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2.
Trials ; 20(1): 465, 2019 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-31362776

RESUMO

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common cause of chronic respiratory failure and its course is punctuated by a series of acute exacerbations which commonly lead to hospital admission. Exacerbations are managed through the application of non-invasive ventilation and, when this fails, tracheal intubation and mechanical ventilation. The need for mechanical ventilation significantly increases the risk of death. An alternative therapy, extracorporeal carbon dioxide removal (ECCO2R), has been shown to be efficacious in removing carbon dioxide from the blood; however, its impact on respiratory physiology and patient outcomes has not been explored. METHODS/DESIGN: A randomised controlled open label trial of patients (12 in each arm) with acute exacerbations of COPD at risk of failing conventional therapy (NIV) randomised to either remaining on NIV or having ECCO2R added to NIV with a primary endpoint of time to cessation of NIV. The change in respiratory physiology following the application of ECCO2R and/or NIV will be measured using electrical impedance tomography, oesophageal pressure and parasternal electromyography. Additional outcomes, including patient tolerance, outcomes, need for readmission, changes in blood gases and biochemistry and procedural complications, will be measured. Physiological changes will be compared within one patient over time and between the two groups. Healthcare costs in the UK system will also be compared between the two groups. DISCUSSION: COPD is a common disease and exacerbations are a leading cause of hospital admission in the UK and worldwide, with a sizeable mortality. The management of patients with COPD consumes significant hospital and financial resources. This study seeks to understand the feasibility of a novel approach to the management of patients with acute exacerbations of COPD as well as to understand the underlying physiological changes to explain why the approach does or does not assist this patient cohort. Detailed respiratory physiology has not been previously undertaken using this technique and there are no other randomised controlled trials currently in the literature. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02086084.


Assuntos
Dióxido de Carbono/sangue , Circulação Extracorpórea , Hipercapnia/terapia , Pulmão/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/terapia , Respiração , Biomarcadores/sangue , Terapia Combinada , Progressão da Doença , Circulação Extracorpórea/efeitos adversos , Humanos , Hipercapnia/sangue , Hipercapnia/diagnóstico , Hipercapnia/fisiopatologia , Londres , Ventilação não Invasiva , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/sangue , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento
3.
J Pak Med Assoc ; 69(8): 1146-1149, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31431769

RESUMO

OBJECTIVE: The aim was to access the effectiveness of Bilevel Positive Airway Pressure (BiPAP) in patients with type II respiratory failure secondary to Post Tuberculosis (TB) sequelae and determine the factors that can predict its success. PostTB pulmonary sequelae are complications after healing of TB and type II respiratory failure is frequently encountered in this group. . METHODS: This prospective study was carried out in the department of Chest Medicine, Jinnah Postgraduate Medical Center Karachi. (JPMC) Total 78 patients, between 20-80 years of age having hypercapnic respiratory failure, were included. Patients were given BiPAP along with standard treatment. RESULTS: Among 78 patients, 45 (56.3%) were males and 33 (43.7%) were females. Patients mean age was 50.6 } 15.76 years. The BiPAP success rate was 70.5% (55/78). There is significant difference in age (p=0.008), duration of disease (p=0.021), baseline pH (p=0.00), PaCO2 (p=0.004), Glasgow Coma Score (p=0.031), Chest X-ray (p<0.05) and systolic blood pressure (p=0.007) between responders and non-responders. Improvement in Abgs and vitals was observed among responders following 3 hours of therapy while pH drops significantly at 3 hours in non-responders. CONCLUSIONS: This study reveals that BiPAP is also efficacious method in patients with Type II respiratory failure post TB sequelae. Potential non responders can be identified relatively early in course of treatment and considered for ventilator.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas/métodos , Hipercapnia/terapia , Ventilação não Invasiva/métodos , Insuficiência Respiratória/terapia , Tuberculose Pulmonar/complicações , Adulto , Fatores Etários , Idoso , Gasometria , Pressão Sanguínea , Feminino , Escala de Coma de Glasgow , Humanos , Concentração de Íons de Hidrogênio , Hipercapnia/etiologia , Masculino , Pessoa de Meia-Idade , Pressão Parcial , Prognóstico , Radiografia Torácica , Insuficiência Respiratória/sangue , Insuficiência Respiratória/diagnóstico por imagem , Insuficiência Respiratória/etiologia , Fatores de Tempo
4.
Int J Chron Obstruct Pulmon Dis ; 14: 1411-1421, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31308647

