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The level of partial pressure of carbon dioxide affects organ perfusion in respiratory failure patients undergoing pressure support ventilation with venovenous extracorporeal membrane oxygenation: a prospective study

BMC Pulmonary Medicine volume 24, Article number: 424 (2024) Cite this article

Abstract

Background

We evaluated the influence of different partial carbon dioxide pressure (PaCO2) levels on organ perfusion in patients with respiratory failure receiving pressure-support ventilation with veno-venous extracorporeal membrane oxygenation (V-V ECMO).

Methods

In this twelve patients prospective study, ECMO gas-flow was decreased from baseline (PaCO2 < 40 mmHg) until PaCO2 increased by 5–10 mmHg (High-CO2 phase). Resistance indices of gut, spleen, and snuffbox artery, the peripheral perfusion index (PPI), and heart rate variability were measured at baseline and High-CO2 phase.

Results

When PaCO2 increased from 36 (36–37) mmHg at baseline to 42 (41–43) mmHg in the High-CO2 phase (p < 0.001), PPI decreased significantly (p = 0.026). The snuffbox artery (p = 0.022), superior mesenteric artery (p = 0.042), and spleen (p = 0.012) resistance indices increased significantly. The root mean square of successive differences (RMSSD) decreased from 19.5(18.1–22.7) to 15.9(14.4–18.6) ms (p = 0.034), and the ratio of low-frequency to high-frequency components(LF/HF) increased from 0.47 ± 0.23 to 0.70 ± 0.38 (p = 0.013).

Conclusions

High PaCO2 might cause decreased peripheral tissue and visceral organ perfusion through autonomic nervous system in patients with respiratory failure undergoing PSV with V-V ECMO.

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Background

Respiratory drive and effort are commonly increased in patients with respiratory failure [1], even after receiving veno-venous extracorporeal membrane oxygenation (V-V ECMO) support, due to low pulmonary compliance or high systemic inflammation [2].Excessive respiratory effort may cause inspiratory muscle injuries and self-inflicted lung injury (SILI) [3,4,5], as well as worsening of extrapulmonary organ perfusion [6]. An elevation in the partial pressure of carbon dioxide in the arterial blood (PaCO2) stimulates the respiratory center [3] and triggers an excitatory response. Increased sympathetic nervous system activity is frequently accompanied by hyperexcitation of the respiratory center and autonomic nervous system(ANS) [7, 8]. As a result, this sympathetic hyperactivity induces alterations in cardiac output and vascular resistance, which ultimately has an effect on the perfusion of visceral organs and peripheral tissues.

Different levels of extracorporeal carbon dioxide removal in patients with respiratory failure undergoing V-V ECMO has been shown to alter respiratory drive and effort [9, 10]. This study sought to investigate the impact of different CO2 levels on ANS and organ perfusion in a cohort of patients with respiratory failure undergoing pressure-support ventilation (PSV) with V-V ECMO.

Methods

This study was authorized by the Peking Union Medical College Hospital’s ethical committee(K24C0020). Before enrollment, written informed consent was obtained from all patients or their next of kin.

Patients

This trial was conducted in a 30-bed adult intensive care unit (ICU). The enrolment period was between December 2022 and November 2023.

The inclusion criteria were as follows: (1) age > 18 years; (2) patients with respiratory failure who received V-V ECMO and PSV via tracheal intubation; and (3) PaCO2 < 40mmHg, peak airway pressure < 25 cmH2O, and respiratory rate < 25 bpm; (4) sinus rhythm.

We excluded patients who had undergone abdominal surgery involving the digestive tract, descending thoracic, or abdominal aortic operations; who had coronary heart disease, renal artery stenosis, or severe mesenteric stenosis; or who had low-quality ultrasound imaging.

Typically, A 21-Fr cannula was used to venous access, and a 17-Fr cannula was used to venous return. The ECMO sweep gas flow (GF) was 2–10 L/min, and the blood flow was 3.0–4.0 L/min in order to preserve arterial oxygenation and normocapnia.

