Weaning From Mechanical Ventilation Using Permissive Hypercarbia

Some patients receiving mechanical ventilation have difficulty weaning off the ventilator because of physiological factors such as pre-existing lung disease, respiratory distress syndrome, and trauma among others. Allowing patients to become hypercarbic (increased blood bicarbonate level) may make it easier for these patients to be taken off the ventilator and resume breathing on their own.

Study Overview

• Status: Terminated
• Conditions: Respiratory Distress Syndrome, Adult; Respiration, Artificial
• Intervention / Treatment: Procedure: Permissive hypercarbia

Detailed Description

The primary objective of this research is to assess the utility of permissive hypercarbia (PH) in the weaning of patients with risk factors for difficult weaning from mechanical ventilation. This pilot study seeks to validate the concept that PH will significantly improve the ability of patients to be weaned from mechanical ventilation and change the approach that physicians take to ventilator weaning for many patients.

Null Hypothesis: Patients with PH will not be weaned from mechanical ventilation more rapidly than those not receiving PH.

Patients with significant lung disease fail weaning from mechanical ventilation either as a result of an inability to oxygenate the blood or to adequately remove carbon dioxide. This results in longer Intensive Care Unit stays and increased morbidity and mortality as these patients have prolonged periods of mechanical ventilation. This study will focus on patients who have failure to adequately remove carbon dioxide (ventilatory failure) and endeavors to evaluate a method for enhanced carbon dioxide elimination by altering the acid-base status of the patients utilizing permissive hypercarbia (PH). PH will be used specifically during weaning from mechanical ventilation to enhance carbon dioxide elimination during this period. PH has used by some intensivists for this purpose but has not been critically evaluated in a clinical study.

Mechanical ventilation using PH maintains an increased CO2 with either partial or complete metabolic compensation. Therefore, the blood pH is either normal or slightly reduced. In patients who are adequately sedated, the reduced pH is well tolerated without respiratory distress or air hunger. However, if PH is to be used in awake patients as proposed here, full metabolic compensation would be required to avoid air hunger while being weaned from ventilator support. The metabolic compensation is produced either as a result of a renal compensation or, more typically in the ICU setting, iatrogenically. Metabolic alkalosis can be produced through the administration of alkalinizing agents or as a result of gastric suctioning or from contraction alkalosis resulting from the use of diuretics.

PH enhances CO2 elimination by increasing the concentration of CO2 in the exhaled gas. The pulmonary capillary pCO2 is elevated and therefore so is the alveolar CO2 and the exhaled or end-tidal CO2. Thus more CO2 is exhaled in an equal volume of exhaled gas. This increased CO2 concentration reduces the minute ventilation required to exhale the CO2 produced by the patient. PH will decrease the minute ventilation requirement even in patients with an increased dead space and will facilitate weaning these patients from mechanical ventilation by the same mechanism as just described.

• Study Type: Interventional
• Enrollment (Actual): 3
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Pennsylvania
    • Hershey, Pennsylvania, United States, 17033
      • Penn State Milton S. Hershey Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Adult (> 18 yo) patients in the intensive care units at the Hershey Medical Center who are on mechanical ventilation
• and whose clinical course permits weaning from mechanical ventilation
• and are felt to have risk factors for difficult weaning. (Risk factors will include patients with rib fractures, pulmonary contusions, obesity (BMI >30), or history of COPD or other significant lung disease.)
• all patients will have failed (rapid shallow breathing index >105) a 30 minute spontaneous breathing test.

Exclusion Criteria:

• Overt signs of sepsis including: a temperature > 38.5F, white blood cell count > 14000, systolic blood pressure < 100 mmHg,
• intracranial hypertension (ICP > 18 or based upon clinical exam and/or history),
• or pulmonary hypertension (by history or PAsys > 40 mmHg).
• or history of recent(past 6 mos)MI

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Time for weaning from positive pressure support mechanical ventilation

Secondary Outcome Measures

Outcome Measure
Percentage of subjects/group successfully weaned within seven days of trial participation

Collaborators and Investigators

• Sponsor: Milton S. Hershey Medical Center
• Investigators: Principal Investigator: Kane M High, MD, Penn State University, College of Medicine, Penn State Milton S. Hershey Medical Center

Study record dates

Study Major Dates

• Study Start: August 1, 2006
• Primary Completion (Actual): June 14, 2007
• Study Completion (Actual): June 14, 2007

Study Registration Dates

• First Submitted: July 27, 2006
• First Submitted That Met QC Criteria: July 27, 2006
• First Posted (Estimate): July 28, 2006

Study Record Updates

• Last Update Posted (Actual): October 20, 2017
• Last Update Submitted That Met QC Criteria: October 18, 2017
• Last Verified: October 1, 2017

More Information

Terms related to this study

• Keywords: permissive hypercarbia; weaning from mechanical ventilation
• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Respiration Disorders; Lung Diseases; Infant, Newborn, Diseases; Signs and Symptoms, Respiratory; Lung Injury; Infant, Premature, Diseases; Respiratory Distress Syndrome; Respiratory Distress Syndrome, Newborn; Acute Lung Injury; Hypercapnia
• Other Study ID Numbers: 23214