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Objectives/hypothesis: To describe the use of capillary blood gas (CBG) sampling to detect and quantify hypoventilation in infants with Robin sequence (RS)., Methods: Case series with chart review at two institutions. Infants with RS presenting over a 10-year period were identified using departmental databases. CBG values obtained during infancy or until airway intervention (AI) were reviewed., Results: From 2008 to 2018, 111 infants with RS were identified as having had been assessed and managed from birth or transfer until discharge home and having CBG data available. In most cases, CBG sampling was obtained every other day until intervention or discharge. A total of 81 (73%) infants required AI: 72 (89%) underwent mandibular distraction osteogenesis, five (6%) underwent tracheotomy, and four (5%) were discharged home with a nasopharyngeal airway. The mean PCO 2 at day of life (DOL) 7-30 for the AI group was 52.7 mmHg (95% confidence interval: 51.7-53.7) and for the no AI group was 45.9 mmHg (44.8-47.0; P < .0001). The mean HCO 3 at DOL 7-30 for the AI group was 29.8 mEq/L (29.4-30.1) and for the no AI group was 27.0 mEq/L (26.5-27.4; P < .0001). Receiver operating characteristic curves were created for maximum PCO 2 and HCO 3 values and cutoffs were established by optimizing a balance of sensitivity and specificity. Infants requiring AI surpassed the PCO 2 and HCO 3 cutoff at a median of DOL 9., Conclusions: Among infants with RS and hypoventilation, objective measures of respiratory acidosis may be apparent by DOL 9., Level of Evidence: 4 Laryngoscope, 131:2789-2794, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

Alkali therapy for certain organic acidoses remains a topic of ongoing controversy, but little attention has been given to a related medical controversy, namely the prescription of alkali for respiratory acidosis. We first describe the determinants of carbon dioxide retention in the 2 types of respiratory failure; hypercapnic respiratory failure and hypoxemic respiratory failure with coexisting hypercapnia. We then highlight the deleterious consequences of severe acidemia for several organ systems, particularly the cardiovascular and central nervous systems. We argue that alkali therapy is not indicated for respiratory acidosis as a simple acid-base disturbance. Notwithstanding, we recommend prescription of alkali for severe acidemia caused by mixed acidosis (ie, combined respiratory and metabolic acidosis) or permissive hypercapnia. We examine the utility of alkali therapy in various clinical scenarios incorporating respiratory acidosis. We conclude that controlled studies will be required to test the impact of alkali therapy on clinical outcomes of these clinical settings. Such studies should also examine the optimal mode of administering alkali (amount, rate, and tonicity) and the blood pH to be targeted. The development of new buffers should be explored, especially systems that do not generate carbon dioxide or even consume it., (Copyright © 2019 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

High flow nasal cannula (HFNC) provides warmed and humidified air with flow rates up to 60 liters/min with relatively fixed oxygen content (FiO2). It has been extensively evaluated for hypoxemic respiratory failure and has been used in mild acute respiratory distress syndrome, pre-intubation, bronchoscopy and pediatric obstructive sleep apnea. Recent data has suggested a role in stable hypercapnic chronic obstructive pulmonary disease (COPD) and even in acute exacerbations, though, the use has not been advocated by any guidelines yet. We present a case of acute hypercapnic exacerbation of COPD, intolerant to non-invasive ventilation, showing response and improvement on use of HFNC. This case highlights this potential mechanisms and prospects for the same.

Background: S100B protein is one of the most accurate biomarkers for diagnosis of neuroapoptosis and brain damage. The aim was to evaluate the lactate concentration and acid-base balance (pH, pCO 2 , pO 2 , HCO 3 c and BEb) in umbilical cord blood to predict high risk of neuroapoptosis and analyze the relationship between the levels of these biomarkers and umbilical cord blood S100B protein concentration at birth., Methods: Apparently healthy newborns were included. S100B protein and blood gas test (lactate and acid-base balance) were determined in umbilical cord blood at birth. Newborns were classified into two groups: with and without high risk of neuroapoptosis. Newborns with high umbilical cord blood S100B protein concentration were considered newborns at high risk of neuroapoptosis., Results: Sixty-one newborns were included, 12 had high risk of neuroapoptosis and 49 did not. S100B protein concentration correlate directly with pCO 2 levels (Rho: 0.286, p = .0321) and lactate concentration (Rho: 0.278, p = .0315); and indirectly with pH (Rho: -0.332, p = .01). The analysis of the ROC curves yielded significant curves for pH and pCO 2 to predict high risk of neuroapoptosis, pH optimal cutoff value was 7.19 (sensitivity: 50%, specificity: 83.7%, AUC: 0.708); and pCO 2 optimal cutoff value was 60 mmHg (sensitivity: 30%, specificity: 85.4%, AUC: 0.705)., Conclusions: Respiratory acidosis is associated to high concentrations of S100B protein in umbilical cord blood at birth. Umbilical cord blood pH and pCO 2 may be useful in differentiating newborns at high risk of neuroapoptosis. Umbilical cord blood gas test may be valuable as risk indicator for neuroapoptosis at birth., (Copyright © 2019 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Maternal hemodynamics, positioning, and anesthesia technique for cesarean delivery influence neonatal acid-base balance; direct effects from drugs that cross the placenta also have an influence. Spinal anesthesia limits fetal exposure to depressant drugs and avoids maternal airway instrumentation, but is associated with hypotension. Hypotension may be prevented/treated with vasopressors and intravenous fluids. Current evidence supports phenylephrine as the first-line vasopressor. Fifteen degrees of lateral tilt during cesarean delivery has been advocated to relieve vena caval obstruction, but routine use may be unnecessary in healthy nonobese women having elective cesarean delivery if maternal blood pressure is maintained near baseline., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Benzodiazepines and opioids are commonly used for conscious sedation (CS) in cardiac catheterization laboratory (CCL) patients. Both drugs are known to predispose to hypoxemia, apnea and decreased responsiveness to PCO 2 , resulting in decreased arterial pH and PO 2 , as well as increased PCO 2 . We want to determine the effects of CS on arterial blood gas (ABG) in CCL patient, and identify if pulse oximetry monitoring is adequate., Methods: We enrolled 18 subjects undergoing elective catheterization. Measurement of ABGs at one-minute intervals was done from the moment of arterial access until case end. The results of ABGs were not available to the clinician who administered sedation. Relationships of pH, PCO 2 , PaO 2 and SaO 2 were studied by plotting time series graphs. Significant changes were defined as pH <7.30, SaO 2  < 90, and PCO 2  > 50 mmHg., Results: No significant change in pH, PCO 2 , PaO 2 and SaO 2 was noted in 4/18 (22%) subjects. A significant drop in SaO 2 was noted in 4/18 (22%). A significant change in PCO 2 and/or pH was noted in 10/18 (55%) cases. Among the 16 (16/18) subjects receiving supplemental oxygen, 7 (7/18, 39%) had no drop in SaO 2 , but developed respiratory acidosis. At the end of the case, 5/18 (28%) subjects had respiratory acidosis with normal PaO 2 ., Conclusion: Significant hypercarbia and acidosis occurred frequently in this small study during CS in patients undergoing cardiac catheterization. Relying on pulse oximetry alone especially with patients on supplemental oxygen may lead to failure in detecting respiratory acidosis in a significant number of patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

