0
September 28, 1994, Vol 272, No. 12 >
ARTICLE | September 28, 1994

Permissive Hypercapnia in Acute Respiratory Failure FREE

Akhil Bidani, MD, PhD; Alexander E. Tzouanakis, MD; Victor J. Cardenas, Jr, MD; Joseph B. Zwischenberger, MD
[+] Author Affiliations

Reprint requests to Pulmonary Division, 0561, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-0561 (Dr Bidani).

Concepts in Emergency and Critical Care section editor: Roger C. Bone, MD, Consulting Editor, JAMA. Advisory Panel: Bart Chernow, MD, Baltimore, Md; David Dantzker, MD, New Hyde Park, NY; Jerrold Leiken, MD, Chicago, Ill; Joseph E. Parrillo, MD, Chicago, Ill; William J. Sibbald, MD, London, Ontario; and Jean-Louis Vincent, MD, PhD, Brussels, Belgium.


JAMA. 1994;272(12):957-962. doi:10.1001/jama.1994.03520120067033
Text Size: A A A
Published online
Article
References

Objective.  —To evaluate the potential efficacy of pressure limitation with permissive hypercapnia in the treatment of acute respiratory failure/adult respiratory distress syndrome on the basis of current theories of ventilator-induced lung injury, potential complications of systemic hypercarbia, and available human outcome studies.

Data Sources.  —Articles were identified through MEDLINE, reference citations of published data, and consultation with authorities in their respective fields.

Study Selection.  —Animal model experimentation and human clinical trials were selected on the basis of whether they addressed the questions of pressure limitation with or without hypercapnia, the pathophysiologic effects of hypercapnia, or the concept of ventilator-induced parenchymal lung injury. Frequently cited references were preferentially included.

Data Extraction.  —Data were analyzed with particular emphasis on obtaining the following variables from the clinical studies: peak inspiratory pressures, tidal volumes, minute ventilation, and Pco2. Quantitative aspects of respiratory physiology were used to analyze the theoretical effects of permissive hypercapnia on ventilatory requirements in normal and injured lungs.

Data Synthesis.  —Extensive animal model data support the hypothesis that ventilator-driven alveolar overdistention can induce significant parenchymal lung injury. The heterogeneous nature of lung injury in adult respiratory distress syndrome, with its small physiologic lung volume, may render the lung susceptible to this type of injury through the use of conventional tidal volumes (10 to 15 mL/kg). Permissive hypercapnia is an approach whereby alveolar overdistention is minimized through either pressure or volume limitation, and the potential deleterious consequences of respiratory acidosis are accepted. Uncontrolled human trials of explicit or implicit permissive hypercapnia have demonstrated improved survival in comparison with models of predictive mortality.

Conclusions.  —Avoidance of alveolar overdistention through pressure or volume limitation has significant support based on animal models and computer simulation. Deleterious effects of the associated hypercarbia in severe lung injury do not appear to be a significant limiting factor in preliminary human clinical trials. Although current uncontrolled studies suggest benefit, controlled trials are urgently needed to confirm these findings before adoption of the treatment can be endorsed.(JAMA. 1994;272:957-962)