RESUMO

Background: Despite the encouraging results of noninvasive ventilation (NIV) in chronic hypercapnic COPD patients, it is also evident that some patients do not tolerate NIV or do not benefit from it. We conducted a study in which COPD patients with stable, chronic hypercapnia were treated with NIV and nasal high-flow (NHF) to compare effectiveness. Methods: In a multi-centered, randomized, controlled, cross-over design, patients received 6 weeks of NHF ventilation followed by 6 weeks of NIV ventilation or vice-versa (TIBICO) between 2011 and 2016. COPD patients with stable daytime hypercapnia (pCO2≥50 mmHg) were recruited from 13 German centers. The primary endpoint was pCO2 changes from baseline blood gas, lung function, quality of life (QoL), the 6 min walking test, and duration of device use were secondary endpoints. Results: A total of 102 patients (mean±SD) age 65.3±9.3 years, 61% females, body mass index 23.1±4.8 kg/m2, 90% GOLD D, pCO2 56.5±5.4 mmHg were randomized. PCO2 levels decreased by 4.7% (n=94; full analysis set; 95% CI 1.8-7.5, P=0.002) using NHF and 7.1% (95% CI 4.1-10.1, P<0.001) from baseline using NIV (indistinguishable to intention-to-treat analysis). The difference of pCO2 changes between the two devices was -1.4 mmHg (95% CI -3.1-0.4, P=0.12). Both devices had positive impact on blood gases and respiratory scores (St. George's Respiratory Questionnaire, Severe Respiratory Insufficiency Questionnaire). Conclusions: NHF may constitute an alternative to NIV in COPD patients with stable chronic hypercapnia, eg, those not tolerating or rejecting NIV with respect to pCO2 reduction and improvement in QoL.


Assuntos
Hipercapnia/terapia , Pulmão/fisiopatologia , Ventilação não Invasiva , Oxigenoterapia , Doença Pulmonar Obstrutiva Crônica/terapia , Administração Intranasal , Idoso , Estudos Cross-Over , Alemanha , Humanos , Hipercapnia/diagnóstico , Hipercapnia/fisiopatologia , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Qualidade de Vida , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento
5.
Trials ; 20(1): 450, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31331372

RESUMO

BACKGROUND: Noninvasive ventilation (NIV) is indicated to treat respiratory acidosis due to exacerbation of chronic obstructive pulmonary disease (COPD). Recent nonrandomized studies also demonstrated some physiological effects of high-flow nasal therapy (HFNT) in COPD patients. We designed a prospective, unblinded, multicenter, randomized controlled trial to assess the noninferiority of HFNT compared to NIV with respect to the reduction of arterial partial pressure of carbon dioxide (PaCO2) in patients with hypercapnic acute respiratory failure with mild-to-moderate respiratory acidosis. METHODS: We will enroll adult patients with acute hypercapnic respiratory failure, as defined by arterial pH between 7.25 and 7.35 and PaCO2 ≥ 55 mmHg. Patients will be randomly assigned 1:1 to receive NIV or HFNT. NIV will be applied through a mask with a dedicated ventilator in pressure support mode. Positive end-expiratory pressure will be set at 3-5 cmH2O with inspiratory support to obtain a tidal volume between 6 and 8 ml/kg of ideal body weight. HFNT will be initially set at a temperature of 37 °C and a flow of 60 L/min. At 2 and 6 h we will assess arterial blood gases, vital parameters, respiratory rate, treatment intolerance and failure, need for endotracheal intubation, time spent under mechanical ventilation (both invasive and NIV), intensive care unit and hospital length of stay, and hospital mortality. Based on an α error of 5% and a ß error of 80%, with a standard deviation for PaCO2 equal to 15 mmHg and a noninferiority limit of 10 mmHg, we computed a sample size of 56 patients. Considering potential drop-outs and nonparametric analysis, the final computed sample size was 80 patients (40 per group). DISCUSSION: HFNT is more comfortable than NIV in COPD patients recovering from an episode of exacerbation. If HFNT would not be inferior to NIV, HFNT could be considered as an alternative to NIV to treat COPD patients with mild-to-moderate respiratory acidosis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03370666 . Registered on December 12, 2017.


Assuntos
Hipercapnia/terapia , Pulmão/fisiopatologia , Ventilação não Invasiva , Oxigenoterapia/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Doença Aguda , Estudos de Equivalência como Asunto , Humanos , Hipercapnia/diagnóstico , Hipercapnia/fisiopatologia , Itália , Estudos Multicêntricos como Assunto , Ventilação não Invasiva/efeitos adversos , Oxigenoterapia/efeitos adversos , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
6.
Int J Chron Obstruct Pulmon Dis ; 14: 1229-1237, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31239658

