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Query: UMLS:C0020440 (hypercapnia)
 7,939 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The paediatric patient we are describing suffered a scald injury covering 83 per cent of the total body surface area (TBSA). This injury was complicated by Klebsiella pneumoniae septicaemia resulting in multiorgan failure (MOF). Acute respiratory distress syndrome (ARDS), gastrointestinal insufficiency, hepathopathy and wound conversion to full thickness posed the main problems. The boy was ventilated with pressure-controlled mechanical ventilation. The concept of permissive hypercapnia (PHC) resulted in a complete resolution of ARDS within 4 weeks. From our experience, further lung injury among infants and children suffering from severe ARDS can be avoided by using controlled mechanical hypoventilation. It is a simple and safe technique that allows adequate oxygenation.
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PMID:Controlled mechanical hypoventilation in a paediatric burn patient as treatment of acute respiratory distress syndrome. 917 87

Pulmonary contusion is a common lesion occurring in patients sustaining severe blunt chest trauma. Alveolar hemorrhage and parenchymal destruction are maximal during the first 24 hours after injury and then usually resolve within 7 days. The diagnosis of traumatic lung injury is usually made clinically with confirmation by chest x-ray films. The chest computed tomography scan is highly sensitive in identifying pulmonary contusion and may help predict the need for mechanical ventilation. Respiratory distress is common after lung trauma, with hypoxemia and hypercarbia greatest at about 72 hours. Although management of patients with pulmonary contusion is supportive, pneumonia and adult respiratory distress syndrome with long-term disability occur frequently.
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PMID:Pulmonary contusion: review of the clinical entity. 919 84

Despite more than 25 years of extensive research, the mortality of ARDS patients remains high. The inflammatory process within the lung and the associated gas exchange disturbances require an aggressive ventilatory regimen, which itself may harm the lung. Therapeutic measures which are used to reduce iatrogenic damage to the lung are pressure controlled mechanical ventilation in combination with PEEP and permissive hypercapnia, dehydration and extracorporeal gas exchange. At present, new strategies such as intratracheal instillation of surfactant, partial liquid ventilation and inhalation of nitric oxide (NO) are being evaluated. Surfactant reduces the surface tension, forming a monomolecular layer at the air/tissue interface. It thereby decreases the forces necessary to expand the alveoli and prevents alveoli with small diameter from collapsing. In ARDS, a disturbance of surfactant synthesis, function and re-uptake is the rationale for treatment with exogenous surfactant. Initial clinical results suggest a limited positive effect independently of the surfactant preparation used, the dose and the application mode. Experience with partial liquid ventilation with perfluorocarbons in ARDS has also been reported. Perfluorocarbons are liquids with a high binding capacity for oxygen and carbon dioxide. During normal mechanical ventilation with gas, repetitive doses of perfluorocarbons are instilled into the lungs up to a volume equal to the functional residual capacity. The liquid is pushed into collapsed alveoli and keeps them open by reducing the surface tension. First clinical studies have demonstrated the possible improvement in pulmonary gas exchange. In ARDS, inhalation of NO may cause a predominantly selective vasodilation in blood vessels of ventilated lung regions, resulting in an increase in PaO2 and a decrease in pulmonary artery pressure. The effect of NO on the pulmonary vasculature also induces a reduction in right ventricular afterload and also in pulmonary capillary pressure, which may lead to a faster resolution of pulmonary edema. However, in spite of the promising results of these new strategies, further studies are needed to evaluate their influence on morbidity and mortality.
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PMID:[Perspectives in mechanical ventilation in ARDS]. 928 30

Acute respiratory distress syndrome (ARDS) is a severe condition that has a high mortality. Mechanical ventilation is required and concepts have evolved over the last few decades as to the methods and principles guiding such ventilatory support. In particular, volutrauma as a feature of ventilator-associated lung injury has been well documented, leading to pressure-limited strategies with consequent permissive hypercapnia. Such an approach is in direct contrast to traditional ventilatory teaching of high tidal volumes and normal PaCO2. Current strategies therefore emphasis lower tidal volumes, adequate positive end-expiratory pressure (PEEP), minimum FiO2, and the use of pressure-control modes (plus or minus inverse-ratio ventilation). Hypercapnia is allowed to develop, and adjunctive methods are employed to improve oxygenation in order to minimise the "pressure-cost" of maintaining adequate oxygenation. With such an approach, overall mortality is reported to be around 40%.
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PMID:Ventilatory strategies for acute respiratory distress syndrome. 977 89

