Reduced ventilator pressure and improved P/F ratio during percutaneous arteriovenous carbon dioxide removal for severe respiratory failure

Scott K. Alpard, Joseph B. Zwischenberger, Weike Tao, Donald J. Deyo, Akhil Bidani

    Research output: Contribution to journalArticle

    37 Citations (Scopus)

    Abstract

    Objective: To evaluate the effect of percutaneous arteriovenous carbon dioxide removal (AVCO2R) on ventilator pressures and P/F ratio in a clinically relevant large-animal model of severe respiratory failure. Summary Background Data: AVCO2R was developed as a simple arteriovenous shunt with a commercially available low-resistance gas exchange device of sufficient surface area for near-total CO2 removal. With an AV shunt 10% to 15% of cardiac output, AVCO2R allows a reduction in ventilator airway pressures without hypercapnia or the complex circuitry and monitoring required for conventional ECMO. Methods: AVCO2R was applied to a new, clinically relevant large-animal model of severe respiratory failure created by smoke inhalation and cutaneous flame burn injury. Adult sheep (n = 9, 38 ± 6 kg) received a 40% total body surface area, third-degree cutaneous flame bum and 36 breaths of cotton smoke insufflation. After injury, all animals were placed on volume-controlled mechanical ventilation to achieve Pao2 > 60 mmHg and Paco2 < 40 mmHg. Animals were placed on AVCO2R within 40 to 48 hours of injury when the Pao2/Fio2 was < 200. Animals underwent cannulation of the carotid artery and jugular vein with percutaneous 10F arterial and 14F venous cannulas. Shunt flow was continuously monitored using an ultrasonic flow probe and calculated as a percentage of cardiac output. Results: AVCO2R flows of 800 to 900 ml/min (11% to 13% cardiac output) achieved 77 to 104 ml/min of CO2 removal (95% to 97% total CO2 production) while maintaining normocapnia. Significant reductions in ventilator settings were tidal volume, 421.3 ± 39.8 to 270.0 ± 6.3 ml; peak inspiratory pressure, 24.8 ± 2.4 to 13.7 ± 0.7 cm H2O; minute ventilation, 12.7 ± 1.4 to 6.2 ± 0.8 L/min; respiratory rate, 25.4 ± 1.3 to 18.4 ± 1.8 breaths/min; and Fio2, 0.88 ± 0.1 to 0.39 ± 0.1. The P/F ratio increased from 151.5 ± 40.0 at baseline to 320.0 ± 17.8 after 72 hours. Conclusions: Percutaneous AVCO2R allows near- total CO2 removal and significant reductions in ventilator pressures with improvement in the P/F ratio.

    Original languageEnglish
    Pages (from-to)215-224
    Number of pages10
    JournalAnnals of Surgery
    Volume230
    Issue number2
    DOIs
    StatePublished - Aug 1999

    Fingerprint

    Mechanical Ventilators
    Carbon Dioxide
    Respiratory Insufficiency
    Cardiac Output
    Pressure
    Smoke
    Wounds and Injuries
    Animal Models
    Insufflation
    Skin
    Hypercapnia
    Body Surface Area
    Tidal Volume
    Jugular Veins
    Respiratory Rate
    Carotid Arteries
    Artificial Respiration
    Ultrasonics
    Catheterization
    Inhalation

    ASJC Scopus subject areas

    • Surgery

    Cite this

    Reduced ventilator pressure and improved P/F ratio during percutaneous arteriovenous carbon dioxide removal for severe respiratory failure. / Alpard, Scott K.; Zwischenberger, Joseph B.; Tao, Weike; Deyo, Donald J.; Bidani, Akhil.

    In: Annals of Surgery, Vol. 230, No. 2, 08.1999, p. 215-224.

