How to suspect hypoven/la/on? David Orlikowski M.D., Ph.D. Clinical investigation center INSERM 1429 Intensive care and home ventilation unit, Reference Centre for Neuromuscular Disease hôpital Raymond Poincaré, Garches
system leads to a distinct entity (fig. 1). In general, the lung caused by a variety of lung diseases (e.g. pn emphysema and interstitial lung disease) leads to hy with normocapnia or hypocapnia (hypoxaemic respiratory failure). Failure of the pump (e.g. drug results in alveolar hypoventilation and hypercapn capnic or type II respiratory failure). Although th existent hypoxaemia, the hallmark of ventilatory fai increase in Pa,CO 2. Undoubtedly, both types of r C. Roussos, A. Koutsoukou. Eur Respir J 2003
Who is concerned? Piper and Brendon, Comprehensive physiology 2014
What are we looking for? Clinical signs? Hypercapnia on blood gazes? Base excess or bicarbonate level? Nocturnal desatura/on? Hypercapnia on transcutaneous PCO2 or expiratory gazes? APNEA/HYPOPNEA?
When are we looking for? Consensus conference, Chest 1999
Which criteria? Day/me par/al arterial pressure of CO2 >45 mmhg Day/me base excess 4 mmol/l Nocturnal SpO2 88% for 5 consecu/ve minutes Mean nocturnal SpO2 <90% or SpO2 <90% during 10% of the recording /me TcCO2 >55 mmhg for 10 minutes Increase in TcCO2 10 mmhg (in comparison to an awake supine value) to a value exceeding 50 mmhg for 10 minutes Peak TcCO2 49 mmhg Mean TcCO2 >50 mmhg
Prevalence of hypoven/la/on N=232 unven/lated Day/me par/al arterial pressure of CO2 >45 mmhg Day/me base excess 4 mmol/l Nocturnal SpO2 88% for 5 consecu/ve minutes Mean nocturnal SpO2 <90% or SpO2 <90% during 10% of the recording /me TcCO2 >55 mmhg for 10 minutes Increase in TcCO2 10 mmhg (in comparison to an awake supine value) to a value exceeding 50 mmhg for 10 minutes Peak TcCO2 49 mmhg Mean TcCO2 >50 mmhg Ogna et al., submiaed
Clinical signs Piper and Brendon, Comprehensive physiology 2014, Ward et al., Thorax 2005
BLOOD GAZES VA l/min C. Roussos, A. Koutsoukou. Eur Respir J 2003 J.F. Nunn. Applied respiratory physiology, 1987
BLOOD GAZES é CO 2 Muscles Charge =>EARLY NOCTURNAL ALTERATION Rage%e, 2002; Hukins, 2000; Arnulf, 2000 Ferguson, 1996; Khan, 1994
NOCTURNAL ALTERATION Becker et al., AJRCCM 1999
BLOOD GAZES Par/al arterial pressure of CO2 >45 mmhg Usual defini/on: day/me Diurnal or nocturnal Arterial or capillary?
Correla/on arterial/capillary samples Fig. 2. Linear models predicting arterial PO 2 and PCO 2 values from fingertip and earlobe PO 2 = 0.84 fingertip PO 2 + 21.8, the residual standard error is 15.0, the adjusted coefficient of dete PO 2 + 5.8, the residual standard error is 5.9, the adjusted coefficient of determination r 2 = 0.88, and p < standard error is 2.9, the adjusted coefficient of determination r 2 = 0.95, and p < 0.01. Arterial PCO 2 the adjusted coefficient of determination r 2 = 0.94, and p < 0.01. The dashed lines are the line of iden how much care was taken during capillary sampling. Proper care includes not squeezing or milking the puncture site, making sure that no air bubbles are present in the capillary tubes, and ensuing that samples are minimally exposed to room air. Studies which may have allowed samples to be partially exposed to room air could have allowed the PO 2 in the samples to be artificially raised. Allowing capillary samples to be partially exposed decreased wi why the year in the mean d There ma in the 1960 mission bias to show tha Zavorsky and al., Resp Physiol Neurobiol 2006
BLOOD GAZES Day/me PaCO2/VC PaCO2 /Respiratory muscle strength Rageae et al., Thorax 2002
BLOOD GAZES and sleep Hukins and Hillman AJRCCM 2000
Morning BLOOD GAZES Pa,CO 2 was highly correlated with severity of SH. Thi first study to document the prevalence of SH in hype COPD. A number of studies have examined the preval REM-related oxygen desaturation in sleep in COPD O Donoghue et al., ERJ 2003, Chin et al., Internal Medicine 1997