RESUMO

Background: High-flow nasal cannula (HFNC) oxygen therapy in acute hypoxic respiratory failure is becoming increasingly popular. However, evidence to support the use of HFNC in acute respiratory failure (ARF) with hypercapnia is limited. Methods: Chronic obstructive pulmonary disease (COPD) patients with moderate hypercapnic ARF (arterial blood gas pH 7.25-7.35, PaCO2>50 mmHg) who received HFNC or non-invasive ventilation (NIV) in the intensive care uint from April 2016 to March 2018 were analyzed retrospectively. The endpoint was treatment failure, defined as either invasive ventilation, or a switch to the other study treatment (NIV for patients in the NFNC group, and vice-versa), and 28-day mortality. Results: Eighty-two COPD patients (39 in the HFNC group and 43 in the NIV group) were enrolled in this study. The mean age was 71.8±8.2 and 54 patients (65.9%) were male. The treatment failed in 11 out of 39 patients with HFNC (28.2%) and in 17 of 43 patients with NIV (39.5%) (P=0.268). No significant differences were found for 28-day mortality (15.4% in the HFNC group and 14% in the NIV group, P=0.824). During the first 24 hrs of treatment, the number of nursing airway care interventions in the HFNC group was significantly less than in the NIV group, while the duration of device application was significantly longer in the HFNC group (all P<0.05). Skin breakdown was significantly more common in the NIV group (20.9% vs 5.1%, P<0.05). Conclusion: Among COPD patients with moderate hypercarbic ARF, the use of HFNC compared with NIV did not result in increased rates of treatment failure, while there were fewer nursing interventions and skin breakdown episodes reported in the HFNC group.


Assuntos
Cânula , Hipercapnia/terapia , Pulmão/fisiopatologia , Ventilação não Invasiva , Oxigenoterapia/instrumentação , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Administração Intranasal , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipercapnia/diagnóstico , Hipercapnia/mortalidade , Hipercapnia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/efeitos adversos , Ventilação não Invasiva/mortalidade , Oxigenoterapia/efeitos adversos , Oxigenoterapia/mortalidade , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Falha de Tratamento
7.
G Ital Nefrol ; 36(3)2019 Jun 11.
Artigo em Italiano | MEDLINE | ID: mdl-31250997

RESUMO

In bicarbonate-dialysis the dialysate is acid, thus allowing salts to remain in their soluble form, as a result of the chemical reaction of bicarbonate with any acid that yields carbon dioxide (CO2). The residual anion, commonly acetate or more rarely citrate, reaches the patients' bloodstream. CO2 also spreads to the patients and ventilation needs therefore to be increased to avoid hypercapnia. In addition, during on-line haemodiafiltration in post-dilution mode, the dialysate - in the form of infusate - carries CO2 (and acetate) to the patient, bypassing the filtering membrane. On the contrary, in Acetate-Free Biofiltration (AFB) the dialysate is free of acid and, uniquely, is also a CO2-free bath. Despite the infusion of bicarbonate in post-dilution mode, the blood coming back from the extracorporeal circuit does not carry any burden of CO2. As a result, AFB is the recommended renal replacement therapy for patients affected by lung disease and those with CO2 retention (respiratory acidosis). Patients with some degree of ventilatory dysfunction may in fact experience acute hypercapnia (acidosis by dialysate) at the beginning of the treatment if bicarbonate-dialysis or on-line HDF is performed (and regardless of whether acetate-containing or citrate-containing bath is employed). Acidosis by dialysate is characterized by respiratory symptoms first and by haemodynamic instability later, which make it look very similar to acetate intolerance. To discriminate between these two conditions, blood gas analysis is mandatory. The presence of hypercapnia can be revealed by using the Very Simple Formula (expected pCO2 = bicarbonate + 15), thus identifying those patients that may take the most advantage of AFB.


Assuntos
Hemodiafiltração , Hipercapnia/terapia , Dióxido de Carbono , Humanos , Diálise Renal
8.
Rev. bras. ter. intensiva ; 31(2): 156-163, abr.-jun. 2019. tab, graf
Artigo em Português | LILACS | ID: biblio-1013763