In vivo metabolic studies typically concern complex open systems. However, a closed system allows better assessment of the metabolic limits. Ischemic priapism (IP) constitutes a special model of the compartment syndrome that allows direct sampling from a relatively large blood compartment formed by the corpora cavernosa (CC). The purpose of our study was to measure metabolic changes and the accumulation of end products within the CC during IP. Blood gas and biochemical analyses of aspirates of the CC were analyzed over an 8-year period. Mean ± SD pH, pCO 2 , pO 2 , O 2 -saturation, lactate, and glucose of the aspirated blood were determined with a point-of-care analyzer. Forty-seven initial samples from 21 patients had a pH of 6.91 ± 0.16, pCO 2 of 15.3 ± 4.4 kPa, pO 2 of 2.4 ± 2.0 kPa, and an O 2 -saturation of 19 ± 24% indicating severe hypoxia with severe combined respiratory and metabolic acidosis. Glucose and lactate levels were 1.1 ± 1.5 and 14.6 ± 4.8 mmol/L, respectively. pH and pCO 2 were inversely correlated (R 2  = 0.86; P < 0.001), glucose and O 2 -saturation were positively correlated (R 2  = 0.83; P < 0.001), and glucose and lactate were inversely correlated (R 2  = 0.72; P < 0.001). The positive correlation of CO 2 and lactate (R 2  = 0.69; P < 0.001) was similar to that observed in vitro, when blood was titrated with lactic acid. The observed combined acidosis underscores that IP behaves as a closed system where severe hypoxia and glycopenia coexist, indicating that virtually all energy reserves have been consumed., (© 2019 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of The Physiological Society and the American Physiological Society.)

Background: Acute heart failure (AHF) is one of the leading causes of admission to emergency department (ED); severe hypoxemic AHF may be treated with noninvasive ventilation (NIV). Despite the demonstrated clinical efficacy of NIV in relieving symptoms of AHF, less is known about the hyperacute effects of bilevel positive airway pressure (BiPAP) ventilation on hemodynamics of patients admitted to ED for AHF. We therefore aimed to assess the effect of BiPAP ventilation on principal hemodynamic, respiratory, pulse oximetry, and microcirculation indexes in patients admitted to ED for AHF, needing NIV., Methods: Twenty consecutive patients admitted to ED for AHF and left ventricular systolic dysfunction, needing NIV, were enrolled in the study; all patients were treated with NIV in BiPAP mode. The following parameters were measured at admission to ED (T 0 , baseline before treatment), 3 hours after admission and initiation of BiPAP NIV (T 1 ), and after 6 hours (T 2 ): arterial blood oxygenation (pH, partial pressure of oxygen in the alveoli/fraction of inspired oxygen ratio, Paco 2 , lactate concentration, HCO 3- ), hemodynamics (tricuspid annular plane systolic excursion, transpulmonary gradient, transaortic gradient, inferior vena cava diameter, brain natriuretic peptide [BNP] levels), microcirculation perfusion (end-tidal CO 2 [etco 2 ], peripheral venous oxygen saturation [SpvO 2 ])., Results: All evaluated indexes significantly improved over time (analysis of variance, P < .001 in quite all cases.)., Conclusions: The BiPAP NIV may rapidly ameliorate several hemodynamic, arterial blood gas, and microcirculation indexes in patients with AHF and left ventricular systolic dysfunction.

White sturgeon (Acipenser transmontanus) completely protect intracellular tissue pH (pH i ) despite large reductions in extracellular (blood) pH (pH e ), termed preferential pH i regulation, in response to elevated environmental PCO 2 (hypercarbia) and in general appear to be relatively resilient to stressors. Preferential pH i regulation is thought to be associated with hypercarbia tolerance in general, but has also recently been observed to protect pH i against metabolic acidoses induced by exhaustive exercise and anoxia in a tropical air breathing catfish. We hypothesized that preferential pH i regulation may also be a general strategy of acid-base regulation in sturgeon. To address this hypothesis, severe acidoses were imposed to reduce pH e , and the presence or absence of preferential pH i regulation was assessed in red blood cells (RBC), heart, brain, liver and white muscle. A respiratory acidosis was imposed using hyperoxia, while metabolic acidoses were induced by exhaustive exercise, anoxia or air exposure. Reductions in pH e occurred following hyperoxia (0.15 units), exhaustive exercise (0.30 units), anoxia (0.10 units) and air exposure (0.35 units); all acidoses reduced RBC pH i . Following hyperoxia, heart, brain and liver pH i were preferentially regulated against the reduction in pH e , similar to hypercarbia exposure. Following all metabolic acidoses heart pH i was protected and brain pH i remained unchanged following exhaustive exercise and air exposure, however, brain pH i was reduced following anoxia. Liver and white muscle pH i were reduced following all metabolic acidoses. These results suggest preferential pH i regulation may be a general strategy during respiratory acidoses but during metabolic acidoses, the response differs between source of acidoses and tissues.

