Analysis of patients with reversible respiratory acidosis after noninvasive mechanical ventilation response in acute hypercapnic respiratory failure

Abstract

Aim: In this study, we aimed to analyze patients with a diagnosis of acute hypercapnic respiratory failure (AHRF) who responded to noninvasive mechanical ventilation (NIMV) in the intensive care unit (ICU) in the first hours but developed severe respiratory acidosis again soon after switching to nasal oxygen. Material and Method: Between January 2009 and April 2010, data of 139 patients who were followed up in the ICU due to AHRF (pH <7.35 and PaCO2> 45 mmHg) and responded NIMV treatment in the first 1-4 hours, were analyzed retrospectively. Patients were divided into two groups as those with rebound hypercapnia (group 1) and those without rebound hypercapnia (group 2) in their follow-up after the termination of NIMV treatment. Demographic characteristics of the patients, causes of AHRF, duration of NIMV administration, arterial blood gas (ABG) values, APACHE II and SOFA scores, duration of hospitalization (days), need for invasive mechanical ventilation (IMV) and life situations were recorded. Nonparametric Mann-Withney-U test was used for numerical data and Chi-square test for categorical data was used to compare the properties of the groups. Results: 139 patients were included in the study. There was no difference between the demographic characteristics of the groups and the duration of NIMV use, and the length of stay in the ICU and hospital. Thoracic deformity-muscular diseases (8.6% in group 1, 1.2% in group 2), and obesity hypoventilation syndrome (OHS) (17.2% in group 1, 9.9% in group 2) were more in group 1, parenchymal lung diseases was higher in group 2 (6.9% in group 1, 18.5% in group 2). The situation of using oxygen and NIMV devices at home was similar for both groups. While the pH and PaCO2 values of the groups were similar during ICU admission, there was a significant improvement in group 1 compared to group 2 at the first control (p<0.005, p<0.039 respectively), while a significant deterioration was observed in group 1 after switching to nasal oxygen (p<0.0001, p<0.0001 respectively). However, ABG values at ICU discharge were similar between the two groups. ICU stay days of both groups were found to be similar as 8 (5-12) days in group 1 and 6 (4-10) days in group 2. Necessity of IMV (10.3%; 7.4%, p>0.53 respectively) and mortality rates (6.9%; 9.9% p>0.38 respectively) in group 1 and 2 were found similar. Conclusion: In our study, we determined that patients with AHRF accompanied by thoracic deformity-muscle diseases and OHS had a rapid clinical response to NIMV administration, but ABG values rapidly deteriorated after switching to nasal oxygen. In this patient group, rapid improvement after NIMV application should not be misleading. Especially, patients who are planned to be hospitalized from the emergency department should be monitored and followed closely after switching to nasal oxygen therapy.

Keywords

• Respiratory acidosis
• noninvasive mechanical ventilation
• hypercapnia
• intensive care

Akut hiperkapnik solunum yetmezliğinde noninvaziv mekanik ventilasyon yanıtı sonrasında geri dönüşümlü respiratuvar asidozlu hastaların analizi

Abstract

Amaç: Bu çalışmada akut hiperkapnik solunum yetmezliği (AHSY) tanısı ile yoğun bakım ünites (YBÜ)’inde noninvaziv mekanik ventilasyon (NIMV) uygulamasına ilk saatlerde iyi yanıt alınan, ancak nazal oksijene geçildikten kısa süre sonra tekrar ciddi solunumsal asidoz gelişen hastaların analizini yapmayı planladık. Gereç ve Yöntem: Ocak 2009-Nisan 2010 tarihleri arasında, AHSY (pH<7,35 ve PaCO2 >45 mmHg) nedeniyle YBÜ’de takip edilen ve uygulanan ilk 1-4 saatlik NIMV tedavisine yanıt veren 139 hastanın verisi retrospektif olarak incelendi. Hastalar, NIMV tedavisi sonlandırıldıktan sonraki takiplerinde rebound hiperkapni gelişen (grup 1) ve gelişmeyen (grup 2) olmak üzere iki gruba ayrıldı. Hastaların demografik özellikleri, AHSY nedenleri, NIMV uygulama süreleri, arteriyel kan gazı (AKG) değerleri, APACHE-II ve SOFA skorları, hastanede yatış süresi (gün), invaziv mekanik ventilatör (İMV) ihtiyacı ve yaşam durumları kaydedildi. Grupların özelliklerini karşılaştırmada numerik veriler için nonparametrik Mann-Withney-U testi ve kategorik veriler için Ki-kare testi kullanıldı. Bulgular: Çalışmaya 139 hasta dâhil edildi. Grupların demografik özellikleri ve NIMV süreleri, YBÜ ve hastane kalış süreleri arasında fark bulunmadı. Grup 1’de toraks deformitesi-kas hastalıkları (grup 1’de %8,6; grup 2’de %1,2) ve obezite hipoventilasyon sendromu (OHS) (grup 1’de %17,2; grup 2’de %9,9) daha fazla iken; grup 2’de parankimal akciğer hastalıkları fazla (grup 1’de %6,9; grup 2’de %18,5) idi. Her iki grup için evde oksijen ve NIMV cihazı kullanıyor olma durumları benzerdi. Grupların pH ve PaCO2 değerleri YBÜ’ye kabul esnasında benzerken, ilk kontrolde grup 1’de grup 2’ye göre belirgin düzelme varken (sırasıyla p<0,005 ve p<0,039) nazal oksijene geçilmesiyle grup 1’de belirgin kötüleşme görüldü (sırasıyla p<0,0001 ve p<0,0001); ancak YBÜ çıkış AKG değerleri iki grup arasında benzerdi. Her iki grubun YBÜ kalış günleri grup 1’de 8 (5-12) gün; grup 2’de 6 (4-10) gün olarak benzer bulundu. Grup 1 ve 2’de YBÜ’de IMV’ye geçiş (sırasıyla %10,3; %7,4, p>0,53) ve mortalite oranları (sırasıyla %6,9; %9,9, p>0,38) benzer saptandı. Sonuç: Çalışmamızda toraks deformitesi-kas hastalıkları ve OHS’nin eşlik ettiği AHSY olan hastalarda NIMV uygulanmasına hızlı klinik yanıt alındığını ancak nazal oksijene geçildikten kısa süre sonra AKG değerlerinin kötüleştiğini saptadık. Bu hasta grubunda NIMV uygulaması sonrası hızlı düzelme yanıltıcı olmamalıdır. Özellikle acil servisten yatışı planlanan bu hastalar nazal oksijen tedavisine geçilse bile mutlaka monitörize edilerek yakın takibe alınmalıdır.

Keywords

• noninvaziv mekanik ventilasyon
• hiperkapni
• respiratuvar asidoz
• yoğun bakım

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