RESUMO

RESUMO Objetivo: Avaliar a eficácia e a segurança da oxigenoterapia com uso de cânula nasal de alto fluxo no tratamento da insuficiência respiratória hipercápnica moderada em pacientes que não conseguem tolerar ou têm contraindicações para ventilação mecânica não invasiva. Métodos: Estudo prospectivo observacional de 13 meses envolvendo participantes admitidos a uma unidade de terapia intensiva com insuficiência respiratória hipercápnica ou durante o processo de seu desenvolvimento. Os parâmetros clínicos e de troca gasosa foram registrados em intervalos regulares durante as primeiras 24 horas. Os parâmetros finais foram saturação de oxigênio entre 88 e 92%, juntamente da redução do esforço respiratório (frequência respiratória) e da normalização do pH (≥ 7,35). Os participantes foram considerados não responsivos em caso de necessidade de utilização de suporte ventilatório. Resultados: Trinta participantes foram tratados utilizando oxigenoterapia com cânula nasal de alto fluxo. Esta foi uma população mista com exacerbação de doença pulmonar obstrutiva crônica, edema pulmonar cardiogênico agudo, e insuficiência respiratória aguda pós-operatória e pós-extubação. Observou-se melhora não significante na frequência respiratória (28,0 ± 0,9 versus 24,3 ± 1,5; p = 0,22), que foi aparente nas primeiras 4 horas do tratamento. Ocorreu melhora do pH, embora só se tenham obtido níveis normais após 24 horas de tratamento com cânula nasal de alto fluxo (7,28 ± 0,02 versus 7,37 ± 0,01; p = 0,02). A proporção de não responsivos foi de 13,3% (quatro participantes), dos quais um necessitou e aceitou ventilação mecânica não invasiva, e três necessitaram de intubação. A mortalidade na unidade de terapia intensiva foi de 3,3% (um participante), e um paciente morreu após a alta para a enfermaria (mortalidade hospitalar de 6,6%). Conclusão: O oxigenoterapia com cânula nasal de alto fluxo é eficaz para a insuficiência respiratória hipercápnica moderada e ajuda a normalizar os parâmetros clínicos e de troca gasosa, com taxa aceitável de não responsivos que necessitaram de suporte ventilatório.


ABSTRACT Objective: To assess the efficacy and safety of high-flow nasal cannula oxygen therapy in treating moderate hypercapnic respiratory failure in patients who cannot tolerate or have contraindications to noninvasive mechanical ventilation. Methods: A prospective observational 13-month study involving subjects admitted to an intensive care unit with or developing moderate hypercapnic respiratory failure. Clinical and gas exchange parameters were recorded at regular intervals during the first 24 hours. The endpoints were a oxygen saturation between 88 and 92% along with a reduction in breathing effort (respiratory rate) and pH normalization (≥ 7.35). Subjects were considered nonresponders if they required ventilatory support. Results: Thirty subjects were treated with high-flow nasal cannula oxygen therapy. They consisted of a mixed population with chronic obstructive pulmonary disease exacerbation, acute cardiogenic pulmonary edema, and postoperative and postextubation respiratory failure. A nonsignificant improvement was observed in respiratory rate (28.0 ± 0.9 versus 24.3 ± 1.5, p = 0.22), which was apparent in the first four hours of treatment. The pH improved, although normal levels were only reached after 24 hours on high-flow nasal cannula therapy (7.28 ± 0.02 versus 7.37 ± 0.01, p = 0.02). The rate of nonresponders was 13.3% (4 subjects), of whom one needed and accepted noninvasive mechanical ventilation and three required intubation. Intensive care unit mortality was 3.3% (1 subject), and a patient died after discharge to the ward (hospital mortality of 6.6%). Conclusion: High-flow nasal cannula oxygen therapy is effective for moderate hypercapnic respiratory failure as it helps normalize clinical and gas exchange levels with an acceptable rate of nonresponders who require ventilatory support.


Assuntos
Humanos , Masculino , Feminino , Idoso , Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , Hipercapnia/terapia , Unidades de Terapia Intensiva , Oxigênio/administração & dosagem , Oxigênio/metabolismo , Oxigenoterapia/efeitos adversos , Troca Gasosa Pulmonar , Estudos Prospectivos , Resultado do Tratamento , Cânula , Pessoa de Meia-Idade
9.
Rev Bras Ter Intensiva ; 31(2): 156-163, 2019 May 23.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31141082

RESUMO

OBJECTIVE: To assess the efficacy and safety of high-flow nasal cannula oxygen therapy in treating moderate hypercapnic respiratory failure in patients who cannot tolerate or have contraindications to noninvasive mechanical ventilation. METHODS: A prospective observational 13-month study involving subjects admitted to an intensive care unit with or developing moderate hypercapnic respiratory failure. Clinical and gas exchange parameters were recorded at regular intervals during the first 24 hours. The endpoints were a oxygen saturation between 88 and 92% along with a reduction in breathing effort (respiratory rate) and pH normalization (≥ 7.35). Subjects were considered nonresponders if they required ventilatory support. RESULTS: Thirty subjects were treated with high-flow nasal cannula oxygen therapy. They consisted of a mixed population with chronic obstructive pulmonary disease exacerbation, acute cardiogenic pulmonary edema, and postoperative and postextubation respiratory failure. A nonsignificant improvement was observed in respiratory rate (28.0 ± 0.9 versus 24.3 ± 1.5, p = 0.22), which was apparent in the first four hours of treatment. The pH improved, although normal levels were only reached after 24 hours on high-flow nasal cannula therapy (7.28 ± 0.02 versus 7.37 ± 0.01, p = 0.02). The rate of nonresponders was 13.3% (4 subjects), of whom one needed and accepted noninvasive mechanical ventilation and three required intubation. Intensive care unit mortality was 3.3% (1 subject), and a patient died after discharge to the ward (hospital mortality of 6.6%). CONCLUSION: High-flow nasal cannula oxygen therapy is effective for moderate hypercapnic respiratory failure as it helps normalize clinical and gas exchange levels with an acceptable rate of nonresponders who require ventilatory support.


