Pediatric Respiratory Acidosis Clinical Presentation
- Author: Mithilesh K Lal, MD, MBBS, MRCP, FRCPCH, MRCPCH(UK); Chief Editor: Timothy E Corden, MD more...
The following questions should be asked in the course of the history:
- Does the patient have a history of headaches? (With chronic hypercapnia, headaches typically occur at nighttime or when the patient awakens in the morning)
- Does the patient have disturbed sleep patterns? (Chronic hypercapnia can disturb sleep patterns, leading to a reversed sleep-wake cycle)
- Is the patient irritable or anxious, or is he or she having trouble concentrating?
- Does the patient have a possible or known exposure to sedatives (eg, narcotics, benzodiazepines, tricyclic antidepressants)? Is the patient recovering from a procedure in which general anesthesia was used?
- Does the patient have symptoms of neuromuscular weakness or paralysis? (Such symptoms might include bulbar dysfunction suggesting myasthenia gravis, proximal or distal weakness suggesting a myopathy or Guillain-Barré syndrome, and apnea associated with a traumatic injury suggesting an injury to the cervical spinal cord)
- Does the patient have a long-standing pulmonary disease, such as bronchopulmonary dysplasia, cystic fibrosis, asthma, or emphysema?
- Does the patient have an acute change in mental status (eg, signs of stroke, postictal state)? If so, is the change in mental status associated with a fever, which may suggest encephalitis or meningitis? Does the patient have signs of increased intracranial pressure (eg, headaches, visual changes, or emesis)?
- Does the patient have a potential for an anaphylactic reaction?
- Does the patient have a potential traumatic mechanism leading to brain injury?
Neurologic findings associated with respiratory acidosis include the following:
- Early signs include anxiety, disorientation, confusion, and lethargy
- Somnolence or coma occurs when the arterial partial pressure of carbon dioxide (Pa CO2) exceeds 70 mm Hg
- Tremor, myoclonus, or asterixis are occasionally seen
- Brisk deep tendon reflexes are seen in mild-to-moderate respiratory acidosis
- Depressed deep tendon reflexes are seen in severe respiratory acidosis
- Papilledema or blurring of the optic disc may be present
Cardiovascular findings associated with respiratory acidosis include the following:
- Bounding arterial pulses
- Hypotension (severe respiratory acidosis or acidemia and hypoxemia)
Cutaneous findings associated with respiratory acidosis include the following:
- Warm, flushed, or mottled skin
Respiratory findings associated with respiratory acidosis include the following:
- Acute hypercapnia is seen in association with increase work of breathing
- Tachypnea, dyspnea, or deep labored breaths may be observed
- Accessory muscle use and nasal flaring are usually present
- With central or peripheral nervous system disease, respiratory distress may not be present
- Decreased aeration, crackles, wheezes, or other signs of airway disease may be observed
- Clubbing is a sign of chronic respiratory disease
Epstein SK, Singh N. Respiratory acidosis. Respir Care. 2001 Apr. 46(4):366-83. [Medline].
Ramamoorthy C, Tabbutt S, Kurth CD, et al. Effects of inspired hypoxic and hypercapnic gas mixtures on cerebral oxygen saturation in neonates with univentricular heart defects. Anesthesiology. 2002 Feb. 96(2):283-8. [Medline].
Goldstein B, Shannon DC, Todres ID. Supercarbia in children: clinical course and outcome. Crit Care Med. 1990 Feb. 18(2):166-8. [Medline].
Makhoul IR, Bar-Joseph G, Blazer S, et al. Intratracheal pulmonary ventilation in premature infants and children with intractable hypercapnia. ASAIO J. 1998 Jan-Feb. 44(1):82-8. [Medline].
Laffey JG, O'Croinin D, McLoughlin P, Kavanagh BP. Permissive hypercapnia--role in protective lung ventilatory strategies. Intensive Care Med. 2004 Mar. 30(3):347-56. [Medline].
ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000. 342:1301-8. [Medline].
Annane D, Orlikowski D, Chevret S, Chevrolet JC, Raphael JC. Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. Cochrane Database Syst Rev. 2007. (4):CD001941. [Medline].
Brian JE. Carbon dioxide and the cerebral circulation. Anesthesiology. 1998 May. 88(5):1365-86. [Medline].
Halpern P, Raskin Y, Sorkine P, Oganezov A. Exposure to extremely high concentrations of carbon dioxide: a clinical description of a mass casualty incident. Ann Emerg Med. 2004 Feb. 43(2):196-9. [Medline].
Kiely DG, Cargill RI, Lipworth BJ. Effects of hypercapnia on hemodynamic, inotropic, lusitropic, and electrophysiologic indices in humans. Chest. 1996 May. 109(5):1215-21. [Medline].
Low JM, Gin T, Lee TW, Fung K. Effect of respiratory acidosis and alkalosis on plasma catecholamine concentrations in anaesthetized man. Clin Sci (Lond). 1993 Jan. 84(1):69-72. [Medline].
Mas A, Saura P, Joseph D, et al. Effect of acute moderate changes in PaCO2 on global hemodynamics and gastric perfusion. Crit Care Med. 2000 Feb. 28(2):360-5. [Medline].
Mazzeo AT, Spada A, Pratico C, et al. Hypercapnia: what is the limit in paediatric patients? A case of near-fatal asthma successfully treated by multipharmacological approach. Paediatr Anaesth. 2004 Jul. 14(7):596-603. [Medline].
Thome UH, Carlo WA. Permissive hypercapnia. Semin Neonatol. 2002 Oct. 7(5):409-19. [Medline].
Vavilala MS, Lee LA, Lam AM. Cerebral blood flow and vascular physiology. Anesthesiol Clin North America. 2002 Jun. 20(2):247-64. [Medline].