Letter to the Editor
Respiratory Acidosis Secondary to Drug Therapy
Acidosis respiratoria secundaria a fármacos
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This therapy is not without its complications, most notably respiratory center depression and respiratory acidosis requiring ventilatory support. It is therefore essential to be aware of these complications and identify which patients are at greater risk.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the findings from a series of patients admitted to the Respiratory Monitoring Unit of the Hospital Universitario de La Princesa (Madrid) over a period of 2 years. During this time, 302 patients were admitted with respiratory acidosis. A study of their medical records and urinalysis showed that in 10 cases (3.3%) the condition was associated with the use of CNS depressants. The doses given were estimated from clinical interview with the patient and/or carer, and in all cases drug-specific antagonists were used, together with non-invasive mechanical ventilation (NIV). Patients requiring emergency orotracheal intubation, patients transferred to the Intensive Care Unit for monitoring or intensive care, and those in whom NIV was ruled out by the Respiratory Medicine Department (approximately 12% of all patients admitted for respiratory acidosis) were excluded from the series. At admission, mean pH was 7.28 and mean PaCO<span class="elsevierStyleInf">2</span> was 69.4<span class="elsevierStyleHsp" style=""></span>mmHg, both determined by arterial blood gas measurement. In many cases, progress was determined by other hypoventilation factors.</p><p id="par0015" class="elsevierStylePara elsevierViewall">All patients included in the series were women with a mean age of 78.9 years. Of these, 80% were under treatment for a depressive syndrome, and 50% regularly took more than 2 CNS depressants. The combination drugs given were benzodiazepines (BZD), in 50%, and opiates, in 10%. This combination was responsible for 30% of cases. Predisposing factors, in addition to the therapy given, were found in 80% of patients (obesity in 60%, chronic obstructive pulmonary disease [COPD] in 30%, and kyphoscoliosis in 20%). In 1 case, drug toxicity was the result of an attempted suicide, and the patient died (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">BZDs are anxiolytic, hypnotic, anticonvulsant and antispasmodic drugs that enhance the inhibitory action of gamma-aminobutyric acid (GABA) receptors in the CNS. Opiates specifically bind to different central and peripheral receptors to regulate pain, amongst other actions. The use of these drugs, particularly in combination, inhibits the activity of the medullary and bulbopontine respiratory centers, which in turn diminishes the ventilatory response to hypoxia and hypercapnia, and can cause respiratory acidosis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> This is particularly important in elderly patients with chronic pulmonary disease.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Recent studies in patients with severe COPD have shown that high dose BZDs and opiates are associated with increased mortality.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Long-term use of BZDs has also been associated with onset of acute hypercapnic respiratory failure in obese patients with sleep apnea/hypopnea syndrome (SAHS).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, patients with alveolar hypoventilation (SAHS, obesity, COPD) taking CNS depressants (BZD, opiates, etc.) alone or in combination are at greater risk of respiratory acidosis. It is important to bear this in mind when considering the use of these drugs in this high-risk population.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alonso T, García E, Segrelles G, Zamora E. Acidosis respiratoria secundaria a fármacos. Arch Bronconeumol. 2015;51:204–205.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BZD: benzodiazepines; CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease; F: female; HTM: hypertension; TCA: tricyclic antidepressants.