Assuntos
Hipercapnia/terapia , Unidades de Terapia Intensiva , Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , Idoso , Cânula , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/administração & dosagem , Oxigênio/metabolismo , Oxigenoterapia/efeitos adversos , Estudos Prospectivos , Troca Gasosa Pulmonar , Resultado do Tratamento
10.
Eur Respir Rev ; 28(151)2019 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-30872398

RESUMO

Obesity hypoventilation syndrome (OHS) is defined as a combination of obesity (body mass index ≥30 kg·m-2), daytime hypercapnia (arterial carbon dioxide tension ≥45 mmHg) and sleep disordered breathing, after ruling out other disorders that may cause alveolar hypoventilation. OHS prevalence has been estimated to be ∼0.4% of the adult population. OHS is typically diagnosed during an episode of acute-on-chronic hypercapnic respiratory failure or when symptoms lead to pulmonary or sleep consultation in stable conditions. The diagnosis is firmly established after arterial blood gases and a sleep study. The presence of daytime hypercapnia is explained by several co-existing mechanisms such as obesity-related changes in the respiratory system, alterations in respiratory drive and breathing abnormalities during sleep. The most frequent comorbidities are metabolic and cardiovascular, mainly heart failure, coronary disease and pulmonary hypertension. Both continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) improve clinical symptoms, quality of life, gas exchange, and sleep disordered breathing. CPAP is considered the first-line treatment modality for OHS phenotype with concomitant severe obstructive sleep apnoea, whereas NIV is preferred in the minority of OHS patients with hypoventilation during sleep with no or milder forms of obstructive sleep apnoea (approximately <30% of OHS patients). Acute-on-chronic hypercapnic respiratory failure is habitually treated with NIV. Appropriate management of comorbidities including medications and rehabilitation programmes are key issues for improving prognosis.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas , Pulmão/fisiopatologia , Ventilação não Invasiva , Síndrome de Hipoventilação por Obesidade/terapia , Obesidade/fisiopatologia , Ventilação Pulmonar , Adulto , Índice de Massa Corporal , Feminino , Humanos , Hipercapnia/epidemiologia , Hipercapnia/fisiopatologia , Hipercapnia/terapia , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/epidemiologia , Síndrome de Hipoventilação por Obesidade/diagnóstico , Síndrome de Hipoventilação por Obesidade/epidemiologia , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Qualidade de Vida , Recuperação de Função Fisiológica , Fatores de Risco , Resultado do Tratamento
11.
Artif Organs ; 43(8): 719-727, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30706485

RESUMO

Low flow extracorporeal veno-venous CO2 removal (ECCO2 R) therapy is used to remove CO2 while reducing ventilation intensity. However, the use of this technique is limited because efficiency of CO2 removal and potential beneficial effects on pulmonary hemodynamics are not precisely established. Moreover, this technique requires anticoagulation that may induce severe complications in critically ill patients. Therefore, our study aimed at determining precise efficiency of CO2 extraction and its effects on right ventricular (RV) afterload, and comparing regional anticoagulation with citrate to systemic heparin anticoagulation during ECCO2 R. This study was performed in an experimental model of severe hypercapnic acidosis performed in two groups of three pigs. In the first group (heparin group), pigs were anticoagulated with a standard protocol of unfractionated heparin while citrate was used for ECCO2 R device anticoagulation in the second group (citrate group). After sedation, analgesia and endotracheal intubation, pigs were connected to a volume-cycled ventilator. Severe hypercapnic acidosis was obtained by reducing tidal volume by 60%. ECCO2 R was started in both groups when arterial pH was lower than 7.2. Pump Assisted Lung Protection (PALP, Maquet, Rastatt, Germany) system was used to remove CO2 . CO2 extraction, arterial pH, PaCO2 as well as systemic and pulmonary hemodynamic were continuously followed. Mean arterial pH was normalized to 7.37 ± 1.4 at an extracorporeal blood flow of 400 mL/min, coming from 7.11 ± 1.3. RV end-systolic pressure increased by over 30% during acute hypercapnic acidosis and was normalized in parallel with CO2 removal. CO2 extraction was not significantly increased in citrate group as compared to heparin group. Mean ionized calcium and MAP were significantly lower in the citrate group than in the heparin group during ECCO2 R (1.03 ± 0.20 vs. 1.33 ± 0.19 and 57 ± 14 vs. 68 ± 15 mm Hg, respectively). ECCO2 R was highly efficient to normalize pH and PaCO2 and to reduce RV afterload resulting from hypercapnic acidosis. Regional anticoagulation with citrate solution was as effective as standard heparin anticoagulation but did not improve CO2 removal and lead to more hypocalcemia and hypotension.


