smooth muscle, but with in vivo modulation by a host of factors including the vascular endothelium, erythrocytes, pulmonary innervation, circulating hormones and acid-base status to name only a few. This review will provide a broad overview of HPV and its mechansms and discuss the advantages and disadvantages of HPV in normal physiology, disease and high altitude.
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Affiliation(s)
- Erik R Swenson
- Department of Medicine, University of Washington, VA Puget Sound Health Care System, Seattle, WA 98108, USA.
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Croft QPP, Formenti F, Talbot NP, Lunn D, Robbins PA, Dorrington KL. Variations in alveolar partial pressure for carbon dioxide and oxygen have additive not synergistic acute effects on human pulmonary vasoconstriction. PLoS One 2013; 8:e67886. [PMID: 23935847 PMCID: PMC3729950 DOI: 10.1371/journal.pone.0067886] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 05/23/2013] [Indexed: 11/19/2022] Open
Abstract
The human pulmonary vasculature constricts in response to hypercapnia and hypoxia, with important consequences for homeostasis and adaptation. One function of these responses is to direct blood flow away from poorly-ventilated regions of the lung. In humans it is not known whether the stimuli of hypercapnia and hypoxia constrict the pulmonary blood vessels independently of each other or whether they act synergistically, such that the combination of hypercapnia and hypoxia is more effective than the sum of the responses to each stimulus on its own. We independently controlled the alveolar partial pressures of carbon dioxide (Paco2) and oxygen (Pao2) to examine their possible interaction on human pulmonary vasoconstriction. Nine volunteers each experienced sixteen possible combinations of four levels of Paco2 (+6, +1, −4 and −9 mmHg, relative to baseline) with four levels of Pao2 (175, 100, 75 and 50 mmHg). During each of these sixteen protocols Doppler echocardiography was used to evaluate cardiac output and systolic tricuspid pressure gradient, an index of pulmonary vasoconstriction. The degree of constriction varied linearly with both Paco2 and the calculated haemoglobin oxygen desaturation (1-So2). Mixed effects modelling delivered coefficients defining the interdependence of cardiac output, systolic tricuspid pressure gradient, ventilation, Paco2 and So2. No interaction was observed in the effects on pulmonary vasoconstriction of carbon dioxide and oxygen (p>0.64). Direct effects of the alveolar gases on systolic tricuspid pressure gradient greatly exceeded indirect effects arising from concurrent changes in cardiac output.
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Affiliation(s)
- Quentin P. P. Croft
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Federico Formenti
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Nick P. Talbot
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Daniel Lunn
- Department of Statistics, University of Oxford, Oxford, United Kingdom
| | - Peter A. Robbins
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Keith L. Dorrington
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
- * E-mail:
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Emery MJ, Eveland RL, Min JH, Hildebrandt J, Swenson ER. CO2 relaxation of the rat lung parenchymal strip. Respir Physiol Neurobiol 2013; 186:33-9. [PMID: 23305910 DOI: 10.1016/j.resp.2012.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 12/29/2012] [Accepted: 12/29/2012] [Indexed: 01/13/2023]
Abstract
Evidence from liquid-filled rat lungs supported the presence of CO2-dependent, active relaxation of parenchyma under normoxia by unknown mechanisms (Emery et al., 2007). This response may improve matching of alveolar ventilation (V˙A) to perfusion (Q˙) by increasing compliance and V˙A in overperfused (high CO2) regions, and decrease V˙A in underperfused regions. Here, we have more directly studied CO2-dependent parenchymal relaxation and tested a hypothesized role for actin-myosin interaction in this effect. Lung parenchymal strips (∼1.5mm×1.5mm×15mm) from 16 rats were alternately exposed to normoxic hypocapnia ( [Formula: see text] ) or hypercapnia ( [Formula: see text] ). Seven specimens were used to construct length-tension curves, and nine were tested with and without the myosin blocker 2,3-butanedione monoxime (BDM). The results demonstrate substantial, reversible CO2-dependent changes in parenchyma strip recoil (up to 23%) and BDM eliminates this effect, supporting a potentially important role for parenchymal myosin in V˙A/Q˙ matching.
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Affiliation(s)
- Michael J Emery
- Pulmonary and Critical Care Medicine (S-111-PULM), VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA.
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Lee SK, Kim DH, Choi WA, Won YH, Kim SM, Kang SW. The Significance of Transcutaneous Continuous Overnight CO(2) Monitoring in Determining Initial Mechanical Ventilator Application for Patients with Neuromuscular Disease. Ann Rehabil Med 2012; 36:126-32. [PMID: 22506245 PMCID: PMC3309316 DOI: 10.5535/arm.2012.36.1.126] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 10/10/2011] [Indexed: 11/22/2022] Open
Abstract
Objective To reveal the significance of continuous transcutaneous carbon dioxide (CO2) level monitoring through reviewing cases which showed a discrepancy in CO2 levels between arterial blood gas analysis (ABGA) and continuous transcutaneous blood gas monitoring. Method Medical record review was conducted retrospectively of patients with neuromuscular diseases who had started home mechanical ventilation between June 2008 and May 2010. The 89 patients underwent ABGA at the 1st hospital day, and changes to their CO2 level were continuously monitored overnight with a transcutaneous blood gas analysis device. The number of patients who initially appeared to show normal PaCO2 through ABGA, yet displayed hypercapnea through overnight continuous monitoring, was counted. Results 36 patients (40.45%) presented inconsistent CO2 level results between ABGA and continuous overnight monitoring. The mean CO2 level of the 36 patients using ABGA was 37.23±5.11 mmHg. However, the maximum and mean CO2 levels from the continuous monitoring device were 52.25±6.87 mmHg and 46.16±6.08 mmHg, respectively. From the total monitoring period (357.28±150.12 minutes), CO2 retention over 45 mmHg was detected in 198.97 minutes (55.69%). Conclusion Although ABGA only reflects ventilatory status at the puncturing moment, ABGA results are commonly used to monitor ventilatory status in most clinical settings. In order to decide the starting point of home mechanical ventilation in neuromuscular patients, continuous overnight monitoring should be considered to assess latent CO2 retention.
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Affiliation(s)
- Soon Kyu Lee
- Department of Rehabilitation Medicine and Rehabilitation Institute of Muscular Disease, Yonsei University College of Medicine, Seoul 135-720, Korea
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