Measurements

Indices of peripheral perfusion

Peripheral blood flow was assessed using two clinical indices: peripheral perfusion index (PPI), and resistance index (RI) of the snuffbox artery (SBRI).

The PPI is an index obtained from the photoelectric plethysmographic output of a pulse oximeter. It was assessed using an A Viridia/56S monitor (Philips Medical Systems, Hamburg, Germany) to determine the proportion of the plethysmographic waveform that is pulsatile compared to non-pulsatile.

The SBRI was measured at a depth of 1 cm in the radial artery of the snuffbox using a 3–10 MHz linear probe and evaluated by Doppler ultrasound (Portable Doppler Ultrasound System, M10, Mindray, Shenzhen, China), as described in a previous study [11]. The RI was defined as the peak systolic velocity minus the end diastolic velocity (EDV) divided by the peak systolic velocity. It was obtained by waveform analysis in B-mode.

Indices of visceral perfusion

Doppler indices were assessed twice independently by two skilled doctors, and the mean of the two measurements were then calculated. The doctors have at least three years’ critical care experience and have been trained by the China Critical Care Ultrasound Study Group.

The RI, as a Doppler ultrasound indicator, reflects the blood flow velocity variations. The lower values of RI indicated the lower vascular tension [12,13,14,15]. The visceral Doppler measurements were measured with a 2–5 MHz convex probe.

The RI values of the spleen and intestine were taken by identifying the most significant artery in each organ (spleen: subbranch of the splenic artery; intestine: initial part of the superior mesenteric artery) using colour Doppler mode. Three regions of the spleen were measured (inferior pole/posterior pole, superior pole/anterior pole and interpole) and averaged.

The superior mesenteric artery RI (SMA-RI) was assessed 1 cm proximal to the abdominal aort.

Heart rate variability

Heart rate variability(HRV) is considered to be a sensitive indicator of ANS function and was calculated during consecutive electrocardiogram (ECG) recordings over 5 min (Philips Medical Systems, Hamburg, Germany). The root mean square of successive difference between heart beats(RMSSD) and the frequency domain indices were obtained as HRV parameters. RMSSD quantifies vagal activity and is the main time-domain measure used for this purpose. The frequency domain indices used were the low-frequency power (LF, 0.04- to 0.15-Hz) and high-frequency power (HF, 0.15- to 0.4-Hz) and the ratio of LF and HF (LF/HF). LF/HF indicates the balance between sympathetic and parasympathetic activity [16].

Blood gas analysis and hemodynamics

The mechanical ventilation parameters, heart rate (HR), mean arterial pressure were recorded. A Radiometer ABL800 FLEX analyser (Radiometer Medical ApS, Copenhagen, Denmark) was used for blood gas analysis, which was calibrated daily to ensure accurate measurements. The Pv-aCO2 was calculated by subtracting PaCO2 from central venous carbon dioxide tension.

All patients underwent mechanical PSV and had end-tidal carbon dioxide (etCO2) monitoring with a CAPNOSTAT M2501A CO2 sensor (Philips, The Netherlands).

Study protocol

Once the patient was enrolled, ECMO GF was adjusted to achieve stable baseline conditions, defined as peak airway pressure < 25 cmH2O, respiratory rate < 25 bpm, and PaCO2 < 40 mmHg. Before commencing the study, sedative medications were adjusted to achieve Richmond agitation-sedation scale scores ranging from − 3 to − 2, and the PSV mode was performed.

The inspired oxygen fraction, PEEP, PSV, norepinephrine dose, sedative and analgesic doses, and ECMO blood flow remained constant during the protocol. Peripheral perfusion and ultrasound parameters were measured immediately, and HRV and hemodynamic parameters were collected. All data collection was completed within 10 min.

