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

An 81-yr-old man with severe chronic obstructive pulmonary disease and hypercapnia presented to the emergency department (ED) obtunded and in acute respiratory distress. He had instructed his family to refuse intubation but agreed to all other measures to sustain his life. Treatment measures included the administration of intravenous doxapram, which was followed promptly by a marked improvement in his respiratory function and mentation. Respiratory stimulants may be useful as a temporizing measure in this difficult ED therapeutic problem.
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PMID:Doxapram in hypercapnic chronic obstructive pulmonary disease with respiratory failure. 927 5

The associated use of permissive hypercapnia (PHY) and high PEEP levels (PEEP(IDEAL)) has been recently indicated as part of a lung-protective-approach (LPA) in acute respiratory distress syndrome (ARDS). However, the net hemodynamic effect produced by this association is not known. We analyzed the temporal hemodynamic effects of this combined strategy in 48 patients (mean age 34 +/- 13 yr) with ARDS, focusing on its immediate (after 1 h), early (first 36 h), and late (2nd-7th d) consequences. Twenty-five patients were submitted to LPA--with the combined use of permissive hypercapnia (PHY), VT < 6 ml/kg, distending pressures above PEEP < 20 cm H2O, and PEEP 2 cm H2O above the lower inflection point on the static inspiratory P-V curve (P(FLEX))- and 23 control patients were submitted to conventional mechanical ventilation. LPA was initiated at once, resulting in an immediate increase in heart rate (p = 0.0002), cardiac output (p = 0.0002), oxygen delivery (DO2l, p = 0.0003), and mixed venous Po2 (p = 0.0006), with a maintained systemic oxygen consumption (p = 0.52). The mean pulmonary arterial pressure markedly increased (mean increment 8.8 mm Hg; p < 0.0001), but the pulmonary vascular resistance did not change (p = 0.32). Cardiac filling pressures increased (p < 0.001) and the systemic vascular resistance fell (p = 0.003). All these alterations were progressively attenuated in the course of the first 36 h, despite persisting hypercapnia. Plasma lactate suffered a progressive decrement along the early period in LPA but not in control patients (p < 0.0001). No hemodynamic consequences of LPA were noticed in the late period and renal function was preserved. A multivariate analysis suggested that these acute hyperdynamic effects were related to respiratory acidosis, with no depressant effects ascribed to high PEEP levels. In contrast, high plateau pressures were associated with cardiovascular depression. Thus, as long as sufficiently low distending pressures are concomitantly applied, the sudden installation of PHY plus PEEP(IDEAL) induces a transitory hyperdynamic state and pulmonary hypertension without harmful consequences to this young ARDS population.
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PMID:Temporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS. 937 61

Partial liquid ventilation using conventional ventilatory schemes improves lung function in animal models of respiratory failure. We examined the feasibility of high-frequency partial liquid ventilation in the preterm lamb with respiratory distress syndrome and evaluated its effect on pulmonary and systemic hemodynamics. Seventeen lambs were studied in three groups: high-frequency gas ventilation (Gas group), high-frequency partial liquid ventilation (Liquid group), and high-frequency partial liquid ventilation with hypoxia-hypercarbia (Liquid-Hypoxia group). High-frequency partial liquid ventilation increased oxygenation compared with high-frequency gas ventilation over 5 h (arterial oxygen tension 253 +/- 21.3 vs. 17 +/- 1.8 Torr; P < 0.001). Pulmonary vascular resistance decreased 78% (P < 0.001), pulmonary blood flow increased fivefold (P < 0.001), and aortic pressure was maintained (P < 0.01) in the Liquid group, in contrast to progressive hypoxemia, hypercarbia, and shock in the Gas group. Central venous pressure did not change. The Liquid-Hypoxia group was similar to the Gas group. We conclude that high-frequency partial liquid ventilation improves gas exchange and stabilizes pulmonary and systemic hemodynamics compared with high-frequency gas ventilation. The stabilization appears to be due in large part to improvement in gas exchange.
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PMID:High-frequency partial liquid ventilation in respiratory distress syndrome: hemodynamics and gas exchange. 945 53

