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Acetazolamide: a second wind for a respiratory stimulant in the intensive care unit?

Nicholas Heming1*, Saïk Urien2 and Christophe Faisy1

Author Affiliations

1 Medical Intensive Care Unit, European Georges Pompidou Hospital (AP-HP), Université Paris Descartes, Sorbonne Paris Cité, 20 rue Leblanc, 75908 Paris, France

2 CIC-0109 Cochin-Necker Inserm, Unité de Recherche Clinique, Tarnier Hospital, (AP-HP) and E.A. 3620 Université Paris Descartes, Sorbonne Paris Cité, 27 Rue du Faubourg Saint-Jacques 75014 Paris, France

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Critical Care 2012, 16:318  doi:10.1186/cc11323

Published: 7 August 2012

Abstract

Patients with chronic obstructive pulmonary disease (COPD) are affected by episodes of respiratory exacerbations, some of which can be severe and may necessitate respiratory support. Prolonged invasive mechanical ventilation is associated with increased mortality rates. Persistent failure to discontinue invasive mechanical ventilation is a major issue in patients with COPD. Pure or mixed metabolic alkalosis is a common finding in the intensive care unit (ICU) and is associated with a worse outcome. In patients with COPD, the condition is called post-hypercapnic alkalosis and is a complication of mechanical ventilation. Reversal of metabolic alkalosis may facilitate weaning from mechanical ventilation of patients with COPD. Acetazolamide, a non-specific carbonic anhydrase inhibitor, is one of the drugs employed in the ICU to reverse metabolic alkalosis. The drug is relatively safe, undesirable effects being rare. The compartmentalization of the different isoforms of the carbonic anhydrase enzyme may, in part, explain the lack of evidence of the efficacy of acetazolamide as a respiratory stimulant. Recent findings suggest that the usually employed doses of acetazolamide in the ICU may be insufficient to significantly improve respiratory parameters in mechanically ventilated patients with COPD. Randomized controlled trials using adequate doses of acetazolamide are required to address this issue.