Assuntos
Acidose/terapia , Anticoagulantes/uso terapêutico , Dióxido de Carbono/isolamento & purificação , Citratos/uso terapêutico , Oxigenação por Membrana Extracorpórea/métodos , Hipercapnia/terapia , Acidose/etiologia , Animais , Feminino , Heparina/uso terapêutico , Hipercapnia/complicações , Masculino , Respiração Artificial/métodos , Suínos
12.
Clin Respir J ; 13(3): 184-188, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30661288

RESUMO

INTRODUCTION: Non-invasive ventilation (NIV) is recommended for treatment of acute hypercapnic respiratory failure (AHRF) in acute exacerbations of COPD. National UK audit data suggests that mortality rates are rising in COPD patients treated with NIV. OBJECTIVE: To investigate temporal trends in in-hospital mortality in COPD patients undergoing a first episode of ward-based NIV for AHRF. METHODS: Retrospective study of hospitalised COPD patients treated with a first episode of ward-based NIV at a large UK teaching hospital between 2004 and 2017. Patients were split into two cohorts based on year of admission, 2004-2010 (Cohort 1) and 2013-2017 (Cohort 2), to facilitate comparison of patient characteristics. RESULTS: In total, 547 unique patients were studied. There was no difference in in-hospital mortality rate between the time periods studied (17.6% vs 20.5%, P = .378). In Cohort 2 there were more females, a higher rate of co-morbid bronchiectasis and pneumonia on admission and more severe acidosis, hypercapnia and hypoxia. More patients in Cohort 2 had NIV as the ceiling of treatment. Patients in Cohort 2 experienced a longer time from AHRF diagnosis to application of NIV, higher maximum inspiratory positive airway pressure, lower maximum oxygen and shorter duration of NIV. Finally, patients in Cohort 2 experienced a shorter hospital length of stay (LOS), with no differences observed in rate of transfer to critical care or intubation. CONCLUSION: In-hospital mortality remained stable and LOS decreased over time, despite greater comorbidity and more severe AHRF in COPD patients treated for the first time with ward-based NIV.


Assuntos
Mortalidade Hospitalar/tendências , Hipercapnia/terapia , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Idoso , Estudos de Coortes , Feminino , Humanos , Hipercapnia/complicações , Hipercapnia/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/métodos , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/mortalidade , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Análise de Sobrevida
13.
Intern Med J ; 49(7): 834-837, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30515940

RESUMO

BACKGROUND: Many patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have type 2 respiratory failure (T2RF). Often arterial blood gases are not performed and correlation with venous blood gases (VBG) is controversial. The venous pH and bicarbonate (HCO3 ) are useful, but VBG pCO2 (PvCO2 ) is considered too unpredictable. AIM: To examine the utility of VBG in this cohort of patients. METHODS: A prospective study of AECOPD patients with T2RF presenting to the emergency department was performed. Patients being considered for non-invasive ventilation and who required an arterial blood gas were invited to participate. A subsequent VBG was also taken, and Bland-Altman plots were used for analysis. RESULTS: Sixty-three patients were included in this study. The limits of agreement for pH and HCO3 were narrow. Wider limits of agreement with a systematic bias of 7.7 mmHg were noted with pCO2 . CONCLUSIONS: The utility of VBG pH and HCO3 was again demonstrated. VBG pCO2 in this cohort of patients may have a role in the assessment of patients with AECOPD. Further study is needed on the possible role of VBG in the management of such patients with T2RF particularly those using non-invasive ventilation.


Assuntos
Serviço Hospitalar de Emergência , Hipercapnia/sangue , Doença Pulmonar Obstrutiva Crônica/sangue , Insuficiência Respiratória/sangue , Idoso , Idoso de 80 Anos ou mais , Gasometria/métodos , Estudos de Coortes , Feminino , Humanos , Hipercapnia/epidemiologia , Hipercapnia/terapia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/terapia
14.
Artif Organs ; 43(6): 599-604, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30431163

RESUMO

Extracorporeal removal of carbon dioxide in patients experiencing severe hypercapnia due to lung protective mechanical ventilation was first described over four decades ago. There have been many devices developed and described in the interim, many of which require additional training, resources, and staff. This manuscript describes a readily available and relatively simple adjunct that can provide partial lung support in patients with acute respiratory distress syndrome complicated by severe hypercapnia and acute kidney injury requiring dialysis.


