The diagnostic importance of the blood carbon dioxide content of patients with central cyanosis

The diagnostic importance of the blood carbon dioxide content of patients with central cyanosis

THE DIAGNOSTIC CONTENT IMPORTANCE OF PATIENTS MARGARET WILLIAM M. OF THE BLOOD WITH CENTRAL PLATTS, WHITAKER, SHEFFIELD, M.B., M.R.C.P., hII.D...

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THE

DIAGNOSTIC CONTENT

IMPORTANCE OF PATIENTS MARGARET WILLIAM

M.

OF THE BLOOD WITH CENTRAL

PLATTS,

WHITAKER, SHEFFIELD,

M.B., M.R.C.P., hII.D., M.R.C.P.

CARBON DIOXIDE CYANOSIS AND

ENGLAND

is sometimes difficult I Tcongenital cardiovascular

to distinguish clinically between cyanosis due to a anomaly, .which transfers systemic venous blood into the systemic arterial tree without passage through the pulmonary capillaries and that due to chronic lung disease, which impairs the aeration of blood in the pulmonary circulation. The observations of Campbell and others’, Bing and others,” Fasciolo and others3 and Davison and others,” showing low or normal arterial blood carbon dioxide levels in patients with cyanotic congenital heart disease, and of Platts5 who found that patients with congestive heart failure complicating chronic lung disease were anoxic and had carbon dioxide retention, suggested that the blood carbon dioxide level was of diagnostic importance in patients with central cyanosis. The present investigations were made to determine the significance of the arterial blood carbon dioxide content in such patients. Fifty-five cyanotic patients were studied : Sixteen had congenital heart disease and two of these (1 and 3) had also congestive heart failure, twenty-three had chronic bronchitis and emphysema and sixteen had chronic bronchitis and emphysema complicated by congestive heart failure. Specimens of blood were obtained by brachial or femoral artery puncture while the patients were at rest in bed, and the oxygen and carbon dioxide contents and the oxygen capacity of each specimen were determined by the technique of Van Slyke and Neill. The percentage saturation of the blood with oxygen was calculated from the oxygen content and the oxygen capacity of the sample. RESULTS

The oxygen saturation and the carbon dioxide content of arterial blood are shown in Tables I, II, and III and Fig. 1. The arterial blood carbon dioxide content ranges from 31 to 59 volume per cent with a mean of 40.4 volume per cent in patients with cyanotic congenital heart disease, from 38 to 63 volume per cent with a mean of 53.6 volume per cent in cyanosed patients with chronic bronchitis and emphysema, and from 62 to 71 volume per cent with a mean of 65.4 volume per cent in patients with chronic bronchitis and emphysema complicated by From the University vascular Centre. The City Received for publication

Department of Medicine, General Hospital, Sheffield, Jan. 11, 1954.

The Royal England.

Hospital,

and

The

Regional

Cardio-

78

AMERICAN TABLE

I.

-

_-

II

ARTERIAL IN PATIENTS

BLOOD WITH

CARBON DIOSIDE COMTENT VOL. (70)

SATURATION (%I

-1*

90 81

33

:* 4 5 6 7

8858 :5

:; 40 39 43 33 42 53

76 83 81

: 10 11 12

4 7 26

::

l

CONTENT

DIAGNOSIS

Patent ductus arteriosus Patent ductus arteriosus Atria1 septal defect Eisenmenger’s complex Eisenmenger’s complex Fallot’s tetralogy Tricuspid atresia Fallot’s tetralogy Anomalous pulmonary veins with defect Transposition of the great vessels Transposition of the great vessels Eisenmenger’s complex Tricuspid atresia Anomalous pulmonary veins with defect Transposition of the great vessels Fallot’s tetralogy

:; 38 31 44

1.5 16

48 37

-

-

II. ARTERIAL IN CYANOSED

=

BLOODOXYGENSATURATIONAND PATIENTS WITH CHRONIC

OXYGEN

61 66 46 51

i: 36 37

BRONCHITIS

:t 62

.-

dioxide dioxide

DIOXIDE EMPHYSEMA

CONTENT

CARBONDIOXIDE VOL.

CONTENT (%)

90

52

:; 90 86

ii 50 52 60 58

44 SE 60 49 49 49

;; 82 88 84 79

48 58

-

SATURATION (%I

ii 8.5 89 90 81 82 81 84 89

5”: 63

Range of carbon Mean of carbon

CARBON AND

is

2:: 51 32 60 63 46

:t

septal

81

2x ii 40 41 42 43 44 45 46 47 48 49 SO 51 52 53

atria1

BGE

33

septal

vol. per cent vol. per cent

ZZX

SEX

atria1

-

Range of carbon dioxide contents-31-59 Mean of carbon dioxide contents--CO.4 *Patient in congestive heart failure

CASE NO.

CARBON DIOXIDE HEART DISEASE

--

AGE

TABLE

JOURNAL

OXYGENSATURATIO~-.~ND CYANOTIC CONGENITAL

OXYGEN

CASE NO.

HEART

contents-38-03 contents-53.6

vol. per cent vol. per cent

PLATTS

AND

WHJTAKEK:

T~HLE

=

BLOOD

CAKBON

III. ARTERIAL BLOOD IN CYANOSED PATIENTS COMPLICATED

DIOXIDE

OXYGEN

NO.

-

-

AGE

SEX

IN

SATURATION AND CARBON CHRONIC BRONCHITIS AND BY CONGESTIVE HEART FAILURE

WITH

OXYGEN CASE

CONTENT

SATURATION (%I

1

DIOXIDE EMPHYSEMA

CARRON

79

CYANOSIS CONTENT

DIO?llDE VOL.