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main comorbidities \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Caused by \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Progress \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Depressive syndrome, HT, obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BZD, opiates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Depressive syndrome, obesity, COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BZD, TCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HTN, angina, renal failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pregabalin, opiates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Depressive syndrome, kyphoscoliosis, obesity, COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BZD, opiates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary sarcoidosis, depressive syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BZD, paroxetine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">COPD, lung neoplasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BZD, opiates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Exitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Atrial fibrillation, kyphoscoliosis, depressive syndrome, obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BZD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Depressive syndrome, HT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BZD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Depressive syndrome, obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BZD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Depressive syndrome, CHF, obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Opiates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Satisfactory \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 1 | 10 |
| 2024 October | 72 | 16 | 88 |
| 2024 September | 96 | 15 | 111 |
| 2024 August | 96 | 48 | 144 |
| 2024 July | 92 | 30 | 122 |
| 2024 June | 118 | 46 | 164 |
| 2024 May | 108 | 30 | 138 |
| 2024 April | 65 | 26 | 91 |
| 2024 March | 68 | 25 | 93 |
| 2024 February | 37 | 27 | 64 |
| 2023 March | 17 | 5 | 22 |
| 2023 February | 83 | 24 | 107 |
| 2023 January | 95 | 40 | 135 |
| 2022 December | 85 | 38 | 123 |
| 2022 November | 83 | 42 | 125 |
| 2022 October | 108 | 35 | 143 |
| 2022 September | 61 | 40 | 101 |
| 2022 August | 71 | 45 | 116 |
| 2022 July | 49 | 38 | 87 |
| 2022 June | 53 | 36 | 89 |
| 2022 May | 62 | 33 | 95 |
| 2022 April | 68 | 34 | 102 |
| 2022 March | 81 | 46 | 127 |
| 2022 February | 65 | 34 | 99 |
| 2022 January | 58 | 40 | 98 |
| 2021 December | 50 | 43 | 93 |
| 2021 November | 61 | 37 | 98 |
| 2021 October | 70 | 38 | 108 |
| 2021 September | 55 | 37 | 92 |
| 2021 August | 79 | 42 | 121 |
| 2021 July | 47 | 34 | 81 |
| 2021 June | 73 | 42 | 115 |
| 2021 May | 64 | 30 | 94 |
| 2021 April | 211 | 94 | 305 |
| 2021 March | 122 | 20 | 142 |
| 2021 February | 99 | 23 | 122 |
| 2021 January | 75 | 24 | 99 |
| 2020 December | 49 | 24 | 73 |
| 2020 November | 78 | 18 | 96 |
| 2020 October | 86 | 21 | 107 |
| 2020 September | 81 | 15 | 96 |
| 2020 August | 71 | 15 | 86 |
| 2020 July | 91 | 27 | 118 |
| 2020 June | 85 | 19 | 104 |
| 2020 May | 93 | 36 | 129 |
| 2020 April | 81 | 31 | 112 |
| 2020 March | 59 | 20 | 79 |
| 2020 February | 72 | 17 | 89 |
| 2020 January | 63 | 19 | 82 |
| 2019 December | 78 | 21 | 99 |
| 2019 November | 86 | 20 | 106 |
| 2019 October | 60 | 4 | 64 |
| 2019 September | 49 | 15 | 64 |
| 2019 August | 50 | 17 | 67 |
| 2019 July | 46 | 13 | 59 |
| 2019 June | 34 | 12 | 46 |
| 2019 May | 57 | 12 | 69 |
| 2019 April | 92 | 37 | 129 |
| 2019 March | 84 | 20 | 104 |
| 2019 February | 76 | 19 | 95 |
| 2019 January | 60 | 16 | 76 |
| 2018 December | 46 | 33 | 79 |
| 2018 November | 87 | 19 | 106 |
| 2018 October | 100 | 23 | 123 |
| 2018 September | 39 | 13 | 52 |
| 2018 May | 19 | 1 | 20 |
| 2018 April | 59 | 5 | 64 |
| 2018 March | 48 | 7 | 55 |
| 2018 February | 26 | 6 | 32 |
| 2018 January | 14 | 4 | 18 |
| 2017 December | 20 | 4 | 24 |
| 2017 November | 15 | 7 | 22 |
| 2017 October | 25 | 11 | 36 |
| 2017 September | 24 | 10 | 34 |
| 2017 August | 25 | 18 | 43 |
| 2017 July | 14 | 12 | 26 |
| 2017 June | 25 | 12 | 37 |
| 2017 May | 30 | 8 | 38 |
| 2017 April | 28 | 10 | 38 |
| 2017 March | 25 | 13 | 38 |
| 2017 February | 10 | 7 | 17 |
| 2017 January | 13 | 10 | 23 |
| 2016 December | 22 | 5 | 27 |
| 2016 November | 31 | 10 | 41 |
| 2016 October | 43 | 12 | 55 |
| 2016 September | 36 | 19 | 55 |
| 2016 August | 31 | 8 | 39 |
| 2016 July | 32 | 8 | 40 |
| 2016 March | 1 | 0 | 1 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 28 | 2 | 30 |
| 2015 September | 42 | 7 | 49 |
| 2015 August | 34 | 9 | 43 |
| 2015 July | 33 | 17 | 50 |
| 2015 June | 0 | 1 | 1 |
| 2015 May | 0 | 2 | 2 |
| 2015 April | 0 | 3 | 3 |
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