title: Managing hypercapnia in patients with severe ARDS and low respiratory system compliance: the role of esophageal pressure monitoring--a case cohort study.
abstract: OBJECTIVE
  Patients with severe acute respiratory distress syndrome (ARDS) and hypercapnia present a formidable treatment challenge. We examined the use of esophageal balloon for assessment of transpulmonary pressures to guide mechanical ventilation for successful management of severe hypercapnia.
  
  
  METHODS
  Patients with severe ARDS and hypercapnia were studied. Esophageal balloon was inserted and mechanical ventilation was guided by assessment of transpulmonary pressures. Positive end expiratory pressure (PEEP) and inspiratory driving pressures were adjusted with the aim of achieving tidal volume of 6 to 8 mL/kg based on ideal body weight (IBW), while not exceeding end inspiratory transpulmonary (EITP) pressure of 25 cm H2O.
  
  
  RESULTS
  Six patients with severe ARDS and hypercapnia were studied. Mean PaCO2 on enrollment was 108.33 ± 25.65 mmHg. One hour after adjustment of PEEP and inspiratory driving pressure guided by transpulmonary pressure, PaCO2 decreased to 64.5 ± 16.89 mmHg (P < 0.01). Tidal volume was 3.96 ± 0.92 mL/kg IBW before and increased to 7.07 ± 1.21 mL/kg IBW after intervention (P < 0.01). EITP pressure before intervention was low with a mean of 13.68 ± 8.69 cm H2O and remained low at 16.76 ± 4.76 cm H2O (P = 0.18) after intervention. Adjustment of PEEP and inspiratory driving pressures did not worsen oxygenation and did not affect cardiac output significantly.
  
  
  CONCLUSIONS
  The use of esophageal balloon as a guide to mechanical ventilation was able to treat severe hypercapnia in ARDS patients.
authors.affiliation: Intensive Care Unit, E. Wolfson Medical Center, 62 HaLohamim Street, P.O. Box 5, 58100 Holon, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Arie
authors.identifier: 0000-0002-3331-6963
authors.initials: A
authors.lastname: Soroksky
authors.affiliation: Intensive Care Unit, E. Wolfson Medical Center, 62 HaLohamim Street, P.O. Box 5, 58100 Holon, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Julia
authors.initials: J
authors.lastname: Kheifets
authors.affiliation: Intensive Care Unit, E. Wolfson Medical Center, 62 HaLohamim Street, P.O. Box 5, 58100 Holon, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Zehava
authors.initials: Z
authors.lastname: Girsh Solomonovich
authors.affiliation: Intensive Care Unit, E. Wolfson Medical Center, 62 HaLohamim Street, P.O. Box 5, 58100 Holon, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Emad
authors.initials: E
authors.lastname: Tayem
authors.affiliation: Intensive Care Unit, E. Wolfson Medical Center, 62 HaLohamim Street, P.O. Box 5, 58100 Holon, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Balmor
authors.initials: B
authors.lastname: Gingy Ronen
authors.affiliation: Intensive Care Unit, E. Wolfson Medical Center, 62 HaLohamim Street, P.O. Box 5, 58100 Holon, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Boris
authors.initials: B
authors.lastname: Rozhavsky
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006801:Humans; D006935:Hypercapnia / Q000503:physiopathology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration / Q000379:methods; D012121:Respiration, Artificial / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000503:physiopathology* / Q000628:therapy*; D012137:Respiratory System / Q000503:physiopathology*; D013990:Tidal Volume / Q000502:physiology