Acute respiratory distress syndrome (ARDS) is a severe condition with a high mortality rate, despite conventional treatment using mechanical ventilation. Better understanding of the pathophysiology and awareness of important iatrogenic lung injury secondary to mechanical ventilation has led to new therapeutic principles. Mechanical ventilation strategy during ARDS is characterized by positive end-expiratory pressure, increase in the inspiratory time, high inspiratory oxygen concentration and, more recently, use of permissive hypercapnia. High frequency ventilation allows optimal lung recruitment under small tidal volume. The effectiveness of extracorporeal oxygenation techniques is demonstrated, but because of their cost and morbidity these therapies are rational only in patients who seem likely to die. Partial liquid ventilation and inhaled nitric oxide have great potential but require further studies. Intratracheal exogenous surfactant might be beneficial but controlled trials are needed to confirm the usefulness of this expensive therapy. Finally, a number of adjuncts to mechanical ventilation are currently available to minimize iatrogenic lung injury and improve the outcome. The role of these new treatments must be defined with randomized and controlled clinical trials using homogenous inclusion criteria.
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PMID:[Recent developments in the treatment of pediatric acute respiratory distress syndrome]. 980 55

When conventional respiratory strategies fail to maintain adequate oxygenation treatment of severe ARDS is largely empirical. Modern techniques such as inverse ratio ventilation, permissive hypercapnia, NO inhalation and lowering tidal volumes/pressures are advocated. We report on a patient with severe ARDS who showed all the complications of the disease. The risks and benefits of (non)conventional ventilatory strategies are discussed and illustrated.
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PMID:Non-conventional mechanical ventilation in severe ARDS, illustrated by a complicated case. 985 8

Many animal studies have demonstrated that mechanical ventilation with high peak inspiratory pressures (PIP) can result in a form of acute lung injury closely resembling ARDS, ie characterised by hyaline membranes, granulocyte infiltration, increased pulmonary and systemic vascular permeability, and eventually proliferation of fibroblasts and type II pneumocytes. These studies have led to a concern that, in some patients, orthodox ventilatory management in severe ARDS may result in additional lung injury and, possibly, remote organ dysfunction. Mortality may be increased as a consequence. In an attempt to avoid such ventilator-induced lung injury in severe ARDS, several modifications of ventilatory management have been evaluated. We have previously reported the technique of low volume pressure limited ventilation with permissive hypercapnia, using tidal volumes of 5-7 ml/kg and allowing the PaCO 2 to rise substantially (maximum PaCO 2 17.2 kPa [129 mmHg]), mean maximum 8.3 kPa [62 mmHg]). In an uncontrolled study the mortality was significantly lower than that predicted by Apache II (16% vs 39.6%, p less than 0.01). Acute hypercapnia can cause many physiological disturbances but most of these appear to be due to the resulting intracellular acidosis and should not occur in hypercapnia of gradual onset, allowing the intracellular pH to be normalised. The time scales for compensation of intracellular and extracellular acidosis are markedly different. However, even severe acute hypercapnia appears to be remarkably well tolerated. Several clinical studies suggest that the avoidance of high PIP may reduce mortality in ARDS, but a randomised trial will be required to establish whether pressure limitation and permissive hypercapnia do improve outcome.
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PMID:Low volume ventilation with permissive hypercapnia in the Adult Respiratory Distress Syndrome. 1014 4

Despite more than 25 years of extensive research the mortality of ARDS patients remains high. Besides the often deleterious course of the underlying disease, another reason for this high mortality lies in the aggressive ventilatory regimen which is required to maintain arterial blood gases in a more or less normal range. Therapeutic methods which are used to reduce iatrogenic damage to the lungs are pressure controlled ventilation with permissive hypercapnia, differential lung ventilation, positioning therapy, dehydration, and extracorporeal gas exchange with membrane lungs. Nevertheless, many of these patients still die following hypoxaemia or multiple organ failure. Therefore, the need remains to develop new therapeutic strategies and to investigate their influence on the morbidity and mortality of this life-threatening disease. First experiences with nitric oxide (NO) inhalation, intravenous application of antioxidants, intratracheal instillation of surfactant, tracheal gas insufflation and combined fluid/gas ventilation with perfluorocarbon are presented. All these new methods have proved their efficacy, at least in animal studies, however, they should still be regarded as experimental.
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PMID:Recent advances in the treatment of ARDS. 1015 Aug 1

