Acid-Base Disturbances in Cardiogenic Pulmonary Edema

O’Donovan, Richard A.; McGowan, John A.; Lupinacci, Lillian; Palomino, Celestino; Hoy, R. J.; Puschett, Jules B.

doi:10.1159/000186305

Cited by 9 publications

(5 citation statements)

References 6 publications

(14 reference statements)

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“…Pulmonary edema occurs in patients with congestive heart failure and acute respiratory distress syndrome and often requires mechanical ventilation [1], [2]. It has been proposed that to prevent ventilator induced lung injury, patients should be ventilated with low tidal volumes which may result in hypercapnia [3], [4].…”

Section: Introductionmentioning

confidence: 99%

High CO2 Levels Impair Alveolar Epithelial Function Independently of pH

et al. 2007

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BackgroundIn patients with acute respiratory failure, gas exchange is impaired due to the accumulation of fluid in the lung airspaces. This life-threatening syndrome is treated with mechanical ventilation, which is adjusted to maintain gas exchange, but can be associated with the accumulation of carbon dioxide in the lung. Carbon dioxide (CO2) is a by-product of cellular energy utilization and its elimination is affected via alveolar epithelial cells. Signaling pathways sensitive to changes in CO2 levels were described in plants and neuronal mammalian cells. However, it has not been fully elucidated whether non-neuronal cells sense and respond to CO2. The Na,K-ATPase consumes ∼40% of the cellular metabolism to maintain cell homeostasis. Our study examines the effects of increased pCO2 on the epithelial Na,K-ATPase a major contributor to alveolar fluid reabsorption which is a marker of alveolar epithelial function.Principal FindingsWe found that short-term increases in pCO2 impaired alveolar fluid reabsorption in rats. Also, we provide evidence that non-excitable, alveolar epithelial cells sense and respond to high levels of CO2, independently of extracellular and intracellular pH, by inhibiting Na,K-ATPase function, via activation of PKCζ which phosphorylates the Na,K-ATPase, causing it to endocytose from the plasma membrane into intracellular pools.ConclusionsOur data suggest that alveolar epithelial cells, through which CO2 is eliminated in mammals, are highly sensitive to hypercapnia. Elevated CO2 levels impair alveolar epithelial function, independently of pH, which is relevant in patients with lung diseases and altered alveolar gas exchange.

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Section: Introductionmentioning

confidence: 99%

High CO2 Levels Impair Alveolar Epithelial Function Independently of pH

et al. 2007

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“…Its provenance can be described as being a physiologic response to an earliest posed metabolic and hypoxic threat, beginning with hyperventilation, primary respiratory alkalosis, and an increase in blood oxygen stores. Isolated respiratory alkalosis (RA) has been shown to be the most common early clinical manifestation in patients with sepsis, [18-20], CHF [21], and pulmonary embolism [22]. It characteristically evolves into a persistent alkalosis despite subsequent progressive increases in anion gap and lactic acid levels, well before the development of dominate metabolic acidosis (MA).…”

Section: Resultsmentioning

confidence: 99%

Patterns of unexpected in-hospital deaths: a root cause analysis

Lynn¹,

2011

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BackgroundRespiratory alarm monitoring and rapid response team alerts on hospital general floors are based on detection of simple numeric threshold breaches. Although some uncontrolled observation trials in select patient populations have been encouraging, randomized controlled trials suggest that this simplistic approach may not reduce the unexpected death rate in this complex environment. The purpose of this review is to examine the history and scientific basis for threshold alarms and to compare thresholds with the actual pathophysiologic patterns of evolving death which must be timely detected.MethodsThe Pubmed database was searched for articles relating to methods for triggering rapid response teams and respiratory alarms and these were contrasted with the fundamental timed pathophysiologic patterns of death which evolve due to sepsis, congestive heart failure, pulmonary embolism, hypoventilation, narcotic overdose, and sleep apnea.ResultsIn contrast to the simplicity of the numeric threshold breach method of generating alerts, the actual patterns of evolving death are complex and do not share common features until near death. On hospital general floors, unexpected clinical instability leading to death often progresses along three distinct patterns which can be designated as Types I, II and III. Type I is a pattern comprised of hyperventilation compensated respiratory failure typical of congestive heart failure and sepsis. Here, early hyperventilation and respiratory alkalosis can conceal the onset of instability. Type II is the pattern of classic CO2 narcosis. Type III occurs only during sleep and is a pattern of ventilation and SPO2 cycling caused by instability of ventilation and/or upper airway control followed by precipitous and fatal oxygen desaturation if arousal failure is induced by narcotics and/or sedation.ConclusionThe traditional threshold breach method of detecting instability on hospital wards was not scientifically derived; explaining the failure of threshold based monitoring and rapid response team activation in randomized trials. Furthermore, the thresholds themselves are arbitrary and capricious. There are three common fundamental pathophysiologic patterns of unexpected hospital death. These patterns are too complex for early detection by any unifying numeric threshold. New methods and technologies which detect and identify the actual patterns of evolving death should be investigated.

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“…In heart failure, various ABDs can develop due to the renal loss of hydrogen ions, the reduction in the effective circulating volume, hypoxemia and renal failure. This issue explains the occurrence of metabolic alkalosis, metabolic acidosis, respiratory alkalosis, and respiratory acidosis alone or in combination (31)(32)(33). Both the underlying disease and the therapeutic interventions used to treat them can contribute to the development of ABDs in patients with malignancies.…”

Section: Discussionmentioning

confidence: 99%

Acid-Base Disorders in the Emergency Department: Incidence, Etiologies and Outcomes

Köse¹,

Armağan²,

Öner³

et al. 2014

JAEM

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Objective: Acid-base disorders (ABDs) are usually correlated with high rates of morbidity and mortality. The objective of this study was to analyze the causes, outcomes, types and incidences of ABDs in patients presenting at the emergency department (ED). Material and Methods:We prospectively analyzed data from patients who presented between January 2011 and May 2011. Data on age, gender, chief complaint, and diagnosis in the ED were collected for ABD cases.Results: Of the 736 cases with an ABD, 173 patients (23.5%) had simple ABD and 563 patients (76.5%) had mixed ABD. The most common ABD was a mixed metabolic acidosis and respiratory alkalosis (MACRAL) (n=408, 55.4%). All ABD types were most commonly observed in patients over 65 years of age. Dyspnea was the most common complaint among ABD patients who presented at the ED (44.4%). In cases of ABD, pneumonia was the most common diagnosis (16.3%). Of the ABD cases, 379 patients (51.6%) were discharged, while 318 patients (43.2%) were hospitalized. Death was more commonly observed in cases with mixed metabolic and respiratory acidosis (MRAC) (n=6) and MACRAL (n=11). Conclusion:ABDs are quite common in patients presenting at the ED, especially among patients in a critical condition (71%). Mixed MACRAL was the most commonly noted ABD. Dyspnea and pneumonia were the most common diagnoses in ABD patients. Mortality was more common in cases with a mixed MRAC and MACRAL. This knowledge may provide important information concerning the diagnosis, treatment and early prognosis of patients. (JAEM 2014; 13: 4-9)

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Acid-Base Disturbances in Cardiogenic Pulmonary Edema

Cited by 9 publications

References 6 publications

High CO2 Levels Impair Alveolar Epithelial Function Independently of pH

High CO2 Levels Impair Alveolar Epithelial Function Independently of pH

Patterns of unexpected in-hospital deaths: a root cause analysis

Acid-Base Disorders in the Emergency Department: Incidence, Etiologies and Outcomes

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