    Research output: Contribution to journalArticle

    Alpard, Scott K. ; Zwischenberger, Joseph B. ; Tao, Weike ; Deyo, Donald J. ; Bidani, Akhil. / Reduced ventilator pressure and improved P/F ratio during percutaneous arteriovenous carbon dioxide removal for severe respiratory failure. In: Annals of Surgery. 1999 ; Vol. 230, No. 2. pp. 215-224.
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    abstract = "Objective: To evaluate the effect of percutaneous arteriovenous carbon dioxide removal (AVCO2R) on ventilator pressures and P/F ratio in a clinically relevant large-animal model of severe respiratory failure. Summary Background Data: AVCO2R was developed as a simple arteriovenous shunt with a commercially available low-resistance gas exchange device of sufficient surface area for near-total CO2 removal. With an AV shunt 10{\%} to 15{\%} of cardiac output, AVCO2R allows a reduction in ventilator airway pressures without hypercapnia or the complex circuitry and monitoring required for conventional ECMO. Methods: AVCO2R was applied to a new, clinically relevant large-animal model of severe respiratory failure created by smoke inhalation and cutaneous flame burn injury. Adult sheep (n = 9, 38 ± 6 kg) received a 40{\%} total body surface area, third-degree cutaneous flame bum and 36 breaths of cotton smoke insufflation. After injury, all animals were placed on volume-controlled mechanical ventilation to achieve Pao2 > 60 mmHg and Paco2 < 40 mmHg. Animals were placed on AVCO2R within 40 to 48 hours of injury when the Pao2/Fio2 was < 200. Animals underwent cannulation of the carotid artery and jugular vein with percutaneous 10F arterial and 14F venous cannulas. Shunt flow was continuously monitored using an ultrasonic flow probe and calculated as a percentage of cardiac output. Results: AVCO2R flows of 800 to 900 ml/min (11{\%} to 13{\%} cardiac output) achieved 77 to 104 ml/min of CO2 removal (95{\%} to 97{\%} total CO2 production) while maintaining normocapnia. Significant reductions in ventilator settings were tidal volume, 421.3 ± 39.8 to 270.0 ± 6.3 ml; peak inspiratory pressure, 24.8 ± 2.4 to 13.7 ± 0.7 cm H2O; minute ventilation, 12.7 ± 1.4 to 6.2 ± 0.8 L/min; respiratory rate, 25.4 ± 1.3 to 18.4 ± 1.8 breaths/min; and Fio2, 0.88 ± 0.1 to 0.39 ± 0.1. The P/F ratio increased from 151.5 ± 40.0 at baseline to 320.0 ± 17.8 after 72 hours. Conclusions: Percutaneous AVCO2R allows near- total CO2 removal and significant reductions in ventilator pressures with improvement in the P/F ratio.",
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    AU - Deyo, Donald J.

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    N2 - Objective: To evaluate the effect of percutaneous arteriovenous carbon dioxide removal (AVCO2R) on ventilator pressures and P/F ratio in a clinically relevant large-animal model of severe respiratory failure. Summary Background Data: AVCO2R was developed as a simple arteriovenous shunt with a commercially available low-resistance gas exchange device of sufficient surface area for near-total CO2 removal. With an AV shunt 10% to 15% of cardiac output, AVCO2R allows a reduction in ventilator airway pressures without hypercapnia or the complex circuitry and monitoring required for conventional ECMO. Methods: AVCO2R was applied to a new, clinically relevant large-animal model of severe respiratory failure created by smoke inhalation and cutaneous flame burn injury. Adult sheep (n = 9, 38 ± 6 kg) received a 40% total body surface area, third-degree cutaneous flame bum and 36 breaths of cotton smoke insufflation. After injury, all animals were placed on volume-controlled mechanical ventilation to achieve Pao2 > 60 mmHg and Paco2 < 40 mmHg. Animals were placed on AVCO2R within 40 to 48 hours of injury when the Pao2/Fio2 was < 200. Animals underwent cannulation of the carotid artery and jugular vein with percutaneous 10F arterial and 14F venous cannulas. Shunt flow was continuously monitored using an ultrasonic flow probe and calculated as a percentage of cardiac output. Results: AVCO2R flows of 800 to 900 ml/min (11% to 13% cardiac output) achieved 77 to 104 ml/min of CO2 removal (95% to 97% total CO2 production) while maintaining normocapnia. Significant reductions in ventilator settings were tidal volume, 421.3 ± 39.8 to 270.0 ± 6.3 ml; peak inspiratory pressure, 24.8 ± 2.4 to 13.7 ± 0.7 cm H2O; minute ventilation, 12.7 ± 1.4 to 6.2 ± 0.8 L/min; respiratory rate, 25.4 ± 1.3 to 18.4 ± 1.8 breaths/min; and Fio2, 0.88 ± 0.1 to 0.39 ± 0.1. The P/F ratio increased from 151.5 ± 40.0 at baseline to 320.0 ± 17.8 after 72 hours. Conclusions: Percutaneous AVCO2R allows near- total CO2 removal and significant reductions in ventilator pressures with improvement in the P/F ratio.

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