Am. J. Respir. Crit. Care Med., Volume 156, Number 5, November 1997, 1458-1466

Temporal Hemodynamic Effects of Permissive Hypercapnia Associated with Ideal PEEP in ARDS

CARLOS ROBERTO RIBEIRO CARVALHO, CARMEN SILVIA VALENTE BARBAS, DENISE MACHADO MEDEIROS, RICARDO BORGES MAGALDI, GERALDO LORENZI FILHO, RONALDO ADIB KAIRALLA, DANIEL DEHEINZELIN, CARLOS MUNHOZ, MAURO KAUFMANN, MARCO FERREIRA, TERESA YAE TAKAGAKI, and MARCELO BRITTO PASSOS AMATO

Respiratory Intensive Care Unit of the Pulmonary Division of the Hospital das Clínicas, University of São Paulo; and General ICU of the Santa Casa de Misencórdia, Porto Alegre, Brazil

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 LPAwith 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 (DO₂I, 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. Carvalho CRR, Barbas CSV, Medeiros DM, Magaldi RB, Filho GL, Kairalla RA, Deheinzelin D, Munhoz C, Kaufmann M, Ferreira M, Takagaki TY, Amato MBP. Temporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS.

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