Background: Clinicians frequently assume that during arterial puncture for measuring arterial blood gases patients hyperventilate from pain and anxiety. This assumption leads clinicians to falsely interpret a PaCO 2 and pH near the upper limit of normal as a chronic respiratory acidosis corrected by an acute respiratory alkalosis., Objective: Determine if participants hyperventilate during arterial puncture from pain and anxiety., Methods: We recruited participants from a pulmonary function laboratory referred for arterial blood gas measurement. We excluded those with heart failure and included those with any respiratory condition (COPD, asthma, sleep apnea). We measured end tidal PCO 2 (P ET CO 2 ), respiratory rate, and heart rate 15 min before topical anesthesia, during anesthesia, during arterial puncture, and 15 min later. We assessed generalized anxiety before and measured pain during and after arterial puncture., Results: 24 participants were recruited (age: 54 ± 12 years; men: 54%). PaCO 2 was 41 ± 5 mmHg. One had acute respiratory alkalosis. Respiratory rate increased from (19 ± 6 breaths per minute (bpm)) before to a maximum (21 ± 6 bpm) during arterial puncture (p = 0.001). Heart rate was stable throughout. The lowest P ET CO 2 during the procedure (35 ± 5) was similar to P ET CO 2 before the procedure (p = 0.1). The change in P ET CO 2 and respiratory rate did not correlate with pain, anxiety, or lung function., Conclusion: Respiratory rate increased slightly during arterial puncture without any change in P ET CO 2 . Hence, acid-base status must be interpreted without the assumption of procedure induced hyperventilation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To determine whether the presence of nasal flaring is a clinical sign of respiratory acidosis in patients attending emergency departments for acute dyspnea., Methods: Single-center, prospective, observational study of patients aged over 15 requiring urgent attention for dyspnea, classified as level II or III according to the Andorran Triage Program and who underwent arterial blood gas test on arrival at the emergency department. The presence of nasal flaring was evaluated by two observers. Demographic and clinical variables, signs of respiratory difficulty, vital signs, arterial blood gases and clinical outcome (hospitalization and mortality) were recorded. Bivariate and multivariate analyses were performed using logistic regression models., Results: The sample comprised 212 patients, mean age 78years (SD=12.8), of whom 49.5% were women. Acidosis was recorded in 21.2%. Factors significantly associated with the presence of acidosis in the bivariate analysis were the need for pre-hospital medical care, triage level II, signs of respiratory distress, presence of nasal flaring, poor oxygenation, hypercapnia, low bicarbonates and greater need for noninvasive ventilation. Nasal flaring had a positive likelihood ratio for acidosis of 4.6 (95% CI 2.9-7.4). In the multivariate analysis, triage level II (aOR 5.16; 95% CI: 1.91 to 13.98), the need for oxygen therapy (aOR 2.60; 95% CI: 1.13-5.96) and presence of nasal flaring (aOR 6.32; 95% CI: 2.78-14.41) were maintained as factors independently associated with acidosis., Conclusions: Nasal flaring is a clinical sign of severity in patients requiring urgent care for acute dyspnea, which has a strong association with acidosis and hypercapnia., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Acid-base and respiratory disturbances are common in sick and hospitalized veterinary patients; therefore, blood gas analyzers have become integral diagnostic and monitoring tools. This article will discuss uses of blood gas analyzers, types of samples that can be used, sample collection methods, potential sources of error, and potential alternatives to blood gas analyzers and their limitations. It will also discuss the types of analyzers that are available, logistical considerations that should be taken into account when purchasing an analyzer, and the basic principles of how these analyzers work., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objective: Patients with chronic obstructive pulmonary disease (COPD) experiencing acute exacerbation (AE-COPD) with decompensated respiratory acidosis are known to have poor outcomes in terms of recurrent respiratory failure and death. However, the outcomes of AE-COPD patients with compensated respiratory acidosis are not known., Methods: We performed a 1-year prospective, single-centre, cohort study in patients surviving the index admission for AE-COPD to compare baseline factors between groups with normocapnia, compensated respiratory acidosis and decompensated respiratory acidosis. Survival analysis was done to examine time to readmissions, life-threatening events and death., Results: A total of 250 patients fulfilling the inclusion and exclusion criteria were recruited and 245 patients were analysed. Compared with normocapnia, both compensated and decompensated respiratory acidosis are associated with lower FEV1 % (P < 0.001), higher GOLD stage (P = 0.003, <0.001) and higher BODE index (P = 0.038, 0.001) and a shorter time to life-threatening events (P < 0.001). Comparing compensated and decompensated respiratory acidosis, there was no difference in FEV1 (% predicted) (P = 0.15), GOLD stage (P = 0.091), BODE index (P = 0.158) or time to life-threatening events (P = 0.301). High PaCO2 level (P = 0.002) and previous use of non-invasive ventilation (NIV) in acute setting (P < 0.001) are predictive factors of future life-threatening events by multivariate analysis., Conclusions: Compared with normocapnia, both compensated and decompensated respiratory acidosis are associated with poorer lung function and higher risk of future life-threatening events. High PaCO2 level and past history of NIV use in acute settings were predictive factors for future life-threatening events. Compensated respiratory acidosis warrants special attention and optimization of medical therapy as it poses risk of life-threatening events., (© 2015 Asian Pacific Society of Respirology.)

Introduction: In spontaneously breathing mice anesthetized with pentobarbital, we observed unexpected paradoxical bradypnea following 5% inhaled CO2., Methods: Observational study 7-8 week CB6F1/OlaHsd mice (n = 99), anesthetized with 30 mg/kg intraperitoneal pentobarbital. Interventional study: Adult male Wistar rats (n = 18), anesthetized either with 30 mg/kg intraperitoneal pentobarbital, 100 mg/kg intraperitoneal ketamine or 1.5% isoflurane. Rats had femoral artery cannulas inserted for hemodynamic monitoring and serial arterial blood gas measurements., Results: Observational study: There was a marked reduction in respiratory rate following 4 min of normoxic hypercapnia; average reduction of 9 breaths/min (p < 0.001) (17% reduction from baseline). Interventional study: increasing CO2 caused dose-dependent increase in respiratory rate for ketamine-xylazine (p = 0.007) and isoflurane (p = 0.016) but dose-dependent decrease in respiratory rate for pentobarbital (p = 0.046). Increasing inspired CO2 caused dose-dependent acidosis following pentobarbital and isoflurane (p = 0.013 and p = 0.017, respectively); but not following ketamine-xylazine (p = 0.58)., Conclusions: Inhaled CO2 caused paradoxical dose-dependent bradypnea in animals anesthetized with pentobarbital, an observation not hitherto reported as a part of anesthesia-related respiratory depression., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Acidification of blood entering a membrane lung (ML) with lactic acid enhances CO2 removal (VCO2ML). We compared the effects of infusion of acetic, citric, and lactic acids on VCO2ML. Three sheep were connected to a custom-made circuit, consisting of a Hemolung device (Alung Technologies, Pittsburgh, PA), a hemofilter (NxStage, NxStage Medical, Lawrence, MA), and a peristaltic pump recirculating ultrafiltrate before the ML. Blood flow was set at 250 ml/min, gas flow (GF) at 10 L/min, and recirculating ultrafiltrate flow at 100 ml/min. Acetic (4.4 M), citric (0.4 M), or lactic (4.4 M) acids were infused in the ultrafiltrate at 1.5 mEq/min, for 2 hours each, in randomized fashion. VCO2ML was measured by the Hemolung built-in capnometer. Circuit and arterial blood gas samples were collected at baseline and during acid infusion. Hemodynamics and ventilation were monitored. Acetic, citric, or lactic acids similarly enhanced VCO2ML (+35%), from 37.4 ± 3.6 to 50.6 ± 7.4, 49.8 ± 5.6, and 52.0 ± 8.2 ml/min, respectively. Acids similarly decreased pH, increased pCO2, and reduced HCO3 of the post-acid extracorporeal blood sample. No significant effects on arterial gas values, ventilation, or hemodynamics were observed. In conclusion, it is possible to increase VCO2ML by more than one-third using any one of the three metabolizable acids.