REFERENCES

1 +
Dreyfuss D, Saumon G.  Barotrauma is volutrauma, but which volume is the one responsible? Intensive Care Med . 1992;;18:139-141.
2 +
Hickling KG, Henderson SJ, Jackson R.  Low mortality associated with low volume, pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med . 1990;;16:372-377.
3 +
Bendixen HH, Hedley-Whyte J, Laver MB.  Impaired oxygenation in surgical patients during general anesthesia with controlled ventilation: a concept of atelectasis. N Engl J Med . 1963;;269:991-996.
4 +
Ashbaugh DG, Bigelow DB, Petty TL, Levine BE.  Acute respiratory distress in adults. Lancet . 1967;;2:319-323.
5 +
Webb HH, Tierney DF.  Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures: protection by positive end-expiratory pressure. Am Rev Respir Dis . 1974;;110:556-565.
6 +
Dreyfuss D, Basset G, Soler P, Saumon G.  Intermittent positive-pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats. Am Rev Respir Dis . 1985;;132:880-884.
7 +
Dreyfuss D, Soler P, Basset G, Saumon G.  High inflation pressure pulmonary edema: respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis . 1988;;137:1159-1164.
8 +
Hernandez LA, Peevy KJ, Moise AA, Parker JC.  Chest wall restriction limits high airway pressure-induced lung injury in young rabbits. J Appl Physiol . 1989;;66:2364-2368.
9 +
Tsuno K, Miura K, Takeya M, Kolobow T, Morioka T.  Histopathologic pulmonary changes from mechanical ventilation at high peak airway pressures. Am Rev Respir Dis . 1991;;143:1115-1120.
10 +
Corbridge TC, Wood LDH, Crawford GP, et al.  Adverse effects of large tidal volume and low PEEP in canine acid aspiration. Am Rev Respir Dis . 1990;; 142:311-315.
11 +
Bowton DL, Kong DL.  High tidal volume ventilation produces increased lung water in oleic acid-injured rabbit lungs. Crit Care Med . 1989;;17:908-911.
12 +
Kawano T, More S, Cybulsky M, et al.  Effect of granulocyte depletion in a ventilated surfactant-depleted lung. J Appl Physiol . 1987;;62:27-33.
13 +
Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M.  Pressure-volume curve of total respiratory system in acute respiratory failure: computed tomographic study. Am Rev Respir Dis . 1987;; 136:730-736.
14 +
Rahn H.  Why are pH of 7.4 and Pco2 of 40 normal values for man? Bull Eur Physiopathol Res . 1976;;12:5-12.
15 +
Rahn H, Reeves RB, Howell BJ.  Hydrogen ion regulation, temperature, and evolution. Am Rev Respir Dis . 1975;;112:165-172.
16 +
Tenney MS, Bartlett D.  Comparative quantitative morphology of the mammalian lung: trachea. Respir Physiol . 1967;;3:130-135.
17 +
Bidani A, DuBose TD.  Cellular and whole body acid-base regulation.  In: Arieff AI, DeFronzo RA, eds. Fluid, Electrolyte, and Acid Base Disorders . 2nd ed. New York, NY: Churchill Livingstone. In press.
18 +
Siejo BK, Folbergrova J, MacMillen V.  The effect of hypercapnia upon intracellular pH in the brain, evaluated by the bicarbonate-carbonic acid method and from the creatinine phosphokinase equilibrium. J Neurochem . 1972;;19:2483-2495.
19 +
Siejo BK.  Quantification of pH regulation in hypercapnia and hypocapnia. Scand J Clin Lab Invest . 1971;;28:113-119.
20 +
Morris ME, Millar RA.  Blood pH/plasma catecholamine relationships: respiratory acidosis. Br J Anaesth . 1962;;34:672.
21 +
Hoka S, Arimura H, Bosnjak ZJ, Kampine JP.  Regional venous outflow, blood volume, and sympathetic nerve activity during hypercapnia and hypoxic hypercapnia. Can J Physiol Pharmacol . 1992;; 70:1032-1039.
22 +
Ott NT, Shepherd JT.  Modifications of the aortic and vagal depressor reflexes by hypercapnia in the rabbit. Circ Res . 1973;;33:160-165.