Submersion accidents continue to be a significant cause of morbidity and mortality in children and adults. The key to successful management is prevention of these accidents. Proactive efforts to minimize submersion accidents in the community should be made by medical and legislative groups. Anticipatory guidance by primary care physicians, particularly for families and individuals at increased risk, should be performed. Outcomes of individuals who have become victims of submersion accidents can be optimized by the development of a rapid response system, because successful initial resuscitation efforts clearly improve outcomes. For individuals who have nearly drowned and who have arrived in the emergency department, a systematic and aggressive approach needs to be followed with particular emphasis on cardiorespiratory support to optimize neurologic outcome. Despite many studies aimed at developing predictors of outcomes, there is limited information that can be used in a prospective manner to guide the emergency-room physician in limiting the level of interventions. Thus, all aggressive supportive care and resuscitation should be performed at this stage, except in clearly futile situations. Once patients arrive in the ICU, meticulous care, including monitoring of cardiorespiratory and neurologic status and attention to electrolytes and acid-base status, needs to be continued. Besides providing basic supportive measures, the ICU physician should investigate for other associated trauma and medical conditions that may need to be addressed once the patient is stabilized. Patients who have nearly drowned are likely to have long ICU stays, predisposing them to nosocomial infections. Despite efforts at minimizing barotrauma and volutrauma, many patients who have nearly drowned and who need ventilatory support may develop ARDS. The management of these patients is similar to other patients who have ARDS. However, strategies like permissive hypercapnia that are used commonly in patients who have ARDS may not be suitable in patients who have CNS injury. Despite aggressive care, neurologic injury with long-term sequelae secondary to hypoxic ischemic injury remains a major problem in the management of victims of submersion accidents. It is important for the clinician to keep the pathophysiologic and cellular mechanisms of CNS injury in mind, because future interventions are likely to be based on these pathways. Besides providing care for the patient, it is important for the ICU physician to be sensitive to the needs of the family and to support them through this catastrophe that is likely to place a tremendous financial and emotional burden on most of them.
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PMID:Near drowning. 1033 Nov 29

The aim of this study was to compare three ventilatory techniques for reducing PaCO2 in patients with severe acute respiratory distress syndrome treated with permissive hypercapnia: (1) expiratory washout alone at a flow of 15 L/min, (2) optimized mechanical ventilation defined as an increase in the respiratory frequency to the maximal rate possible without development of intrinsic positive end- expiratory pressure (PEEP) combined with a reduction of the instrumental dead space, and (3) the combination of both methods. Tidal volume was set according to the pressure-volume curve in order to obtain an inspiratory plateau airway pressure equal to the upper inflection point minus 2 cm H2O after setting the PEEP at 2 cm H2O above the lower inflection point and was kept constant throughout the study. The three modalities were compared at the same inspiratory plateau airway pressure through an adjustment of the extrinsic PEEP. During conventional mechanical ventilation using a respiratory frequency of 18 breaths/min, respiratory acidosis (PaCO2 = 84 +/- 24 mm Hg and pH = 7.21 +/- 0.12) was observed. Expiratory washout and optimized mechanical ventilation (respiratory frequency of 30 +/- 4 breaths/min) had similar effects on CO2 elimination (DeltaPaCO2 = -28 +/- 11% versus -27 +/- 12%). A further decrease in PaCO2 was observed when both methods were combined (DeltaPaCO2 = -46 +/- 7%). Extrinsic PEEP had to be reduced by 5.3 +/- 2.1 cm H2O during expiratory washout and by 7.3 +/- 1.3 cm H2O during the combination of the two modes, whereas it remained unchanged during optimized mechanical ventilation alone. In conclusion, increasing respiratory rate and reducing instrumental dead space during conventional mechanical ventilation is as efficient as expiratory washout to reduce PaCO2 in patients with severe ARDS and permissive hypercapnia. When used in combination, both techniques have additive effects and result in PaCO2 levels close to normal values.
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PMID:Expiratory washout versus optimization of mechanical ventilation during permissive hypercapnia in patients with severe acute respiratory distress syndrome. 1039 Mar 83


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