Unlabelled: Apart from the HH equation, the acid-base balance of an organism is also described by the Stewart model, which assumes that the proper insight into the ABB of the organism is given by an analysis of: pCO2, the difference of concentrations of strong cations and anions in the blood serum - SID, and the total concentration of nonvolatile weak acids - Acid total. The notion of an anion gap (AG), or the apparent lack of ions, is closely related to the acid-base balance described according to the HH equation. Its value mainly consists of negatively charged proteins, phosphates, and sulphates in blood. In the human medicine, a modified anion gap is used, which, including the concentration of the protein buffer of blood, is, in fact, the combination of the apparent lack of ions derived from the classic model and the Stewart model. In brachycephalic dogs, respiratory acidosis often occurs, which is caused by an overgrowth of the soft palate, making it impossible for a free air flow and causing an increase in pCO2--carbonic acid anhydride The aim of the present paper was an attempt to answer the question whether, in the case of systemic respiratory acidosis, changes in the concentration of buffering ions can also be seen. The study was carried out on 60 adult dogs of boxer breed in which, on the basis of the results of endoscopic examination, a strong overgrowth of the soft palate requiring a surgical correction was found. For each dog, the value of the anion gap before and after the palate correction procedure was calculated according to the following equation: AG = ([Na+ mmol/l] + [K+ mmol/l])--([Cl- mmol/l]+ [HCO3- mmol/l]) as well as the value of the modified AG--according to the following equation: AGm = calculated AG + 2.5 x (albumins(r)--albumins(d)). The values of AG calculated for the dogs before and after the procedure fell within the limits of the reference values and did not differ significantly whereas the values of AGm calculated for the dogs before and after the procedure differed from each other significantly., Conclusions: 1) On the basis of the values of AGm obtained it should be stated that in spite of finding respiratory acidosis in the examined dogs, changes in ion concentration can also be seen, which, according to the Stewart theory, compensate metabolic ABB disorders 2) In spite of the fact that all the values used for calculation of AGm were within the limits of reference values, the values of AGm in dogs before and after the soft palate correction procedure differed from each other significantly, which proves high sensitivity and usefulness of the AGm calculation as a diagnostic method.

Background: Low-flow extracorporeal CO2 removal devices are easy to setup and manage and may provide valuable ventilation support., Methods: We employed a new device (ProLUNG) recently introduced into the clinical arsenal that exploits a simple hemoperfusion technique sustained by blood flows lower than 500 ml/min to remove CO2 from the venous blood. It was used as an adjunctive support to mechanical ventilation during and after four lung transplantations in our center., Results: Two patients with cystic fibrosis, one with pulmonary fibrosis, and one with emphysema were included. They underwent lung transplantation and presented hypercapnia and respiratory acidosis before, during, or after the surgical procedure. After 1 h of treatment with the ProLUNG circuit, all patients showed reduced CO2 levels and increased pH; these variables remained stable until the end of treatment., Conclusions: Our data suggest that this new device is effective in removing CO2 and stabilizing the pH.

Non-invasive ventilation (NIV) is an evidence based management of acidotic, hypercapnic exacerbations of COPD. Previous national and international audits of clinical practice have shown variation against guideline standards with significant delays in initiating NIV. We aimed to map the clinical pathway to better understand delays and reduce the door-to-NIV time to less than 3 hours for all patients with acidotic, hypercapnic exacerbations of COPD requiring this intervention, by mandating the use of a guideline based educational management proforma.The proforma was introduced at 7 acute hospitals in North London and Essex and initiated at admission of the patient. It was used to record the clinical pathway and patient outcomes until the point of discharge or death. Data for 138 patients were collected. 48% of patients commenced NIV within 3 hours with no reduction in door-to-mask time during the study period. Delays in starting NIV were due to: time taken for review by the medical team (101 minutes) and time taken for NIV to be started once a decision had been made (49 minutes). There were significant differences in door-to-NIV decision and mask times between differing respiratory on-call systems, p < 0.05). The introduction of the proforma had no effect on door-to-mask times over the study period. Main reasons for delay were related to timely access to medical staff and to NIV equipment; however, a marked variation in practice within these hospitals was been noted, with a 9-5 respiratory on-call system associated with shorter NIV initiation times.

Background: Open mouthpiece ventilation is efficacious in patients with neuromuscular disease. We used this ventilation technique in patients with exacerbations of COPD with mild to moderate acidosis., Methods: The study was performed in 2 respiratory monitoring care units. Fifty subjects with exacerbations of COPD, breathing frequency > 25, PaCO2 > 45, and pH between 7.25 and 7.30, as well as Kelly scale ≤ 2 were enrolled. Subjects were randomly assigned to receive noninvasive ventilation (NIV) via nasal mask or mouthpiece ventilation. The primary outcome was improvement in arterial blood gases. Arterial blood gases and breathing frequency were recorded 2 h after the start of the enrollment and then after 12, 24, and 48 h. The duration of NIV, hospital stay, and acceptability of the interface (mouthpiece or nasal mask) using a Likert scale were assessed., Results: No subjects had deterioration of gas exchange. The 2 groups had similar trends in arterial blood gases and breathing frequency. No differences in duration of NIV or hospital stay were noted. However, a significant difference in acceptability was found: subjects preferred mouthpiece ventilation (P < .01)., Conclusions: Open mouthpiece ventilation is a useful technique and may prevent further deterioration of gas exchange in COPD patients with mild to moderate acidosis (similar to traditional NIV delivered by a nasal mask). www.chictr.org registration ChiCTR-TRC-12002672., (Copyright © 2014 by Daedalus Enterprises.)

Introduction: While non-invasive ventilation aimed at avoiding intubation has become the modality of choice to treat mild to moderate acute respiratory acidosis, many severely acidotic patients (pH <7.20) still need intubation. Extracorporeal veno-venous CO2 removal (ECCO2R) could prove to be an alternative. The present animal study tested in a systematic fashion technical requirements for successful ECCO2R in terms of cannula size, blood and sweep gas flow., Methods: ECCO2R with a 0.98 m(2) surface oxygenator was performed in six acidotic (pH <7.20) pigs using either a 14.5 French (Fr) or a 19Fr catheter, with sweep gas flow rates of 8 and 16 L/minute, respectively. During each experiment the blood flow was incrementally increased to a maximum of 400 mL/minute (14.5Fr catheter) and 1000 mL/minute (19Fr catheter)., Results: Amelioration of severe respiratory acidosis was only feasible when blood flow rates of 750 to 1000 mL/minute (19Fr catheter) were used. Maximal CO2-elimination was 146.1 ± 22.6 mL/minute, while pH increased from 7.13 ± 0.08 to 7.41 ± 0.07 (blood flow of 1000 mL/minute; sweep gas flow 16 L/minute). Accordingly, a sweep gas flow of 8 L/minute resulted in a maximal CO2-elimination rate of 138.0 ± 16.9 mL/minute. The 14.5Fr catheter allowed a maximum CO2 elimination rate of 77.9 mL/minute, which did not result in the normalization of pH., Conclusions: Veno-venous ECCO2R may serve as a treatment option for severe respiratory acidosis. In this porcine model, ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 mL/minute, while an increase in sweep gas flow from 8 to 16 L/minute had less impact on ECCO2R in this setting.

