Firzli Tarek R, Sathappan Sunil, Siddiqui Faisal
Medical School, University of Nevada Reno School of Medicine, Reno, USA.
Critical Care Medicine, Veterans Affairs Sierra Nevada Health Care System, Reno, USA.
Cureus. 2022 May 1;14(5):e24645. doi: 10.7759/cureus.24645. eCollection 2022 May.
Acute respiratory distress syndrome (ARDS) is a severe complication of coronavirus disease 2019 (COVID-19) infection marked by increased fluid diffusely in alveolar spaces. The management of ARDS can be complicated by mechanical hyperinflation, and thus a mainstay of treatment has included low tidal volume mechanical ventilation. This, however, can lead to ventilation-associated hypercapnia, which may result in respiratory acidosis. COVID-19-associated ARDS (CARDs) has been described in the literature, and guidelines tend to mimic ARDS management. However, the heterogeneous nature of COVID-19 pulmonary disease with respect to dead space, compliance, and shunting could alter guidelines. As low tidal volume remains a cornerstone in CARDS management, hypercapnic acidosis remains a risk. An emerging technology, extracorporeal CO2 removal devices (ECCO2R), has been granted emergency use authorization by the FDA for the management of CARDS. We present a 44-year-old male patient presenting positive for COVID-19. Following admission, the patient's oxygen status continually deteriorated and the patient went into acute respiratory distress, eventually requiring invasive mechanical ventilation. The patient became hypercapnic and acidotic due to low tidal volume ventilation. ECCO2R was used to manage the patient's hypercapnia, resulting in significant amelioration of his partial pressure of carbon dioxide (PCO2) and pH. The patient was eventually transferred to extracorporeal membrane oxygenation (ECMO) certified facility and survived after a prolonged hospital and rehabilitation course. In the management of CARDS patients who require mechanical respiration, there are many unanswered questions as to the appropriate ventilation strategy. Current practice recommends low tidal volume ventilation, carrying, and increased risk of hypercapnic respiratory acidosis as occurred in our patient. We believe that ECCO2R may be an appropriate bridge between low tidal volume ventilation and ECMO to stabilize acid-base disturbances in ventilated patients.
急性呼吸窘迫综合征（ARDS）是2019冠状病毒病（COVID-19）感染的一种严重并发症，其特征为肺泡腔内液体弥漫性增加。ARDS的管理可能因机械性过度充气而变得复杂，因此治疗的主要方法包括低潮气量机械通气。然而，这可能导致通气相关性高碳酸血症，进而可能导致呼吸性酸中毒。COVID-19相关的ARDS（CARDs）在文献中已有描述，指南往往模仿ARDS的管理方法。然而，COVID-19肺部疾病在死腔、顺应性和分流方面的异质性可能会改变指南。由于低潮气量仍然是CARDs管理的基石，高碳酸血症性酸中毒仍然是一种风险。一种新兴技术，体外二氧化碳清除装置（ECCO2R），已获得美国食品药品监督管理局（FDA）的紧急使用授权，用于CARDs的管理。我们报告一名44岁男性患者，COVID-19检测呈阳性。入院后，患者的氧状态持续恶化，进入急性呼吸窘迫状态，最终需要有创机械通气。由于低潮气量通气，患者出现高碳酸血症和酸中毒。使用ECCO2R来管理患者的高碳酸血症，使其二氧化碳分压（PCO2）和pH值得到显著改善。患者最终被转至具备体外膜肺氧合（ECMO）资质的机构，并在经历漫长的住院和康复过程后存活下来。在需要机械通气的CARDs患者的管理中，关于合适的通气策略仍有许多未解决的问题。目前的做法推荐低潮气量通气，但存在如我们患者所发生的高碳酸血症性呼吸性酸中毒风险增加的问题。我们认为，ECCO2R可能是低潮气量通气和ECMO之间的合适桥梁，以稳定通气患者的酸碱紊乱。