A two-year-old boy with a history of slow growth, snoring during sleep and adenoid hypertrophy underwent adenoidectomy and transtympanic drainage under general anesthesia. Immediately after extubation, severe inspiratory stridor and shallow labored breathing began and persisted over a period of two hours, in spite of corticoid administration and oxygen therapy. The signs receded partially when the patient was seated and with a mandibular traction maneuver. As symptoms persisted, foreign body obstruction was ruled out by examination of the cavum and upper airway under general anesthesia and with orotracheal intubation. The patient was transferred to the pediatric intensive care unit, where he remained intubated for 18 hours. After extubation, stridor and shallow labored breathing reappeared but gradually receded as the residual effects of sedation disappeared. The parents mentioned symptoms suggestive of obstructive sleep apnea syndrome (OSAS) occurring since the boy was 6 months old and that had worsened in recent months. OSAS in children is characterized by intermittent obstruction of the upper airway during sleep, causing snoring and periods of apnea/hypopnea that lead to hypoxemia and hypercapnia. The most frequent cause is hypertrophy of the adenoid and tonsils, and the treatment of choice is adenotonsillectomy, although the risk of postoperative respiratory distress in such children is high. It is important to rule out OSAS in children who are candidates for adenotonsillectomy so that such patients are not scheduled for ambulatory surgery, but rather given adequate postoperative monitoring and treatment.
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PMID:[Compromized postadenoidectomy respiration in a child with obstructive sleep apnea syndrome]. 949 65

We describe a patient with combined meningococcal septicemia and meningitis, cerebral edema and acute respiratory distress syndrome, in whom we balanced the conflicting carbon dioxide strategies for optimal pulmonary and neurological management using jugular oxygen saturation (SjvO2) monitoring to identify the upper limit of "tolerable" hypercapnia. Our observations suggest that significant acidosis was not well tolerated; however, cautious induction of pH down to 7.32 and an arterial carbon dioxide tension (PaCO2) < 5.9 kPa was tolerated acutely without significant cerebral hyperemia. Moreover, with the development of metabolic compensation and normal pH, higher levels of PaCO2 could be permitted. In similar cerebro-pulmonary circumstances we suggest that these findings warrant consideration. Alternatively, invasive monitoring of SjvO2 could be undertaken so that patient-specific criteria for permissive hypercapnia can be determined.
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PMID:Combined lung injury, meningitis and cerebral edema: how permissive can hypercapnia be? 1005 Oct 94

Because animal studies have demonstrated that mechanical ventilation at high volume and pressure can be deleterious to the lungs, limitation of airway pressure, allowing hypercapnia if necessary, is already used for ventilation of acute respiratory distress syndrome (ARDS). Whether a systematic and more drastic reduction is necessary is debatable. A multicenter randomized study was undertaken to compare a strategy aimed at limiting the end-inspiratory plateau pressure to 25 cm H2O, using tidal volume (VT) below 10 ml/kg of body weight, versus a more conventional ventilatory approach (with regard to current practice) using VT at 10 ml/kg or above and close to normal PaCO2. Both arms used a similar level of positive end-expiratory pressure. A total of 116 patients with ARDS and no organ failure other than the lung were enrolled over 32 mo in 25 centers. The two groups were similar at inclusion. Patients in the two arms were ventilated with different VT (7.1 +/- 1.3 versus 10.3 +/- 1.7 ml/kg at Day 1, p < 0.001) and plateau pressures (25.7 +/- 5. 0 versus 31.7 +/- 6.6 cm H2O at Day 1, p < 0.001), resulting in different PaCO2 (59.5 +/- 15.0 versus 41.3 +/- 7.6 mm Hg, p < 0.001) and pH (7.28 +/- 0.09 versus 7.4 +/- 0.09, p < 0.001), but a similar level of oxygenation. The new approach did not reduce mortality at Day 60 (46.6% versus 37.9% in control subjects, p = 0.38), the duration of mechanical ventilation (23.1 +/- 20.2 versus 21.4 +/- 16. 3 d, p = 0.85), the incidence of pneumothorax (14% versus 12%, p = 0. 78), or the secondary occurrence of multiple organ failure (41% versus 41%, p = 1). We conclude that no benefit could be observed with reduced VT titrated to reach plateau pressures around 25 cm H2O compared with a more conventional approach in which normocapnia was achieved with plateau pressures already below 35 cm H2O.
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PMID:Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS. 984 75