Background: Patients with COPD have reduced exercise tolerance associated with dyspnea. This exercise intolerance is primarily due to impaired ventilatory mechanics, but it is also associated with a combination of factors, including inefficient gas exchange, lactic acidosis at a low work rate, and exercise-induced hypoxemia. The survival prognosis of COPD patients with severely reduced exercise capacity is extremely poor, but the pathophysiology of these patients during exercise remains to be accurately established. The present study aimed to characterize life-threatening factors such as hypoxemia, acidosis, and sympathetic activation during exercise in these patients., Methods: We monitored changes in life-threatening factors and compared these factors among quartile groups, defined according to their peak oxygen uptake status. Ninety-one COPD subjects (82 males, 9 females, average age 69.7 ± 6.8 y) consecutively underwent incremental cardiopulmonary exercise testing using a cycle ergometer. Arterial blood gases, lactate, and catecholamines were measured during cardiopulmonary exercise testing., Results: The pathophysiology of the COPD differed among the 4 subject groups. Subjects with the most severely reduced exercise capacity (peak oxygen uptake ≤ 623 mL/min) were characterized by exercise-induced steep decrease in PaO2 slope (-78 ± 70 mm Hg/L/min), rapid progression of respiratory acidosis, little change in lactic acidosis, and sympathetic activation at low-intensity work load (plasma norepinephrine 1.41 ± 0.94 ng/mL at 20 watts work load), in addition to the limitation of increase in ventilation and impaired gas exchange., Conclusions: The mechanisms of exercise intolerance in COPD patients significantly differed among subjects with different exercise capacities. Subjects with the most severely reduced exercise capacity had the characteristics of exercise-induced hypoxemia, sympathetic overactivity, and progressive respiratory acidosis at low-intensity exercise. These life-threatening pathophysiological conditions could be improved by medication and/or pulmonary rehabilitation.

The treatment of choice for patients with respiratory failure of neuromuscular origin, especially in patients with hypercapnic respiratory acidosis, is noninvasive ventilation (NIV). Endotracheal intubation and invasive ventilation are indicated for patients with severe respiratory compromise or failure of NIV. In recent years, high-flow oxygen therapy and active humidification devices have been introduced, and emerging evidence suggests that high-flow oxygen may be effective in various clinical settings, such as acute respiratory failure, after cardiac surgery, during sedation and analgesia, in acute heart failure, in hypoxemic respiratory distress, in do-not-intubate patients, in patients with chronic cough and copious secretions, pulmonary fibrosis, or cancer, in critical areas and the emergency department. We report on a patient with amyotrophic lateral sclerosis who arrived at the emergency department with acute hypercapnic respiratory failure. She did not tolerate NIV and refused intubation, but was treated successfully with heated, humidified oxygen via high-flow nasal cannula. Arterial blood analysis after an hour on high-flow nasal cannula showed improved pH, P(aCO2), and awareness. The respiratory acidosis was corrected, and she was discharged after 5 days of hospitalization. Her response to high-flow nasal cannula was similar to that expected with NIV. We discuss the mechanisms of action of heated, humidified high-flow oxygen therapy.

Postnatal mixed respiratory-metabolic acidosis is common in calves, and depending on its severity can impair vitality or even cause death. Carbon dioxide accounts for the respiratory component and L-lactate for the metabolic component of the mixed acidosis, but it remains unclear which component determines the severity and duration of the acidosis. In a first attempt to clarify, this was investigated retrospectively in 31 calves during the first two hours of life, and in 13 calves during the first three days of life. Venous blood was collected for blood gas analysis and measurement of acid-base variables and L-lactate concentration. pH Was more strongly correlated with L-lactate concentration (r(2)=0.808) than with partial pressure of CO2 (pCO2, r(2)=0.418). Duration of parturition had a distinct effect on pH and L-lactate concentration but not on pCO2; calves born within six hours of rupture of the allantoic sac had a higher pH and lower L-lactate concentration than calves born after a longer duration of parturition (both P<0.01). Normalisation of pCO2 took four hours and normalisation of L-lactate took 48 hours. It was concluded that L-lactate is a more important factor in the pathogenesis of acidosis than pCO2, and that the duration of metabolic acidosis exceeds that of respiratory acidosis in perinatal asphyxia of calves.

Rodents are most useful models to study physiological and pathophysiological processes in early development, because they are born in a relatively immature state. However, only few techniques are available to monitor non-invasively heart frequency and respiratory rate in neonatal rodents without restraining or hindering access to the animal. Here we describe experimental procedures that allow monitoring of heart frequency by electrocardiography (ECG) and breathing rate with a piezoelectric transducer (PZT) element without hindering access to the animal. These techniques can be easily installed and are used in the present study in unrestrained awake and anesthetized neonatal C57/Bl6 mice and Wistar rats between postnatal day 0 and 7. In line with previous reports from awake rodents we demonstrate that heart rate in rats and mice increases during the first postnatal week. Respiratory frequency did not differ between both species, but heart rate was significantly higher in mice than in rats. Further our data indicate that urethane, an agent that is widely used for anesthesia, induces a hypoventilation in neonates whilst heart rate remains unaffected at a dose of 1 g per kg body weight. Of note, hypoventilation induced by urethane was not detected in rats at postnatal 0/1. To verify the detected hypoventilation we performed blood gas analyses. We detected a respiratory acidosis reflected by a lower pH and elevated level in CO2 tension (pCO2) in both species upon urethane treatment. Furthermore we found that metabolism of urethane is different in P0/1 mice and rats and between P0/1 and P6/7 in both species. Our findings underline the usefulness of monitoring basic cardio-respiratory parameters in neonates during anesthesia. In addition our study gives information on developmental changes in heart and breathing frequency in newborn mice and rats and the effects of urethane in both species during the first postnatal week.

In day 15 chicken embryos, we determined the time course responses of acid-base balance and hematological respiratory variables during 24h exposure to 15, 20, 40 or 90% O(2), in the presence of 5% CO(2). Hypercapnic respiratory acidosis was initially (2h) only slightly (∼20%) compensated by metabolic alkalosis in normoxic/hyperoxic embryos. After 6h, respiratory acidosis was partially (∼40-50%) compensated not only in normoxic/hyperoxic embryos, but also in hypoxic embryos. However, partial metabolic compensation in 15% O(2) could not be preserved after 24h. Preservation of metabolic compensation required oxygen concentration ([O(2)]) above 20%, but the magnitude of partial metabolic compensation was unrelated to [O(2)]. Hematocrit (Hct), together with mean corpuscular volume (MCV), markedly increased in hypercapnic hypoxia, and was maintained at 24h due to a subsequent increase in red blood cell concentration ([RBC]). In contrast, Hct, together with MCV, decreased in hypercapnic normoxia/hyperoxia accompanied by a subsequent decrease in [RBC] at 24h. Regulation of variables takes place similarly irrespective of environmental [O(2)] above 20%, matching acid-base regulation., (Copyright © 2012. Published by Elsevier B.V.)

