Bench-to-bedside review: Hypercapnic acidosis in lung injury - from 'permissive' to 'therapeutic'

IJland, Marloes M.; Heunks, Leo; Hoeven, Johannes G. van der

doi:10.1186/cc9238

Cited by 54 publications

(43 citation statements)

References 98 publications

(153 reference statements)

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“…In 2 3 4 5 6 7 8 -1 0 1 2 3 4 5 6 7 8 time (hours post-LPS) concordance, in the present study, bicarbonate levels were significantly lower in the trained subjects during practicing of the breathing techniques compared with control subjects. The attenuated cytokine response is unlikely to be a direct result from low pCO 2 and high pH levels because hypocapnic alkalosis, as opposed to hypercapnic acidosis (25), is not associated with antiinflammatory effects. Therefore, epinephrine is the most probable intermediate factor (7).…”

Section: Discussionmentioning

confidence: 99%

Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans

Kox

Eijk

Zwaag

et al. 2014

Proc. Natl. Acad. Sci. U.S.A.

222

239

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Excessive or persistent proinflammatory cytokine production plays a central role in autoimmune diseases. Acute activation of the sympathetic nervous system attenuates the innate immune response. However, both the autonomic nervous system and innate immune system are regarded as systems that cannot be voluntarily influenced. Herein, we evaluated the effects of a training program on the autonomic nervous system and innate immune response. Healthy volunteers were randomized to either the intervention (n = 12) or control group (n = 12). Subjects in the intervention group were trained for 10 d in meditation (third eye meditation), breathing techniques (i.a., cyclic hyperventilation followed by breath retention), and exposure to cold (i.a., immersions in ice cold water). The control group was not trained. Subsequently, all subjects underwent experimental endotoxemia (i.v. administration of 2 ng/kg Escherichia coli endotoxin). In the intervention group, practicing the learned techniques resulted in intermittent respiratory alkalosis and hypoxia resulting in profoundly increased plasma epinephrine levels. In the intervention group, plasma levels of the anti-inflammatory cytokine IL-10 increased more rapidly after endotoxin administration, correlated strongly with preceding epinephrine levels, and were higher. Levels of proinflammatory mediators TNF-α, IL-6, and IL-8 were lower in the intervention group and correlated negatively with IL-10 levels. Finally, flu-like symptoms were lower in the intervention group. In conclusion, we demonstrate that voluntary activation of the sympathetic nervous system results in epinephrine release and subsequent suppression of the innate immune response in humans in vivo. These results could have important implications for the treatment of conditions associated with excessive or persistent inflammation, such as autoimmune diseases.

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Section: Discussionmentioning

confidence: 99%

Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans

Kox

Eijk

Zwaag

et al. 2014

Proc. Natl. Acad. Sci. U.S.A.

222

239

View full text Add to dashboard Cite

show abstract

“…Permissive hypercapnia and permissive hypoxemia should be employed when clinically indicated, to minimize exposure to toxic ventilatory support. 74,[82][83][84][85][86] The target P aO 2 , S pO 2 , and P aCO 2 are likely to differ between patients and within an individual patient over time, based on the degree of ventilatory support the patient requires (ie, risk of ventilatorinduced lung injury).…”

Section: Management Algorithmmentioning

confidence: 99%

Pediatric Acute Respiratory Distress Syndrome

Cheifetz

2011

Respir Care

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The data available to guide clinical management of acute lung injury and acute respiratory distress syndrome are much more limited for infants and children than for adult patients. This paper reviews the available medical data and the pertinent physiology on the management of pediatric patients with acute lung injury. With the collaboration of multicenter investigation networks, definitive pediatric data may be on the horizon to better guide our clinical practice.

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“…[51][52][53][54] Some have even suggested that hypercapneic acidosis could be therapeutic as opposed to permissive. 55 However, the degree of permissive hypercapnia that can be used safely during low V T ventilation is unclear, but it may be that a mild acidosis should be tolerated to enable the use of lower V T values. Patient-ventilator asynchrony is also a potential issue with the use of lower V T values, especially in volume assist control with a fixed flow.…”

mentioning

confidence: 99%

Should A Tidal Volume of 6 mL/kg Be Used in All Patients?

2016

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It has been shown that mechanical ventilation by itself can cause lung injury and affect outcomes. Ventilator-induced lung injury is associated with high tidal volumes in lungs afflicted with ARDS. However, the question is: Do high tidal volumes have this same effect in normal lungs or lungs that have respiratory compromise stemming from something other than ARDS? Many clinicians believe that a tidal volume strategy of 6 mL/kg predicted body weight should be standard practice in all patients receiving mechanical ventilation. There is a growing body of evidence related to this issue, and this is the debate that will be tackled in this paper from both pro and con perspectives. Key words: tidal volume; predicted body weight; mechanical ventilation; lung-protective ventilation; time constant; ARDS; stress; strain; hypercapnia. [Respir Care 2016;61(6):774 -790 . © 2016 Daedalus Enterprises] IntroductionIt is well known that the use of mechanical ventilation has the potential to aggravate pulmonary injury, but emerging evidence indicates that it may also precipitate lung injury in patients with no previous injury. Lung-protective ventilation has evolved over the past couple of decades to the point that it has become standard of care for patients with ARDS. The use of lower tidal volume (V T ) 4 -8 mL/kg predicted body weight (PBW) is part of this lung-protective strategy for mechanical ventilation (mechanical ventilation) along with limiting the plateau pressure to a maximum of 30 cm H 2 O and prudent use of PEEP to prevent atelectasis. Since we now know that the use of lower V T strategies (more specifically 6 mL/kg PBW) helps to limit the pulmonary damage during ARDS, the question now is: Should we be using this strategy in all mechanically ventilated patients? Anatomically speaking, it makes sense to, since the normal physiologic V T for humans is approximately 6 mL/kg PBW. 1 There is a growing body of evidence that points toward the use of lower V T values leading to improved outcomes in patients suffering from other forms and degrees of respiratory failure. The aim of this paper is to examine the evidence relating to the use of lower V T values in conditions other than ARDS in which mechanical ventilation is required. This will be done with viewpoints from both the pro and con positions. Early StudiesThere is a plethora of preclinical evidence from animal studies supporting the fact that the use of high V T values can directly cause injury to normal lungs. Animal studies have shown that high V T ventilation increases levels of pro-inflammatory mediators, leads to pulmonary edema, and causes increased alveolar-capillary permeability and structural abnormalities. [2][3][4][5][6][7][8] With the emergence of these animal data, clinicians began to question the traditional use of V T values in the range of 10 -15 mL/kg PBW in humans. Several small human studies were reported in the mid-to late 1990s that produced conflicting results. 9-11 These studies were hampered by several factors, including higher than predicte...

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Bench-to-bedside review: Hypercapnic acidosis in lung injury - from 'permissive' to 'therapeutic'

Cited by 54 publications

References 98 publications

Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans

Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans

Pediatric Acute Respiratory Distress Syndrome

Should A Tidal Volume of 6 mL/kg Be Used in All Patients?

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