After stabilization of baseline parameters, the protocol was initiated. Initially, the ECMO GF was adjusted to 50% of the baseline value, and subsequent changes in etCO2 levels were closely monitored. Adjustments to the ECMO GF were made at 5-minute intervals, either increasing or decreasing by 0.5 L/min, until the etCO2 stabilized at a level 5–10 mmHg above the baseline value. Once the etCO2 had stabilized, all parameters were re-measured 20 min later to capture the effects of the intervention at high PaCO2 levels. The time between two tests should not exceed one hour to avoid the possibility of interference from other factors (Fig. 1).

Fig. 1
figure 1

Study protocol. ECMO: extracorporeal membrane oxygenation; PSV: pressure support ventilation; etCO2: end tidal carbon dioxide; GF: gas flow

Full size image

Statistical analysis

Descriptive statistics were calculated. All data are expressed as mean ± standard deviation or median (25–75% interquartile range). The normality of the data distribution was assessed using the Shapiro–Wilk test. Variables were compared between the baseline and High-CO2 phases using Student’s paired t-test or paired-samples Wilcoxon signed-rank test. Linear correlations were analyzed using Pearson’s test. The sample size was larger than that used in previous studies on patients with respiratory failure who received V-V ECMO [9, 10, 17]. All comparisons were two-tailed, and p < 0.05 was required to reject the null hypothesis. SPSS version 25.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis.

Results

Twelve respiratory failure patients on V-V ECMO support were enrolled in this prospective study. Basic patient characteristics and demographics are shown in Table 1. Eleven patients received V-V ECMO with internal jugular-femoral vein access, and one patient received a double-lumen neck cannula. The study protocol was successfully completed by all enrolled patients.

Table 1 Characteristics of twelve spontaneously breathing respiratory failure patients with venovenous extracorporeal membrane oxygenation enrolled
Full size table

All patients were male and had a mean age of 72 ± 10 years. Upon enrollment in the study, the mechanical ventilation (MV) time was 19(9–25) days, the Sequential Organ Failure Assessment (SOFA) score was 12 ± 2, and the mean ECMO time was 11(7–18) days (Table 1).

Our results showed that ECMO GF was down-regulated from 5.3 ± 1.4 L/min in the baseline phase to 3.0 ± 1.0 L/min in the High-CO2 phase. Consequently, the PaCO2 increased from 36(36–37) mmHg during the baseline phase to 42(41–43) mmHg during the High-CO2 phase (Table 2).

Table 2 Variations in the breathing pattern between baseline phase and High-CO2 phase in respiratory failure patients undergoing pressure support ventilation with venovenous extracorporeal membrane oxygenation
Full size table

Regarding peripheral perfusion indicators, we observed a significant decrease in PPI (from 1.5 ± 0.5 in the baseline phase to 1.1 ± 0.4 in the High-CO2 phase, p = 0.026). The SBRI increased from 0.89 ± 0.10 during the baseline phase to 0.99 ± 0.13 during the High-CO2 phase, p = 0.022. Concerning indices of visceral perfusion, the SMA-RI (p = 0.042) and spleen-RI (p = 0.012) increased significantly from the baseline phase to the High-CO2 phase (Table 3; Fig. 2).

Table 3 Parameters between baseline phase and High-CO2 phase in respiratory failure patients undergoing pressure support ventilation with venovenous extracorporeal membrane oxygenation
Full size table
Fig. 2
figure 2

Baseline phase vs. High-CO2 phase. PPI: Peripheral perfusion index; SBRI: resistance index of snuffbox artery; SMA-RI: resistance index of superior mesenteric artery; Spleen-RI: resistance index of spleen; RMSSD: the root mean square of successive differences; LF/HF: the ratio of low-frequency to high-frequency components

Full size image

Furthermore, HRV parameters changed significantly with elevation in PaCO2. The RMSSD decreased from 19.5(18.1–22.7) to 15.9(14.4–18.6) ms (p = 0.034), and the LF/HF increased from 0.47 ± 0.23 to 0.70 ± 0.38 (p = 0.013) (Table 3; Fig. 2).