23 +
Prys-Roberts C.  Hypercapnia.  In: Gray TC, Nunn JF, Utting JE, eds. General Anaesthesia . 4th ed. London, England: Butterworths; 1980;:435-460.
24 +
Schieve JF, Wilson WP.  The changes in cerebral vascular resistance of man in experimental alkalosis and acidosis. J Clin Invest . 1953;;32:33.
25 +
Robin ED.  Abnormalities of acid-base regulation in chronic pulmonary disease with special reference to hypercapnia and extracellular acidosis. N Engl J Med . 1963;;268:917-922.
26 +
Lassen NA.  Brain extracellular pH: the main factor controlling cerebral blood flow. Scand J Clin Lab Invest . 1968;;22:247.
27 +
Kontos HA, Raper AJ.  Analysis of vasoactivity of local pH, Pco2 and bicarbonate on pial vessels. Stroke . 1977;;8:358-360.
28 +
Raichle ME, Posner JB, Plum F.  Cerebral blood flow during and after hyperventilation.  In: Ross Russell RW, ed. Brain and Blood Flow . London, England: Pitman Books Ltd; 1971;:223-228.
29 +
Knabe U, Betz E.  The effect of varying extracellular K+, Mg++, and Ca++ on the diameter of pial arteries.  In: Betz B, ed. Vascular Smooth Muscle . Berlin, Germany: Springer Verlag; 1972;:83-85.
30 +
Foëx P, Fordham RMM.  Intrinsic myocardial recovery from the negative inotropic effects of acute hypercapnia. Cardiovasc Res . 1972;;6:257-262.
31 +
Prys-Roberts C.  Regulation of the circulation.  In: Gray TC, Nunn JF, Utting JE, eds. General Anesthesia . 3rd ed. London, England: Butterworths; 1971;:224-39.
32 +
Walley KR, Lewis TH, Wood LDH.  Acute respiratory acidosis decreases left ventricular contractility but increases cardiac output in dogs. Circ Res . 1990;;67:628-635.
33 +
Irwin RL, Draper WB, Whitehead RW.  Urine secretion during diffusion respiration after apnea from neuromuscular block. Anesthesiology . 1957;; 18:594-602.
34 +
Daugherty RM, Scott JB, Dabney JM, Haddy FJ.  Local effects of O2 and CO2 on limb, renal, and coronary vascular resistances. Am J Physiol . 1967;; 5:1102-1110.
35 +
Tzouanakis AE, Nguyen T, Tao W, et al.  Effect of permissive hypercapnia on renal and mesenteric blood flow in an ovine model. Am Rev Respir Dis . 1993;;147:A891.
36 +
Matalon S, Nesarajah MS, Krasney JA, Farhi LE.  Effects of acute hypercapnia on the central and peripheral circulation of conscious sheep. J Appl Physiol . 1983;;54:803-808.
37 +
Fujita Y, Sakai T, Ohsumi A, Takaori M.  Effects of hypocapnia and hypercapnia on splanchnic circulation and hepatic function in the beagle. Anesth Analg . 1989;;69:152-157.
38 +
Epstein RM, Deutsch S, Cooperman LH, et al.  Splanchnic circulation during halothane anesthesia and hypercapnia in normal man. Anesthesiology . 1966;;27:654-661.
39 +
Murray JF, Matthay MA, Luce JM, Flick M.  An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis . 1988;;138:720-723.
40 +
Hickling KG. Cited by: Kacmarek RM, Hickling KG.  Permissive hypercapnia. Respir Care . 1993;; 38:379.
41 +
Darioli A, Perret C.  Mechanical controlled hypoventilation in status asthmaticus. Am Rev Respir Dis . 1984;;129:385-387.
42 +
Zapol WM, Snider MT, Hill JD, et al.  Extracorporeal membrane oxygenation in severe acute respiratory failure: a randomized prospective study. JAMA . 1979;;242:2193-2196.
43 +
Gattinoni L, Pesenti A, Mascheroni D, et al.  Low frequency positive pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA . 1986;;256:881-886.
44 +
Morris A, Wallace CJ, Menlove RL, et al.  Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med . 1994;;149:295-305.
45 +
Lewandowski K, Slama K, Falke KJ.  Approaches to improve survival in severe ARDS.  In: Vincent JL, ed. Update of Intensive Care and Emergency Medicine . Berlin, Germany: Springer Verlag; 1992;:372-383.