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

The underlying principle of the surgical treatment of non-small-cell lung cancer (NSCLC) is complete removal of the local/regional disease within the thorax. Pulmonary resection should be as conservative as possible without compromising the adequacy of tumor removal. A multitude of factors influence the incidence and severity of complications following pulmonary resection including the pre-operative physical and psychological status of the patient, the pathologic process requiring resection, the physiologic impact of the procedure, and the addition of pre-operative or postoperative adjuvant therapy. The insidious onset of interstitial changes on chest X-ray (CXR) 1 to 2 days after pulmonary resection forewarns of respiratory distress; however, the pathophysiology of adult respiratory distress syndrome (ARDS) with progression to respiratory failure requiring mechanical ventilation and advanced critical care often unfolds. Management of patients with severe respiratory failure remains primarily supportive. "Good critical care" is the mainstay of therapy: this includes gentle mechanical ventilation to avoid ventilator-induced barotrauma and over-extension of remaining functional alveoli, diuresis, infection identification and management, and nutritional support. New therapeutic strategies that may impact on outcomes in the adult population include pressure-limited ventilation (permissive hypercapnia), inverse ratio ventilation, high-frequency jet ventilation, high-frequency oscillatory ventilation, intratracheal pulmonary ventilation, and prone position ventilation. In addition, alternative therapies such as partial liquid ventilation, inhaled nitric oxide, and extracorporeal techniques including extracorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide removal (ECCO(2)R), intravascular oxygenation (IVOX), and arteriovenous carbon dioxide removal (AVCO(2)R), provide additional modalities. A component of some or all of these strategies is finding a role in clinical practice.
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PMID:Pathogenesis and management of respiratory insufficiency following pulmonary resection. 1065 20

The approach to mechanical ventilation has been revolutionized by new insights into the pathogenesis of respiratory failure in acute respiratory distress syndrome (ARDS). Concepts such as low-volume ventilation, permissive hypercapnia, inverse ratio ventilation, best and intrinsic positive end-expiratory pressure, airway shear, pressure volume curves, inflection points, and prone positioning have radically transformed thinking about ventilator management. Since 1966, more than 8000 ARDS-related publications have appeared. Studies highlighting the experimental basis for innovations in mechanical ventilation are presented. Selected clinical series that exemplify the use of these new strategies are reviewed, to demonstrate how key experimental and clinical research has altered our understanding about what works, and why. Mismanagement of mechanical ventilation causes lung injury and increases mortality. The strategy of protective ventilation has provided the first substantial reduction of mortality in the history of ARDS.
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PMID:Advances in the management of acute respiratory distress syndrome: protective ventilation. 1066 68

Advanced prehospital emergency medical care of patients with a severe head injury must essentially focus on the impact of secondary cerebral insults of systemic origin on the outcome. The first objective of prehospital care is to prevent hypoxaemia and hypercapnia. Therefore, all patients with a Glasgow Coma Scale score equal to or lower than 8 must be treated with endotracheal intubation and controlled ventilation under continuous monitoring of SpO2 and PETCO2. Treatment is similar in head-injured patients with significant deterioration of consciousness level, seizures, respiratory distress, or severe facial and thoracoabdominal injuries. The endotracheal tube is inserted by the orotracheal route under direct laryngoscopy, after a rapid induction sequence of anaesthesia and immobilization of the cervical spine in neutral position. For the induction of anaesthesia in these high-risk patients (full stomach, unknown medical history, deteriorated haemodynamic status), etomidate and suxamethonium are the preferred agents. Sedation is maintained with an hypnoticopioid association (fentanyl). Simultaneously, the main goal is the maintenance of an optimal cerebral perfusion pressure, as arterial hypotension severely worsens cerebral ischaemia. Volume loading is accomplished with 0.9% saline and hydroxyethyl starch.
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PMID:[Prehospital management of patients with severe head injuries]. 1083 14


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