Discussion

This study explored the correlation between PaCO2 and organ perfusion in respiratory failure patients undergoing PSV with V-V ECMO, which has not been reported previously. The results of this study indicated that, in patients with respiratory failure undergoing PSV with V-V ECMO, an increase in PaCO2 levels from < 40 mmHg to > 40 mmHg was accompanied by a decline in peripheral perfusion indices (PPI and SRBI) and visceral perfusion indices (SMA-RI and spleen-RI), and may associated with sympatho-excitation and parasympatho- inhibition of the ANS.

Effect of PaCO2 on respiratory center and ANS

It has been demonstrated that elevated PaCO2 could increase respiratory effort in patients with respiratory failure undergoing PSV with V-V ECMO [10]. PaCO2 changes are the main factor exciting the respiratory center in humans, and its effect on the respiratory center is mainly achieved through two pathways. One is the central chemoreceptor located in the medulla oblongata, which is very sensitive to changes in PaCO2 levels (note that CO2 effects on the central chemoreceptor is mainly achieved through changes in H+), and a ventilation-enhancing response occurs when PaCO2 increases by 2 mmHg. The other pathway indirectly affects the excitability of the respiratory center by peripheral chemoreceptors, but the sensitivity is much lower. Consequently, the respiratory center is stimulated when PaCO2 is elevated, causing an increase in the respiratory drive sent through the respiratory center, which then leads to increased respiratory effort.

As the respiratory center of the body, the pre-Bötzinger complex (preBötC) also has a direct influence on ANS and systemic haemodynamics. The preBötC participates directly in the regulation of cardiovascular activity. PreBötC neurons project directly to vascular pre-sympathetic and parasympathetic neurons, thereby influencing the vascular tone in various organs. This has also been demonstrated in animal studies [18]. Inhibition of preBötC neurons in rats modulates the activity of cardiac parasympathetic neurons, whereas excitation of preBötC neurons modulates the activity of sympathetic vasomotor neurons, which produce oscillations in heart rate and blood pressure in phase with respiratory rhythms.

HRV parameters could reflect the state of the ANS [19]. RMSSD is thought to reflect parasympathetic activity and is also considered to be a major indicator of vagal-mediated HRV [20]. Some studies suggest an correlation of the LF/HF with the sympathetic and parasympathetic balance of the ANS [21], and elevated LF/HF suggests increased sympathetic excitation. In the present study, it was found that an increase in PaCO2 led to a decrease in RMSSD and an increase in LF/HF. The decrease in patients’ HRV values during the High-PaCO2 phase has suggested an alteration in ANS, possibly confirming the effects on the ANS when the respiratory drive of the pre-BötC is increased.

Effect of PaCO2 on organ perfusion

Based on the results of previous related studies [12, 14, 22, 23], the RI of the visceral and peripheral organs decreased significantly, indicating a reduction of organ perfusion.

The results of this study showed that, in patients with respiratory failure undergoing PSV with V-V ECMO, an increase in PaCO2 was associated with a decline in visceral and peripheral perfusion indices.

As described above, elevated PaCO2 leads to excitation of the respiratory center, which in turn causes sympatho-excitation and parasympatho- inhibition. It leads to micro-arterial constriction, with ensuing increased systemic vascular resistance, which may reduce blood flow to visceral organs, such as the intestine and spleen.

The innate neural network within the gastrointestinal tract, which includes the intestinal muscle plexus, submucosal plexus, and interstitial cells of Cajal, is mainly regulated by the sympathetic nervous system. This system regulates the gastrointestinal blood flow through nerve-dependent vasoconstriction.

Hyperexcitation of the respiratory center is commonly accompanied by hyperactivity of the sympathetic nerves, which alters cardiac output and vascular resistance. These alterations can affect the perfusion of the visceral organs and peripheral tissues.