46 +
Carlon GC, Howland WS, Ray C, et al.  High-frequency jet ventilation: a prospective randomized evaluation. Chest . 1983;;84:551-559.
47 +
Hurst JM, Branson RD, Davis K, et al.  Comparison of conventional mechanical ventilation and high-frequency ventilation: a prospective, randomized trial in patients with respiratory failure. Ann Surg . 1990;;211:486-491.
48 +
Segredo V, Caldwell JE, Matthay MA, et al.  Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med . 1992;;327:524-528.
49 +
Shapiro JM, Condos R, Cole RP.  Myopathy in status asthmaticus: relation to neuromuscular blockade and corticosteroid administration. Intensive Care Med . 1993;;8:144-152.
50 +
Douglass JA, Tuxen DV, Horme M, et al.  Myopathy in severe asthma. Am Rev Respir Dis . 1992;; 146:517-519.
51 +
Kupter Y, Namba T, Kaldawi E, Tessler S.  Prolonged weakness after long term infusion of vercuronium bromide. Ann Intern Med . 1992;;117: 484-486.
52 +
Potkin RT, Swenson ER.  Resuscitation from severe acute hypercapnia: determinants of tolerance and survival. Chest . 1992;;102:1742-1745.
53 +
Arieff AI, Leach W, Park R, Lazarowitz VC.  Systemic effects of NaHCO3- in experimental lactic acidosis in dogs. Am J Physiol . 1982;;242:F586-F591.
54 +
Cooper DJ, Walley KR, Wiggs BR, Russell JA.  Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis: a prospective, controlled clinical study. Ann Intern Med . 1990;;112:492-498.
55 +
Morris LR, Murphy MB, Kitabchi AE.  Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med . 1986;;105:836-840.
56 +
Menitove SM, Goldring RM.  Combined ventilator and bicarbonate strategy in the management of status asthmaticus. Am J Med . 1983;;74:898-901.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Dreyfuss D, Saumon G.  Barotrauma is volutrauma, but which volume is the one responsible? Intensive Care Med . 1992;;18:139-141.
2 +
Hickling KG, Henderson SJ, Jackson R.  Low mortality associated with low volume, pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med . 1990;;16:372-377.
3 +
Bendixen HH, Hedley-Whyte J, Laver MB.  Impaired oxygenation in surgical patients during general anesthesia with controlled ventilation: a concept of atelectasis. N Engl J Med . 1963;;269:991-996.
4 +
Ashbaugh DG, Bigelow DB, Petty TL, Levine BE.  Acute respiratory distress in adults. Lancet . 1967;;2:319-323.
5 +
Webb HH, Tierney DF.  Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures: protection by positive end-expiratory pressure. Am Rev Respir Dis . 1974;;110:556-565.
6 +
Dreyfuss D, Basset G, Soler P, Saumon G.  Intermittent positive-pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats. Am Rev Respir Dis . 1985;;132:880-884.
7 +
Dreyfuss D, Soler P, Basset G, Saumon G.  High inflation pressure pulmonary edema: respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis . 1988;;137:1159-1164.
8 +
Hernandez LA, Peevy KJ, Moise AA, Parker JC.  Chest wall restriction limits high airway pressure-induced lung injury in young rabbits. J Appl Physiol . 1989;;66:2364-2368.
9 +
Tsuno K, Miura K, Takeya M, Kolobow T, Morioka T.  Histopathologic pulmonary changes from mechanical ventilation at high peak airway pressures. Am Rev Respir Dis . 1991;;143:1115-1120.
10 +
Corbridge TC, Wood LDH, Crawford GP, et al.  Adverse effects of large tidal volume and low PEEP in canine acid aspiration. Am Rev Respir Dis . 1990;; 142:311-315.
11 +
Bowton DL, Kong DL.  High tidal volume ventilation produces increased lung water in oleic acid-injured rabbit lungs. Crit Care Med . 1989;;17:908-911.