Background: In patients with acute hypercapnic respiratory failure (AHRF) during exacerbations of COPD, mortality can be high despite noninvasive ventilation (NIV). For some, AHRF is terminal and NIV is inappropriate. However there is no definitive method of identifying patients who are unlikely to survive. The aim of this study was to identify factors associated with inpatient mortality from AHRF with respiratory acidosis due to COPD., Methods: COPD patients presenting with AHRF and who were treated with NIV were studied prospectively. The forced expiratory volume in 1 second (FEV1), World Health Organization performance status (WHO-PS), clinical observations, a composite physiological score (Early Warning Score), routine hematology and biochemistry, and arterial blood gases prior to commencing NIV, were recorded., Results: In total, 65 patients were included for study, 29 males and 36 females, with a mean age of 71 ± 10.5 years. Inpatient mortality in the group was 33.8%. Mortality at 30 days and 12 months after admission were 38.5% and 58.5%, respectively. On univariate analysis, the variables associated with inpatient death were: WHO-PS ≥ 3, long-term oxygen therapy, anemia, diastolic blood pressure < 70 mmHg, Early Warning Score ≥ 3, severe acidosis (pH < 7.20), and serum albumin < 35 g/L. On multivariate analysis, only anemia and WHO-PS ≥ 3 were significant. The presence of both predicted 68% of inpatient deaths, with a specificity of 98%., Conclusion: WHO-PS ≥ 3 and anemia are prognostic factors in AHRF with respiratory acidosis due to COPD. A combination of the two provides a simple method of identifying patients unlikely to benefit from NIV.

Objective: To determine the usefulness of non-invasive ventilation (NIV) in elderly patients (≥75) admitted to a respiratory monitoring unit (RMU) during hospitalization and 1 year later in comparison with the results from the younger age group (<75)., Material and Methods: Ours is a prospective observational study carried out at the Hospital Universitario La Princesa (Madrid, Spain). We recruited all patients who were ≥75 years old and were admitted to our RMU during the period 2008-2009 with respiratory acidosis (pH<7.35 and PaCO(2)>45 mmHg) requiring NIV. We gathered data for basic variables as well as sociodemographics, history of previous pathologies, reason for hospitalization and severity, analysis upon admission and the evolution of blood gases at the start of NIV (within the first hour and after 24 h), complications and evolution at the 1-year follow-up., Results: Mean age of the sample was 80.6. The Charlson index was 3.27. About half of the patients had some limitation for performing daily activities. The main reasons for admission were COPD exacerbation and heart failure. There were complications in 36% of the cases (11 renal failure and 6 atrial fibrillation). The survival rate at the 1-year follow-up was 63.21%., Conclusions: NIV is a good alternative in elderly patients admitted to the hospital with respiratory acidosis. We did not detect differences in mortality during admission between the two groups. The elderly patients were more frequently re-admitted than the younger group in the 6-12 months after hospital discharge. This could be due to their poorer functional state after hospitalization requiring NIV., (Copyright © 2012 SEPAR. Published by Elsevier España, S.L. All rights reserved.)

Socially subordinate rainbow trout (Oncorhynchus mykiss) experience chronic stress that impacts upon a variety of physiological functions, including Na(+) regulation. Owing to the tight coupling between Na(+) and Cl(-) uptake and, respectively, H(+) and HCO(3)(-) loss at the gill, ionoregulatory changes associated with social status may affect acid-base regulation. The present study assessed the responses of dominant, subordinate and control trout to hypercapnia (1% CO(2)) to test this hypothesis. Social status appeared to impact net acid excretion (J(net)H(+)) as subordinate individuals failed to increase net acid flux in response to hypercapnia. However, blood acid-base status was found to be unaffected by social status before or during hypercapnic exposure, indicating that subordinate fish were as effective as dominant or control trout in achieving compensation for the acid-base disturbance induced by hypercapnic exposure. Compensation in all groups involved decreasing Cl(-) uptake in response to hypercapnia. The branchial activities of both Na(+),K(+)-ATPase (NKA) and V-type H(+)-ATPase were affected by social interactions and/or exposure to hypercapnia. Branchial NKA activity was higher but V-ATPase activity was lower in control fish than in dominant or subordinate trout. In addition, control and subordinate but not dominant trout exposed to 24h of hypercapnia exhibited significantly higher branchial V-ATPase activity than fish maintained in normocapnia. Collectively, the data suggest that subordinate trout are able to regulate blood pH during a respiratory acidosis., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aim: To examine whether inhalation of CO(2) -enriched gas would increase steady-state VO(2) during exercise and enlarge O(2) deficit., Methods: Ten physically active men (VO(2) 53.7 ± 3.6 mL min(-1) kg(-1) ; x ± SD) performed transitions from low-load cycling (baseline; 40 W) to work rates representing light (≈ 45% VO(2); 122 ± 15 W) and heavy (≈ 80% VO(2); 253 ± 29 W) exercise while inhaling normal air (air) or a CO(2) mixture (4.2% CO(2) , 21% O(2) , balance N(2) ). Gas exchange was measured with Douglas bag technique at baseline and at min 0-2, 2-3 and 5-6., Results: Inhalation of CO(2) -enriched air consistently induced respiratory acidosis with increases in PCO(2) and decreases in capillary blood pH (P < 0.01). Hypercapnic steady-state VO(2) was on average about 6% greater (P < 0.01) than with air in both light and heavy exercise, presumably because of increased cost of breathing (ΔVE 40-50 L min(-1) ; P < 0.01), and a substrate shift towards increased lipid oxidation (decline in R 0.12; P < 0.01). VO(2) during the first 2 min of exercise were not significantly different whereas the increase in VO(2) from min 2-3 to min 5-6 in heavy exercise was larger with CO(2) than with air suggesting a greater VO(2) slow component. As a result, O(2) deficit was greater with hypercapnia in heavy exercise (2.24 ± 0.51 L vs. 1.91 ± 0.45 L; P < 0.05) but not in light (0.64 ± 0.21 L vs. 0.54 ± 0.20 L; ns)., Conclusion: Inhalation of CO(2)-enriched air and the ensuing respiratory acidosis increase steady-state VO(2) in both light and heavy exercise and enlarges O(2) deficit in heavy exercise., (© 2011 The Authors. Acta Physiologica © 2011 Scandinavian Physiological Society.)

The nutrition support practitioner is confronted with numerous metabolic abnormalities in the daily care of patients. An understanding of the basic principles of acid-base balance, along with the ability to recognize common causes of the various disorders, enhances the clinician's ability to provide specialized nutrition support. The basic metabolic and respiratory disorders, along with common causes, are reviewed in this tutorial.