Moreover, perfusion of peripheral tissue might be affected by blood alkalosis. Skin microcirculatory blood flow decreases markedly with alkalosis [24].

Impact of PaCO2 level on organ protection in V-V ECMO patients undergoing PSV

This study investigated the potential correlation between PaCO2 level and visceral and peripheral organ perfusion in patients with respiratory failure undergoing PSV with V-V ECMO, which may be caused by the neurological stress response. This revelation underscores the need for subsequent, larger-scale, controlled trials to provide a more definitive assessment of the intervention’s impact on organ perfusion dynamics and overall clinical outcomes.

Limitations

This study has some limitations: (1) A non-invasive, indirect measurement method was used. The RI indirectly measures vascular resistance. (2) The size of the sampled population was small, although the statistical outcome was satisfactory. (3) HRV is a useful index of ANS and can be measured easily. But many different physiological processes affect it, and the effect of patients of different ages and comorbidities may have hampered analysis. However, this study used a paired t-test analysis, which can reduce the effect of different ages and comorbidity states on our HRV analyses.

Conclusions

High level of PaCO2 might lead to a decrease in peripheral tissue and visceral organ perfusion through ANS in patients with respiratory failure undergoing PSV with V-V ECMO.

Data availability

Data is provided within supplementary information files(Additional file 1).

Abbreviations

BF:

blood flow

Cst:

Static lung compliance

GF:

gas flow

HF:

high-frequency

HR:

heart rate

LF:

low-frequency

LF/HF:

the ratio of LF to HF components

MAP:

mean arterial pressure

MV:

mechanical ventilation

MVe:

minute volume expiration

NE:

norepinephrine

PaCO2 :

partial pressure of carbon dioxide in arterial blood gas

PaO2 :

Oxygen partial pressure of arterial blood gas

PEEP:

Positive end expiratory pressure

PPI:

Peripheral perfusion index

PSV:

pressure support ventilation

RMSSD:

the root mean square of successive differences

RR:

respiratory rate

SBRI:

resistance index of snuffbox artery

SMA-RI:

resistance index of superior mesenteric artery

SOFA:

Sequential organ failure assessment

Spleen-RI:

resistance index of spleen

Vt:

tidal volume

V-V ECMO:

veno-venous extracorporeal membrane oxygenation

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Acknowledgements

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Funding

This work was supported by the National High Level Hospital Clinical Research Funding(2022-PUMCH-A-216), Central University Education and Teaching Reform Special Funding of Peking Union Medical College in2023(2023zlgl022), the National High Level Hospital Clinical Research Funding (2022-PUMCH-B-115).

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Authors and Affiliations

  1. Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China

    Yuankai Zhou, Liangyu Mi, Shengjun Liu, Yingying Yang, Na Cui, Xiaoting Wang, Huaiwu He & Yun Long

  2. Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China

    Yun Long

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  1. Yuankai Zhou
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Contributions

Yuankai Zhou contributed to the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article, and final approval of the version to be published. Liangyu Mi, Shengjun Liu and Yingying Yang helped in data collection and data analysis; Xiaoting Wang helped to build up the research idea; Na Cui and Huaiwu He guided the discussion; Yun Long guided the whole research program and should be considered the correspondence author of this article.

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Correspondence to Yun Long.

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This study was authorized by the Peking Union Medical College Hospital’s ethical committee(K24C0020). Before enrollment, written informed consent was obtained from all patients or their next of kin.

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The authors declare no competing interests.

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Zhou, Y., Mi, L., Liu, S. et al. The level of partial pressure of carbon dioxide affects organ perfusion in respiratory failure patients undergoing pressure support ventilation with venovenous extracorporeal membrane oxygenation: a prospective study. BMC Pulm Med 24, 424 (2024). https://doi.org/10.1186/s12890-024-03238-9

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Keywords

BMC Pulmonary Medicine

ISSN: 1471-2466

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