Assuntos
Lesão Renal Aguda/terapia , Dióxido de Carbono/isolamento & purificação , Hipercapnia/terapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Lesão Renal Aguda/complicações , Adulto , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Hipercapnia/complicações , Masculino , Pessoa de Meia-Idade , Diálise Renal/métodos , Síndrome do Desconforto Respiratório do Adulto/complicações , Ventiladores Mecânicos/efeitos adversos
15.
Thorax ; 74(3): 298-301, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30166425

RESUMO

Automatically titrated O2 flows (FreeO2) was compared with constant O2 flow on exercise capacity, O2 saturation and risk of hyperoxia-related hypercapnia in patients with severe COPD with baseline hypercapnia and long-term oxygen therapy (LTOT). Twelve patients were enrolled in a randomised double-blind cross-over study to perform exercise with either FreeO2 or constant flow. Endurance time (primary outcome) and SpO2 were both significantly improved with FreeO2compared with constant flow (p<0.04), although pCO2 was similar in both conditions. Automated titration of O2 significantly and clinically improved endurance walking time in patients with severe COPD receiving LTOT, without worsening of pCO2 TRIAL REGISTRATION NUMBER: Results , NCT01575327.


Assuntos
Tolerância ao Exercício/fisiologia , Hipercapnia/fisiopatologia , Hipercapnia/terapia , Oxigenoterapia/métodos , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/terapia , Idoso , Estudos Cross-Over , Método Duplo-Cego , Feminino , Humanos , Hipercapnia/etiologia , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/complicações , Resultado do Tratamento
16.
Acta Neurol Scand ; 139(2): 128-134, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30394534

RESUMO

OBJECTIVES: During the course of amyotrophic lateral sclerosis (ALS), progressive weakness of respiratory muscles leads to chronic hypercapnia which causes various symptoms like sleep disturbances, daytime fatigue, and depression. Non-invasive ventilation (NIV) improves survival and quality of life, but little is known about its effect on these specific symptoms, in particular during the later course of disease. Our aim was to evaluate the short- and long-term effects of NIV on hypercapnia-associated symptoms in ALS. MATERIAL AND METHODS: We prospectively analyzed sleep disturbance, daytime fatigue, and depression using standardized scales (Pittsburgh sleep quality index [PSQI], stanford sleepiness scale [SSS], Beck depression inventory [BDI], and Clinical hypoventilation score [CHS]) in 58 patients with NIV. Follow-up was done every 3 months up to a maximum of 24 months. RESULTS: We found significant improvements of all outcome parameters except BDI within the first three months after NIV initiation. The median PSQI improved from 6.5 (95% CI: 5.0-8.5) to 6.0 (95% CI: 4.5-7.0; P = 0.042), the SSS from 3.0 (95% CI: 2.0-4.0) to 2.0 (95% CI: 2.0-3.0; P = 0.004), and the CHS from 22.0 (95% CI: 19.5-25.0) to 18.0 points (95% CI: 12.0-23.5; P = 0.013). Patients with bulbar and spinal onset were not significantly different, and positive effects were long-lasting. CONCLUSIONS: Our data show that NIV improves hypercapnia-associated symptoms within the first 3 months after initiation in spinal as well as bulbar patients, and that beneficial effects are long-lasting.


Assuntos
Esclerose Amiotrófica Lateral/complicações , Hipercapnia/terapia , Ventilação não Invasiva , Insuficiência Respiratória/terapia , Adulto , Idoso , Feminino , Humanos , Hipercapnia/etiologia , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Insuficiência Respiratória/etiologia , Sono
18.
Intensive Care Med ; 44(12): 2112-2121, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30430209

RESUMO

PURPOSE: We assessed the effects of targeting low-normal or high-normal arterial carbon dioxide tension (PaCO2) and normoxia or moderate hyperoxia after out-of-hospital cardiac arrest (OHCA) on markers of cerebral and cardiac injury. METHODS: Using a 23 factorial design, we randomly assigned 123 patients resuscitated from OHCA to low-normal (4.5-4.7 kPa) or high-normal (5.8-6.0 kPa) PaCO2 and to normoxia (arterial oxygen tension [PaO2] 10-15 kPa) or moderate hyperoxia (PaO2 20-25 kPa) and to low-normal or high-normal mean arterial pressure during the first 36 h in the intensive care unit. Here we report the results of the low-normal vs. high-normal PaCO2 and normoxia vs. moderate hyperoxia comparisons. The primary endpoint was the serum concentration of neuron-specific enolase (NSE) 48 h after cardiac arrest. Secondary endpoints included S100B protein and cardiac troponin concentrations, continuous electroencephalography (EEG) and near-infrared spectroscopy (NIRS) results and neurologic outcome at 6 months. RESULTS: In total 120 patients were included in the analyses. There was a clear separation in PaCO2 (p < 0.001) and PaO2 (p < 0.001) between the groups. The median (interquartile range) NSE concentration at 48 h was 18.8 µg/l (13.9-28.3 µg/l) in the low-normal PaCO2 group and 22.5 µg/l (14.2-34.9 µg/l) in the high-normal PaCO2 group, p = 0.400; and 22.3 µg/l (14.8-27.8 µg/l) in the normoxia group and 20.6 µg/l (14.2-34.9 µg/l) in the moderate hyperoxia group, p = 0.594). High-normal PaCO2 and moderate hyperoxia increased NIRS values. There were no differences in other secondary outcomes. CONCLUSIONS: Both high-normal PaCO2 and moderate hyperoxia increased NIRS values, but the NSE concentration was unaffected. REGISTRATION: ClinicalTrials.gov, NCT02698917. Registered on January 26, 2016.