Malignant tumours are characterised by a low, acidic extracellular pH (pHe) which facilitates invasion and metastasis. Previous research has proposed the potential benefits of manipulating systemic pHe, and recent experiments have highlighted the potential for buffer therapy to raise tumour pHe, prevent metastases, and prolong survival in laboratory mice. To examine the physiological regulation of tumour buffering and investigate how perturbations of the buffering system (via metabolic/respiratory disorders or changes in parameters) can alter tumour and blood pHe, we develop a simple compartmentalised ordinary differential equation model of pHe regulation by the HCO3-/CO2 buffering system. An approximate analytical solution is constructed and used to carry out a sensitivity analysis, where we identify key parameters that regulate tumour pHe in both humans and mice. From this analysis, we suggest promising alternative and combination therapies, and identify specific patient groups which may show an enhanced response to buffer therapy. In addition, numerical simulations are performed, validating the model against well-known metabolic/respiratory disorders and predicting how these disorders could change tumour pHe., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Reports of non-invasive ventilation (NIV) use in clinical practice reveal higher mortality rates than in corresponding randomised clinical trials., Aim: To explore factors related to chronic obstructive pulmonary disease (COPD) admissions and NIV use that may explain some of the previously reported high mortality rates., Methods: National UK audit of clinical care of consecutive COPD admissions from March to May 2008. Retrospective case note audit with prospective case ascertainment. Participating units completed a web-based audit proforma of process and outcomes of clinical care., Results: 232 hospital units collected data on 9716 patients, mean age 73, 50% male. 1678 (20%) of those with gases recorded on admission were acidotic and another 6% became acidotic later. 1077 patients received NIV, 55% had a pH<7.26 and 49% (305/618) had or were still receiving high flow oxygen. 30% (136/453) patients with persisting respiratory acidosis did not receive NIV while 11% (15/131) of acidotic admissions had a pure metabolic acidosis and did. Hospital mortality was 25% (270/1077) for patients receiving NIV but 39% (86/219) for those with late onset acidosis and was higher in all acidotic groups receiving NIV than those treated without. Only 4% of patients receiving NIV who died had invasive mechanical ventilation., Conclusions: COPD admissions treated with NIV in usual clinical practice were severely ill, many with mixed metabolic acidosis. Some eligible patients failed to receive NIV, others received it inappropriately. NIV appears to be often used as a ceiling of treatment including patient groups in whom efficacy of NIV is uncertain. The audit raises concerns that challenge the respiratory community to lead appropriate clinical improvements across the acute sector.

Exacerbations of cystic fibrosis (CF) lung disease are characterized by increased inspissation of abnormally viscid pulmonary secretions with resultant plugging of small airways, worsened ventilation/perfusion mismatch, and increased physiological deadspace. In this circumstance, hypoxic respiratory failure necessitating mechanical ventilation can be life-threatening. We present such a case of CF lung disease poorly responsive to conventional mechanical ventilatory strategies, in which high-frequency percussive ventilation (HFPV) using volumetric diffusive respiration mobilized copious amounts of inspissated pulmonary secretions and improved refractory hypoxia. Subsequent transient hypercarbia necessitated titrating ventilator parameters to return the PaCO(2) to baseline; the voluminous clearance of secretions and improvement in oxygenation were sustained. HFPV appears unique in its ability to function as a methodological continuum from noninvasive percussion to invasive percussive ventilation for airway clearance, a fundamental tenet of the CF treatment paradigm.

Acidification of ocean surface waters by anthropogenic carbon dioxide (CO(2)) emissions is a currently developing scenario that warrants a broadening of research foci in the study of acid-base physiology. Recent studies working with environmentally relevant CO(2) levels, indicate that some echinoderms and molluscs reduce metabolic rates, soft tissue growth and calcification during hypercapnic exposure. In contrast to all prior invertebrate species studied so far, growth trials with the cuttlefish Sepia officinalis found no indication of reduced growth or calcification performance during long-term exposure to 0.6 kPa CO(2). It is hypothesized that the differing sensitivities to elevated seawater pCO(2) could be explained by taxa specific differences in acid-base regulatory capacity. In this study, we examined the acid-base regulatory ability of S. officinalis in vivo, using a specially modified cannulation technique as well as (31)P NMR spectroscopy. During acute exposure to 0.6 kPa CO(2), S. officinalis rapidly increased its blood [HCO(3)(-)] to 10.4 mM through active ion-transport processes, and partially compensated the hypercapnia induced respiratory acidosis. A minor decrease in intracellular pH (pH(i)) and stable intracellular phosphagen levels indicated efficient pH(i) regulation. We conclude that S. officinalis is not only an efficient acid-base regulator, but is also able to do so without disturbing metabolic equilibria in characteristic tissues or compromising aerobic capacities. The cuttlefish did not exhibit acute intolerance to hypercapnia that has been hypothesized for more active cephalopod species (squid). Even though blood pH (pHe) remained 0.18 pH units below control values, arterial O(2) saturation was not compromised in S. officinalis because of the comparatively lower pH sensitivity of oxygen binding to its blood pigment. This raises questions concerning the potentially broad range of sensitivity to changes in acid-base status amongst invertebrates, as well as to the underlying mechanistic origins. Further studies are needed to better characterize the connection between acid-base status and animal fitness in various marine species.

Background: Although the cardiovascular effect of CO2 insufflation has not been reported in pediatric thoracoscopy, several clinical trials have demonstrated significant hemodynamic deterioration in adults. We investigated the concept of therapeutic hypercapnia for counteracting the hemodynamic effect of induced capnothorax., Methods: Twelve pediatric patients who underwent video-assisted thoracoscopic patent ductus arteriosus closure were enrolled in the study. Cardiorespiratory variables were determined during baseline T1 and after CO2 insufflation at pressures of 2 mm Hg T2, 4 mm Hg T3, 6 mm Hg T4, 8 mm Hg T5, and 10 mm Hg T6., Results: CO2 insufflation was not associated with any adverse hemodynamic effects. Cardiac output and central venous oxygen saturation increased progressively throughout the study protocol. Relative to baseline peak velocity, systolic flow time corrected for heart rate, heart rate, and central venous pressure increased significantly during insufflation, but systolic and diastolic blood pressure remained unchanged. Arterial CO2 increased from 40.7 +/- 3 at T1 to 61 +/- 1.6 at T6 mm Hg. Arterial oxygen tension increased from 170.9 +/- 3.3 at T1 to 182 +/- 2 at T6; arterial PH decreased from 7.31 +/- 1.2 at T1 to 7.14 +/- 4.6 at T6., Conclusion: Hypercapnia targeting CO2 50-70 mm Hg was associated with increased cardiac output, central venous O2, and arterial O2 tension in patients undergoing video-assisted thoracoscopic patent ductus arteriosus closure using one-lung ventilation without any deleterious cardiopulmonary effects.

Background: Foetal hypoxia may lead to multi-organ failure and cerebral injury. Usually this process is accompanied by severe metabolic acidosis. The base excess (BE) determined in umbilical artery (UA) blood is the most appropriate parameter to evaluate metabolic acidosis. The correct determination of BE therefore is of paramount importance both for the jeopardised foetus and the obstetrician in litigation. In blood, BE is dependent on the oxygen saturation [sO2 (%)] of haemoglobin (cHb). Due to the normally low foetal pO2 values in UA blood (median: ca. 18 mmHg) sO2 is low as well; therefore computational correction of BE to - by definition - 100 % oxygen saturation seems to be mandatory. This paper presents an analysis of this complex problem in obstetrics., Methods: pH, pCO2, pO2 and cHb were measured in UA blood of 6 302 term infants delivered spontaneously using equipments from Radiometer (Copenhagen). BE was computed according to the equation of Siggaard-Andersen actually used in many blood-gas analysers. sO2 (%) was computed for HbF using the algorithm of Ruiz et al. . The numerical correction of BE was achieved with an equation given again by Siggaard-Andersen . APGAR indices after 1 minute were used., Results: Median BE in UA was - 4.6 and the mean was - 4.9 +/- 3.0 mmol / L, respectively. Correction of BE (BEoxy.) to the actual (calculated) oxygen saturation (%) leads (always) to lower values: a median BE (oxy.) in UA of - 7.4 and a mean of - 7.6 +/- 3.2 mmol / L, respectively. There is no correlation between BE and sO2 in UA blood: r = 0.0078, p = 0.532, n = 6 302 (mean oxygen saturation: 27.7 +/- 18.3 % ). The median cHb amounted to 15.2 and the mean to 15.0 +/- 2.6 g %, respectively. The median delta-BE,UA(BE - BEoxy.) amounts to 2.74 mmol / L; the maximum delta-BE reached 5.2 mmol / L in this sample. Correction of BE to 100 % oxygen saturation based on the (calculated) real oxygen saturation (%) leads to significantly (p = 0.0099) higher correlations with the APGAR index (1 min) and pCO2 in UA (p << 10 (-4)) as well., Conclusion: Correction of BE in UA, i. e., correction of BE to 100 % oxygen saturation using the (calculated) actual oxygen saturation (%) of the blood sample is mandatory in perinatal medicine. Correction uniformly leads to lower BE values (median: 2.7 mmol / L) and significantly higher correlation coefficients with important clinical variables (e. g., the APGAR index).

