We have one female baby having diagnosed with MSUD ( Maple syrup urine disease). This baby acutely deteroriated because of lung infection in NICU. Baby is on mechanical ventilation. CRP, procalcitonin are normal. Blood culture is negative. Pseudomonas aureginosa was isolated on culture of material of deep tracheal aspiration. Treatment is contuining with sensitive drugs according to culture result. Echocardiography is normal. Pulmonary hypertension was not detected. X ray of lungs is not too bad. In blood gas analysis, high CO2 level was detected. We could not decrease high CO2 level. To increase respiratory rate, to increase PIP, to increase inspiratory time, reverse I/E , to make high frequency jet ventilation did not solve problem. We have no HFOV. I would like to learn your recommendation about to decrease high CO2 level?

Sincerely yours.

i transfered the question to a group of intensivist and i will keep updating u with thier response .. but the first response was as long as no pulmonary hypertension no problem and the kidney if good should compensate well

2nd response as follow:

Why would you want to decrease the high PaCO2.

Provided there is not extreme academia we would ignore it - indeed it may even be protective

i transfered the question to a group of intensivist and i will keep updating u with thier response .. but the first response was as long as no pulmonary hypertension no problem and the kidney if good should compensate well

What do you consider a high PaCO2 especially in chronic kids? Would you extubate to BCPAP if PaCO2 is >60 if ph is WNL?

I would like to learn your recommendation about to decrease high CO2 level?

Seems like a problematic case you had there.

If we need to decrease PCO2 we try to increase ventilation by increasing the rate on the ventilator or switch to high freq ventilation. If you treat with HFV you could increase ventilation by decreasing the frequency of the oscillation.

We rarely try to increase tidal volumes, since this could lead to more volutrauma.

Why would you want to decrease the high PaCO2.

Provided there is not extreme academia we would ignore it - indeed it may even be protective

Well, I have a feeling that permissive hypercapnia is getting out of fashion. Take a look at this publication http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16554847&query_hl=1&itool=pubmed_docsum

We try to keep the PaCO2 normal, in our eyes that would be 6-8 kPa.

What do you consider a high PaCO2 especially in chronic kids? Would you extubate to BCPAP if PaCO2 is >60 if ph is WNL?

We would probably not extubate with a PCO2 >60 mmHg/>8 kPa... but sometimes I feel that the endotrach tube is more blocking the airway (due to high resistance from the actual tube) and disturbing the infant and its spontaneous breathing. So in selected patients with PCO2 >60 and if the infant is breathing fine, he/she may just feel better on nCPAP.