12 +
Kawano T, More S, Cybulsky M, et al.  Effect of granulocyte depletion in a ventilated surfactant-depleted lung. J Appl Physiol . 1987;;62:27-33.
13 +
Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M.  Pressure-volume curve of total respiratory system in acute respiratory failure: computed tomographic study. Am Rev Respir Dis . 1987;; 136:730-736.
14 +
Rahn H.  Why are pH of 7.4 and Pco2 of 40 normal values for man? Bull Eur Physiopathol Res . 1976;;12:5-12.
15 +
Rahn H, Reeves RB, Howell BJ.  Hydrogen ion regulation, temperature, and evolution. Am Rev Respir Dis . 1975;;112:165-172.
16 +
Tenney MS, Bartlett D.  Comparative quantitative morphology of the mammalian lung: trachea. Respir Physiol . 1967;;3:130-135.
17 +
Bidani A, DuBose TD.  Cellular and whole body acid-base regulation.  In: Arieff AI, DeFronzo RA, eds. Fluid, Electrolyte, and Acid Base Disorders . 2nd ed. New York, NY: Churchill Livingstone. In press.
18 +
Siejo BK, Folbergrova J, MacMillen V.  The effect of hypercapnia upon intracellular pH in the brain, evaluated by the bicarbonate-carbonic acid method and from the creatinine phosphokinase equilibrium. J Neurochem . 1972;;19:2483-2495.
19 +
Siejo BK.  Quantification of pH regulation in hypercapnia and hypocapnia. Scand J Clin Lab Invest . 1971;;28:113-119.
20 +
Morris ME, Millar RA.  Blood pH/plasma catecholamine relationships: respiratory acidosis. Br J Anaesth . 1962;;34:672.
21 +
Hoka S, Arimura H, Bosnjak ZJ, Kampine JP.  Regional venous outflow, blood volume, and sympathetic nerve activity during hypercapnia and hypoxic hypercapnia. Can J Physiol Pharmacol . 1992;; 70:1032-1039.
22 +
Ott NT, Shepherd JT.  Modifications of the aortic and vagal depressor reflexes by hypercapnia in the rabbit. Circ Res . 1973;;33:160-165.
23 +
Prys-Roberts C.  Hypercapnia.  In: Gray TC, Nunn JF, Utting JE, eds. General Anaesthesia . 4th ed. London, England: Butterworths; 1980;:435-460.
24 +
Schieve JF, Wilson WP.  The changes in cerebral vascular resistance of man in experimental alkalosis and acidosis. J Clin Invest . 1953;;32:33.
25 +
Robin ED.  Abnormalities of acid-base regulation in chronic pulmonary disease with special reference to hypercapnia and extracellular acidosis. N Engl J Med . 1963;;268:917-922.
26 +
Lassen NA.  Brain extracellular pH: the main factor controlling cerebral blood flow. Scand J Clin Lab Invest . 1968;;22:247.
27 +
Kontos HA, Raper AJ.  Analysis of vasoactivity of local pH, Pco2 and bicarbonate on pial vessels. Stroke . 1977;;8:358-360.
28 +
Raichle ME, Posner JB, Plum F.  Cerebral blood flow during and after hyperventilation.  In: Ross Russell RW, ed. Brain and Blood Flow . London, England: Pitman Books Ltd; 1971;:223-228.
29 +
Knabe U, Betz E.  The effect of varying extracellular K+, Mg++, and Ca++ on the diameter of pial arteries.  In: Betz B, ed. Vascular Smooth Muscle . Berlin, Germany: Springer Verlag; 1972;:83-85.
30 +
Foëx P, Fordham RMM.  Intrinsic myocardial recovery from the negative inotropic effects of acute hypercapnia. Cardiovasc Res . 1972;;6:257-262.
31 +
Prys-Roberts C.  Regulation of the circulation.  In: Gray TC, Nunn JF, Utting JE, eds. General Anesthesia . 3rd ed. London, England: Butterworths; 1971;:224-39.
32 +
Walley KR, Lewis TH, Wood LDH.  Acute respiratory acidosis decreases left ventricular contractility but increases cardiac output in dogs. Circ Res . 1990;;67:628-635.
33 +
Irwin RL, Draper WB, Whitehead RW.  Urine secretion during diffusion respiration after apnea from neuromuscular block. Anesthesiology . 1957;; 18:594-602.
34 +