Assuntos
Cuidados Críticos/métodos , Hipercapnia/terapia , Hiperóxia/terapia , Hipocapnia/terapia , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Idoso , Pressão Arterial , Gasometria , Dióxido de Carbono/sangue , Reanimação Cardiopulmonar , Feminino , Humanos , Hipercapnia/diagnóstico , Hipercapnia/etiologia , Hiperóxia/diagnóstico , Hiperóxia/etiologia , Hipocapnia/diagnóstico , Hipocapnia/etiologia , Hipóxia-Isquemia Encefálica/epidemiologia , Hipóxia-Isquemia Encefálica/prevenção & controle , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/sangue , Oxigênio/sangue , Fosfopiruvato Hidratase/sangue , Projetos Piloto
19.
Lancet Respir Med ; 6(11): 874-884, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30484429

RESUMO

As a result of technical improvements, extracorporeal carbon dioxide removal (ECCO2R) now has the potential to play an important role in the management of adults with acute respiratory failure. There is growing interest in the use of ECCO2R for the management of both hypoxaemic and hypercapnic respiratory failure. However, evidence to support its use is scarce and several questions remain about the best way to implement this therapy, which can be associated with serious side-effects. This Review reflects the consensus opinion of an international group of clinician scientists with expertise in managing acute respiratory failure and in using ECCO2R therapies in this setting. We concisely review clinically relevant aspects of ECCO2R, and provide a series of recommendations for clinical practice and future research, covering topics that include the practicalities of ECCO2R delivery, indications for use, and service delivery.


Assuntos
Dióxido de Carbono/sangue , Oxigenação por Membrana Extracorpórea/métodos , Insuficiência Respiratória/terapia , Adulto , Cateterismo Venoso Central/efeitos adversos , Consenso , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/instrumentação , Humanos , Hipercapnia/terapia , Hipóxia/terapia
20.
Int J Chron Obstruct Pulmon Dis ; 13: 3625-3634, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30464445

RESUMO

Purpose: It has recently been shown that chronic noninvasive ventilation (NIV) improves a number of outcomes including survival, in patients with stable hypercapnic COPD. However, the mechanisms responsible for these improved outcomes are still unknown. The aim of the present study was to identify parameters associated with: 1) an improved arterial partial pressure of carbon dioxide (PaCO2) and 2) survival, in a cohort of hypercapnic COPD patients treated with chronic NIV. Patients and methods: Data from 240 COPD patients treated with chronic NIV were analyzed. Predictors for the change in PaCO2 and survival were investigated using multivariate linear and Cox regression models, respectively. Results: A higher level of bicarbonate before NIV initiation, the use of higher inspiratory ventilator pressures, the presence of anxiety symptoms, and NIV initiated following an exacerbation compared to NIV initiated in stable disease were associated with a larger reduction in PaCO2. A higher body mass index, a higher FEV1, a lower bicarbonate before NIV initiation, and younger age and NIV initiation in stable condition were independently associated with better survival. The change in PaCO2 was not associated with survival, neither in a subgroup of patients with a PaCO2 >7.0 kPa before the initiation of NIV. Conclusion: Patients with anxiety symptoms and a high bicarbonate level at NIV initiation are potentially good responders in terms of an improvement in hypercapnia. Also, higher inspiratory ventilator pressures are associated with a larger reduction in PaCO2. However, the improvement in hypercapnia does not seem to be associated with an improved survival and emphasizes the need to look beyond PaCO2 when considering NIV initiation.


Assuntos
Hipercapnia/terapia , Pulmão/fisiopatologia , Ventilação não Invasiva/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Idoso , Ansiedade/fisiopatologia , Bicarbonatos/sangue , Biomarcadores/sangue , Feminino , Humanos , Hipercapnia/diagnóstico , Hipercapnia/mortalidade , Hipercapnia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/efeitos adversos , Ventilação não Invasiva/mortalidade , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Recuperação de Função Fisiológica , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
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