_17 18 a; 21 22 64 61 65 65 62 71 66

ii 65 80

25

26 27

:: 53 49 70 79

ii 30 31

32

4::

Range Mean

of carbon of carbon

dioxide dioxide

b+ +

contents-62-71 contents-65.4

vol. per cent vol. per cent

O $g Go 08 0 Q+ ++0 + 8 O%* + + +

Fig.

l.-Arterial

blood

gases

in patients

with

central

cyanosis.

CONTENT (%I

83

AMERICAN

HEART

JOURNAL

congestive heart failure. The values for the controls shown in Pig. 1 were previously determined by Plattsj who found that the carbon dioxide content of arterial blood ranged from 44 to 52 volume per cent and the oxygen saturation from 93 to 99 per cent in eighteen patients without cardiac, pulmonary, or renal disease. DISCUSSION

The arterial blood carbon dioxide content of patients with congenital heart disease without congestive heart failure is, with one exception of 53 volume per cent, low or normal and in the majority it is less than the lower normal limit of 44 volume per cent, while that of patients with chronic bronchitis and emphysema is normal or raised, with one exception of 38 volume per cent. This suggests that an arterial blood carbon dioxide content less than the lower normal limit of 44 volume per cent indicates congenital heart disease, while one above the upper normal limit of 52 volume per cent favors chronic pulmonary disease as the cause of central cyanosis in a patient whose diagnosis is uncertain from clinical examination. Although there were only two patients with congestive heart failure complicating congenital heart disease among those studied, the arterial blood carbon dioxide contents of these two were not so high as any found in patients with chronic bronchitis and emphysema complicated by congestive heart failure, which suggests that the blood carbon dioxide content is of diagnostic importance in cyanosed patients with congestive heart failure. A low or normal arterial blood carbon dioxide content excludes a diagnosis of congestive heart failure complicating chronic lung disease and suggests congenital heart disease as the cause of cyanosis, while conversely, an arterial blood carbon dioxide content of 62 volume per cent or over suggests that the patient is suffering from congestive heart failure complicating chronic lung disease. The arterial blood carbon dioxide content, the carbon dioxide content of mixed venous blood, and the plasma alkali reserve are all affected by changes in the blood bicarbonate buffer system, and diagnostic criteria, similar to those given here for the arterial blood carbon dioxide content, could be established for the venous blood carbon dioxide content or for the plasma alkali reserve of patients with central cyanosis. The present results offer no new evidence to justify a detailed discussion of the functional disturbances which produce abnormal blood carbon dioxide levels The low levels associated with cyanotic conin patients with central cyanosis. genital heart disease were attributed to chronic hyperventilation by Talbot and others6 while the high levels in patients with chronic lung disease were considered by Platts5 to be due to defective aeration of blood in the pulmonary circulation, which leads to carbon dioxide retention, and a failure of the respiratory center to respond by hyperventilation to a rising blood carbon dioxide level. SUMMARY

1. The arterial blood carbon dioxide contents were measured in fifty-five patients with central cyanosis. Sixteen had congenital heart disease and two

PLATTS

.‘.ND

WtrITAICEK

:

BLOOD

CARBON

DIOXIDE

CONTENT

IN

81

CYANOSIS

of these had also congestive heart failure; twenty-three had chronic bronchitis an d emphysema; and sixteen had congestive heart failure complicating chronic bronchitis and emphysema. 2. The arterial blood carbon dioxide content was below normal in the majority of patients with cyanotic congenital heart disease, normal or raised in the majority of patients cyanosed from chronic bronchitis and emphysema, and invariably raised in patients with congestive heart failure complicating chronic bronchitis and emphysema. 3. The blood carbon dioxide content appears to be of diagnostic importance in patients with central cyanosis. We wish to thank allowing us to investigate

Dr.

J. W. Brown, Dr. C. E. Davies, patients under their care.

and

Prof.

C. H.

Stuart-Harris

for

REFERENCES

1.

5.

Campbell, J. M. H., Hung, G. H., and Poulton, E. P.: An Examination of the Blood Gases and Respiration in Disease, With Reference to the Cause of Breathlessness and Cyanosis, J. Path. Bact. 26:234, 1923. Bing, R. G., Vandam, L. D., Handelsman, J. C., Campbell, J. A., Spencer, R., and Griswold, H. E.: Physiological Studies in Congenital Heart Disease. VI. Adaptations to Anoxia in Congenital Heart Disease With Cyanosis, Bull. Johns Hopkins Hosp. 83:439, 1948. Fasciolo, J. C., Chiodi, H.! Suorey, J. R. E., and Taquini, A. C.: Mechanismos De Algunas Adaptaciones Cardrorrespiratorias En la Anoxia Cronica, Medicina l:l, 1949. Davison, P. H., Armitage, G. H., and Arnott, W. M.: The Mechanisms of Adaptation to a Central Venous-Arterial Shunt, Brit. Heart J. 15:221, 1953. Platts, Margaret M.: The Arterial Blood Gases in Pulmonary Heart Failure, Clin. SC.

6.

Talbot,

2.

3. 4.

12:63,

1953.

J. H., Coombs, F. S., Castleman, B., Chamberlain, F. L., Consolazio, White, P. D.: A Record Case of the Tetralogy of Fallot, With Comments bolic and Pathologic Studies, AM. HEART J. 22:754, 1941.

W. V., and on Meta-