Daugherty RM, Scott JB, Dabney JM, Haddy FJ.  Local effects of O2 and CO2 on limb, renal, and coronary vascular resistances. Am J Physiol . 1967;; 5:1102-1110.
35 +
Tzouanakis AE, Nguyen T, Tao W, et al.  Effect of permissive hypercapnia on renal and mesenteric blood flow in an ovine model. Am Rev Respir Dis . 1993;;147:A891.
36 +
Matalon S, Nesarajah MS, Krasney JA, Farhi LE.  Effects of acute hypercapnia on the central and peripheral circulation of conscious sheep. J Appl Physiol . 1983;;54:803-808.
37 +
Fujita Y, Sakai T, Ohsumi A, Takaori M.  Effects of hypocapnia and hypercapnia on splanchnic circulation and hepatic function in the beagle. Anesth Analg . 1989;;69:152-157.
38 +
Epstein RM, Deutsch S, Cooperman LH, et al.  Splanchnic circulation during halothane anesthesia and hypercapnia in normal man. Anesthesiology . 1966;;27:654-661.
39 +
Murray JF, Matthay MA, Luce JM, Flick M.  An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis . 1988;;138:720-723.
40 +
Hickling KG. Cited by: Kacmarek RM, Hickling KG.  Permissive hypercapnia. Respir Care . 1993;; 38:379.
41 +
Darioli A, Perret C.  Mechanical controlled hypoventilation in status asthmaticus. Am Rev Respir Dis . 1984;;129:385-387.
42 +
Zapol WM, Snider MT, Hill JD, et al.  Extracorporeal membrane oxygenation in severe acute respiratory failure: a randomized prospective study. JAMA . 1979;;242:2193-2196.
43 +
Gattinoni L, Pesenti A, Mascheroni D, et al.  Low frequency positive pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA . 1986;;256:881-886.
44 +
Morris A, Wallace CJ, Menlove RL, et al.  Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med . 1994;;149:295-305.
45 +
Lewandowski K, Slama K, Falke KJ.  Approaches to improve survival in severe ARDS.  In: Vincent JL, ed. Update of Intensive Care and Emergency Medicine . Berlin, Germany: Springer Verlag; 1992;:372-383.
46 +
Carlon GC, Howland WS, Ray C, et al.  High-frequency jet ventilation: a prospective randomized evaluation. Chest . 1983;;84:551-559.
47 +
Hurst JM, Branson RD, Davis K, et al.  Comparison of conventional mechanical ventilation and high-frequency ventilation: a prospective, randomized trial in patients with respiratory failure. Ann Surg . 1990;;211:486-491.
48 +
Segredo V, Caldwell JE, Matthay MA, et al.  Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med . 1992;;327:524-528.
49 +
Shapiro JM, Condos R, Cole RP.  Myopathy in status asthmaticus: relation to neuromuscular blockade and corticosteroid administration. Intensive Care Med . 1993;;8:144-152.
50 +
Douglass JA, Tuxen DV, Horme M, et al.  Myopathy in severe asthma. Am Rev Respir Dis . 1992;; 146:517-519.
51 +
Kupter Y, Namba T, Kaldawi E, Tessler S.  Prolonged weakness after long term infusion of vercuronium bromide. Ann Intern Med . 1992;;117: 484-486.
52 +
Potkin RT, Swenson ER.  Resuscitation from severe acute hypercapnia: determinants of tolerance and survival. Chest . 1992;;102:1742-1745.
53 +
Arieff AI, Leach W, Park R, Lazarowitz VC.  Systemic effects of NaHCO3- in experimental lactic acidosis in dogs. Am J Physiol . 1982;;242:F586-F591.
54 +
Cooper DJ, Walley KR, Wiggs BR, Russell JA.  Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis: a prospective, controlled clinical study. Ann Intern Med . 1990;;112:492-498.
55 +
Morris LR, Murphy MB, Kitabchi AE.  Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med . 1986;;105:836-840.
56 +
Menitove SM, Goldring RM.  Combined ventilator and bicarbonate strategy in the management of status asthmaticus. Am J Med . 1983;;74:898-901.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems