![]() ![]() Marked improvement in Pao2 allowed reduction in Fio2 in all patients, extracorporeal Co2 removal was discontinued in three patients over the ensuing 3 weeks, and one patient was discharged home. Management included extracorporeal Co2 removal, direct thrombin inhibition, pulmonary vasodilators, and inotropic support. DATA SYNTHESIS: There was sequential development of 1) severe hypercapnia attributable to marked elevation of dead space without radiographic changes 2) concomitant coagulopathy manifest by an increase in d-dimer levels 3) progressive shunt with consequent hypoxemia and 4) right ventricular dysfunction. DATA SOURCES Four consecutive patients with confirmed coronavirus disease 2019 infection with sudden hypercapnia and hypoxemia were included. The pillars of management were targeted to improve pulmonary vascular patency via aggressive anticoagulation and support right ventricular function. Hypercapnia could not be explained by worsening lung disease or other common factors, and thus, a pulmonary vascular etiology was suggested. This case series highlights clinical findings and management of coronavirus disease 2019 patients with refractory hypercapnia despite maximal/optimal ventilatory support. Some patients develop sudden refractory hypercapnia and hypoxemia not explained by worsening pulmonary parenchymal disease. ![]() ABSTRACT OBJECTIVES: Mortality rates in intubated coronavirus disease 2019 patients remain markedly elevated. ![]()
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