Our purpose is to evaluate intramucosal gastric pH video imaging by 2('),7(')-bis(carboxyethyl)-5,6-carboxyfluorescein (BCECF) fluorescence ratio techniques. We use a video endoscopic imaging system and BCECF as the pH fluorescent probe. Systemic in vivo pH variations are studied in 10 pigs: five in the control group and five with respiratory acidosis induced through rebreathing. The intramucosal pH of the gastric wall is measured every 5 s and the results demonstrate a good correlation (pearson correlation=0.832) between blood gases pH measurements and pH measured with the video endocopic imaging system. Our results confirm the feasibility of using BCECF fluorescence pH imaging to measure intramucosal pH in vivo.

Objective: To determine concentrations of electrolytes, total bilirubin, urea, creatinine, and hemoglobin; activities of some enzymes; and Hct and number of leukocytes and erythrocytes of newborn calves in relation to the degree of acidosis and treatment with a hypertonic sodium bicarbonate (NaHCO(3)) solution., Animals: 20 acidotic newborn calves with a blood pH < 7.2 and 22 newborn control calves with a blood pH > or = 7.2., Procedures: Approximately 10 minutes after birth, acidotic calves were treated by IV administration of 5% NaHCO(3) solution. The amount of hypertonic solution infused was dependent on the severity of the acidosis., Results: Treatment resulted in a significant increase in the mean +/- SEM base excess from -8.4 +/- 1.2 mmol/L immediately after birth to 0.3 +/- 1.1 mmol/L 120 minutes later. During the same period, sodium concentration significantly increased from 145.3 +/- 0.8 mmol/L to 147.8 +/- 0.7 mmol/L. Mean chloride concentration before NaHCO(3) administration was significantly lower in the acidotic calves (99.6 +/- 1.1 mmol/L) than in the control calves (104.1 +/- 0.9 mmol/L). Calcium concentration in acidotic calves decreased significantly from before to after treatment. Concentrations of potassium, magnesium, and inorganic phosphorus were not affected by treatment., Conclusions and Clinical Relevance: Administration of hypertonic NaHCO(3) solution to acidotic neonatal calves did not have any adverse effects on plasma concentrations of several commonly measured electrolytes or enzyme activities. The treatment volume used was smaller, compared with that for an isotonic solution, which makes it more practical for use in field settings.

In order to address the possible role of blood acid-base status in controlling the rectal gland, dogfish were fitted with indwelling arterial catheters for blood sampling and rectal gland catheters for secretion collection. In intact, unanaesthetized animals, isosmotic volume loading with 500 mmol L-1 NaCl at a rate of 15 mL kg-1 h-1 produced a brisk, stable rectal gland secretion flow of about 4 mL kg-1 h-1. Secretion composition (500 mmol L-1 Na+ and Cl-; 5 mmol L-1 K+; <1 mmol L-1 Ca2+, Mg2+, SO(4)2-, or phosphate) was almost identical to that of the infusate with a pH of about 7.2, HCO3- mmol L-1<1 mmol L-1 and a PCO2 (1 Torr) close to PaCO2. Experimental treatments superimposed on the infusion caused the expected disturbances in systemic acid-base status: respiratory acidosis by exposure to high environmental PCO2, metabolic acidosis by infusion of HCl, and metabolic alkalosis by infusion of NaHCO3. Secretion flow decreased markedly with acidosis and increased with alkalosis, in a linear relationship with extracellular pH. Secretion composition did not change, apart from alterations in its acid-base status, and made negligible contribution to overall acid-base balance. An adaptive control of rectal gland secretion by systemic acid-base status is postulated-stimulation by the "alkaline tide" accompanying the volume load of feeding and inhibition by the metabolic acidosis accompanying the volume contraction of exercise.

Objective: To report the use of pumpless extracorporeal carbon dioxide removal in two cases of acute severe asthma., Design: Case reports., Setting: Adult general intensive care unit, Leeds General Infirmary, Leeds, UK., Patients: A 74-yr-old male and 52-yr-old female with life-threatening asthma developed progressive hypercapnia and severe acidosis that proved nonresponsive to all other therapies., Intervention: Initiation of extracorporeal arteriovenous carbon dioxide removal using the Novalung device (Novalung GmbH, Lotzenäcker 3, D-72379 Hechingen, Germany)., Main Results: The addition of extracorporeal carbon dioxide removal to mechanical ventilation corrected hypercapnia and acidosis, allowing reduction of other supportive measures. In both cases, adequate gas exchange was maintained until their underlying condition improved sufficiently for device removal. The two patients were subsequently weaned from mechanical ventilation and made a full recovery., Conclusions: Extracorporeal carbon dioxide removal proved to be a valuable adjunct to mechanical ventilation and other medical treatment.

In the third and final part of this series looking at blood gas analysis, Liz Allibone and Nicola Nation provide three examples of how arterial blood gas results assist in the diagnosis and management of illness.

The purpose of this study was to find out the impact of acute respiratory acidosis on serum potassium level during laparoscopy. The study was performed on ninety patients who underwent laparoscopic surgery. Ventilation parameters were kept constant throughout the study. Samples for assessment of blood gases were collected in the following sequence: before pneumoperitoneum, a the 20th minute of pneumoperitoneum, at the 60th minute of pneumoperitoneum, and after extubation. The systolic, diastolic pressures and heart rate were recorded simultaneously. Before pneumoperitoneum, heart rate, systolic and diastolic pressures were reduced according to baseline values. With the induction of pneumoperitoneum, both systolic and diastolic pressures returned to the baseline levels except the heart rate. There was a statistically significant increase in potassium level (Control: 3.49 mEq.L(-1), determined high level: 3.75 mEq.L(-1)). Electrolytes, especially potassium, should be monitored during laparoscopy utilizing CO2 pneumoperitoneum and when necessary, ventilatory parameters should be adjusted.