Nocturnal ventilation: indication criteria % N=268 60 50 40 30 20 10 0 Laub et al., J Rehabil Med, 2006
Bicarbonates? Berger et al., J of Appl Physiol 2002
Bicarbonates? Day/me base excess 4 mmol/l DMD Hukins and Hillman AJRCCM 2000
90 80 ALS HYPOVENTILATION Normal Raised bicarbonate Raised bicarbonate and PCO2 70 60 50 40 30 20 10 0 pco2 po2 HCO3- Min O2 TCC Lyall et al., Brain 2001
Pulse oxymetry Nocturnal SpO2 88% for 5 consecu/ve minutes Mean nocturnal SpO2 <90% or SpO2 <90% during 10% of the recording /me Copyright 2015 by the American Thoracic Society Aboussouan, AJRCCM 2015, Consensus conference, Chest 1999, Nardi et al., Respir Care 2012, Janssens et al., Thorax 2011
Pulse oxymetry Fig. 5. Recordings during NREM and REM sleep from 2. Signals are detailed in legend to figure 2. Note consi tory activity in EMGexob during NREM sleep, which, lik EMGint, is suppressed in REM sleep in association with movements. The apparent EMGdi activity is expiratory and to represent contamination by abdominal expiratory mu which it clearly resembles. For abbreviations see legend White et al., ERJ 1995
Pulse oxymetry
White et al., ERJ 1995, Rageae et al., Thorax 2002
Pulse oxymetry
SomnoVNI Group Janssens, Thorax 2011
SomnoVNI Group Janssens, Thorax 2011
Pulse oxymetry SpO2 88% more than 5 min Mean nocturnal SpO2 <90% or SpO2 <90% during 10% Mean nocturnal SpO2 <92% or SpO2 <92% during 10% Nardi et al., Respiratory care 2012
ETCO2 or PtCO2? Both used as surrogate of PaCO2 ETCO2 Fast response : Breath to breath Not usable if O2, fast repiratory rate, low /dal volume, mouth breathing or mask ven/la/on Children ++++ PtCO2 Slow response Usable during O2 treatment or mask ven/la/on Needs calibra/on
ETCO2 versus PaCO2 Tobias and Meyer, Anaesth Analg 1997, Trevisanuto et al., Pediatric pulmonology 2012
PtCO2 versus arterial PaCO2 Kelly and Klim, Respiratory Medicine 2011, Storre et al., Respiratory Medicine 2011, Chin et al., Internal medicine 1997
PtCO2 versus capillary PaCO2 Paiva et al., Intensive care Med 2009
During free breath O Donoghue et al., ERJ 2003
Ward et al., Thorax 2005
During Non Invasive Ven/la/on
Hôpital Raymon +33 01 47 10 79 E-mail addre Or Invasive Ven/la/on 1389-9457/$ - s http://dx.doi.org Nardi et al., Sleep medicine 2012
HOME MONITORING Michigan State University, and Spectrum Health, Grand Rapids, MI. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. in improved mortality and quality of life in amyotro sclerosis (ALS). 5 A practical, cost-effective metho recognition of NH has yet to emerge. Currentl 0003-9993/13/$ http://dx.doi.org 0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2012.08.215 ventilatory support) nz16 (45.7%) II. Determine the severity of nocturnal hypercapnia or oxygen desaturation (patients with daytime ET-PCO 2 47mmHg and not using nocturnal ventilatory support) nz4 (12.1%) III. Determine the effectiveness of TV/BiPAP in preventing nocturnal hypercapnia or oxygen desaturation nz15 (42.9%) 3 (75) 92.38.7 (80e99) 66.1 8 (53.3) 74.327.6 (10e100) 76.5 NOTE. Values are n (%) or mean SD (range). NH Z tc-pco 2 50mmHg for 5% of monitoring time. www.ar
Prevalence of isolated nocturnal hypoven/la/on N=88 1- TcCO2 >55 mmhg for 10 minutes 2- Increase in TcCO2 10 mmhg (comparison to awake supine value) to a value exceeding 50 mmhg for 10 minutes 3- Peak TcCO2 49 mmhg 4- Mean TcCO2 >50 mmhg Ogna et al., submiaed
Recommended but Appropriate calibra/on of sensors is needed Clinical judgement for reading and interpreta/on PtCO2 must should be calibrated with reference gas EtCO2 : Plateau in PCO2 versus /me wave form (reference gas not required)
Poor agrement between defini/on Moderate or agreement for the same techniques used SpO2 and TcCO2 Poor concordance for day/me hypercapnia
Conclusion Many techniques Many tools Many defini/on Many applica/on Diagnosis or monitoring Poor concordance between techniques