A 2-year multicenter, observational, prospective, cohort study on extracorporeal CO2 removal in a large metropolis area

Abstract

Background Extracorporeal carbon dioxide removal (ECCO 2 R) is a promising technique for the management of acute respiratory failure, but with a limited level of evidence to support its use outside clinical trials and/or data collection initiatives. We report a collaborative initiative in a large metropolis. Methods To assess on a structural basis the rate of utilization as well as efficacy and safety parameters of 2 ECCO 2 R devices in 10 intensive care units (ICU) during a 2-year period. Results Seventy patients were recruited in 10 voluntary and specifically trained centers. The median utilization rate was 0.19 patient/month/center (min 0.04; max 1.20). ECCO 2 R was started under invasive mechanical ventilation (IMV) in 59 patients and non-invasive ventilation in 11 patients. The Hemolung Respiratory Assist System (Alung) was used in 53 patients and the iLA Activve iLA kit (Xenios Novalung) in 17 patients. Main indications were ultraprotective ventilation for ARDS patients ( n = 24), shortening the duration of IMV in COPD patients ( n = 21), preventing intubation in COPD patients ( n = 9), and controlling hypercapnia and dynamic hyperinflation in mechanically ventilated patients with severe acute asthma ( n = 6). A reduction in median V T was observed in ARDS patients from 5.9 to 4.1 ml/kg ( p <0.001). A reduction in PaCO 2 values was observed in AE-COPD patients from 67.5 to 51 mmHg ( p < 0.001). Median duration of ECCO 2 R was 5 days (IQR 3–8). Reasons for ECCO 2 R discontinuation were improvement ( n = 33), ECCO 2 R-related complications ( n = 18), limitation of life-sustaining therapies or measures decision ( n = 10), and death ( n = 9). Main adverse events were hemolysis ( n = 21), bleeding ( n = 17), and lung membrane clotting ( n = 11), with different profiles between the devices. Thirty-five deaths occurred during the ICU stay, 3 of which being ECCO 2 R-related. Conclusions Based on a registry, we report a low rate of ECCO 2 R device utilization, mainly in severe COPD and ARDS patients. Physiological efficacy was confirmed in these two populations. We confirmed safety concerns such as hemolysis, bleeding, and thrombosis, with different profiles between the devices. Such results could help to design future studies aiming to enhance safety, to demonstrate a still-lacking strong...

Physiological effects of adding ECCO2R to invasive mechanical ventilation for COPD exacerbations

“…Accordingly, the different initial time points were separated by a delay of 1 h. Therefore, we cannot exclude that a more delayed ECCO 2 R-induced improvement in regional ventilation could have occurred and allowed decreasing RR, I/E ratio or V T, all important determinants of dynamic hyperinflation. We didn't observed severe hemolysis in contrast to other reports [26,28]. However, the observation is limited by the lack of systematic daily plasma free hemoglobin measurement, which is now a standard practice in our centers.…”

Ultraprotective ventilation allowed by extracorporeal CO2 removal improves the right ventricular function in acute respiratory distress syndrome patients: a quasi-experimental pilot study

“…While no strong recommendations routinely support this device in ARDS, veno-venous extracorporeal CO 2 removal (ECCO 2 R) is actually used to facilitate ultraprotective ventilation while avoiding risks of hypercapnia, acidosis and injurious ventilator settings [19][20][21][22][23]. Currently, main indications for ECCO 2 R in French intensive care units are ultraprotective ventilation for ARDS patients, shortening the duration of invasive mechanical ventilation in chronic obstructive pulmonary disease (COPD) patients, preventing intubation in COPD patients, and controlling hypercapnia and dynamic hyperinflation in mechanically ventilated patients with severe acute asthma [24,25].…”

ECCO2R therapy in the ICU: consensus of a European round table meeting

“…Anticoagulation with intravenous unfractionated heparin was the preferred strategy of the group. This reflects recent studies in the literature in which unfractionated heparin appears to be the anticoagulant most frequently used in this setting [10,11]. The post-meeting survey highlighted that anticoagulant activity should be monitored using activated partial thromboplastin time (aPTT) and/or anti-Xa; the monitoring approach remains dependent on local practice.…”

“…Advances in technology to deliver extracorporeal carbon dioxide removal (ECCO 2 R) therapy have simplified this approach, making it easier to deploy for the management of adults with both hypoxaemic and hypercapnic acute respiratory failure (ARF) [1][2][3][4]. In patients with acute respiratory distress syndrome (ARDS), ECCO 2 R therapy may be used to allow ultraprotective lung ventilation (UPLV) and reduce ventilator-induced lung injury (VILI) by decreasing tidal volume (V T ), both plateau (P plat ) and driving pressures and respiratory rate, while also controlling respiratory acidosis [5][6][7][8][9][10][11][12][13][14]. In patients with acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) with severe respiratory acidosis and hypercapnic respiratory failure, ECCO 2 R therapy may be applied to prevent intubation in patients at risk of non-invasive ventilation (NIV) failure [15].…”

“…In patients with acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) with severe respiratory acidosis and hypercapnic respiratory failure, ECCO 2 R therapy may be applied to prevent intubation in patients at risk of non-invasive ventilation (NIV) failure [ 15 ]. It may also be used to hasten weaning from mechanical ventilation (MV) and early extubation in those who require invasive ventilation [ 10 , 15 – 17 ].…”