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

Abstract

Background: With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO 2 removal (ECCO 2 R). However, current evidence in these indications is limited. A European ECCO 2 R Expert Round Table Meeting was convened to further explore the potential for this treatment approach. Methods: A modified Delphi-based method was used to collate European experts' views to better understand how ECCO 2 R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus.

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

“…Twentyfour hours after the ultraprotective ventilation strategy with ECCO 2 R, PaCO 2 and pH were maintained at 52.5 mmHg (44.2-64) and 7.31 (7.27-7.33), respectively. The reduction in V T was associated with a significant reduction in P Plat from 25.5 (24)(25)(26)(27)(28) at baseline to 21.5 (20-25.8) cm H 2 O (D0 ECCO 2 R 4 ml/kg). The evolution of P Plat remained significant throughout the study protocol (p = 0.04).…”

“…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].…”

Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome

“…Low-flow CO 2 removal is able to decrease the mechanical power and to maintain oxygenation, and it is relatively easy and safe to apply at the bedside 84 , [85] . The use of ECCO 2 R is VILI-saving by reducing V T and Pplat while also controlling respiratory acidosis [86] . However, questions remain concerning its indications; most of the literature is observational with small case series of patients and retrospective.…”

“…In 2020, a consensus on ECCO 2 R use in ARDS patients defined the target criteria for MV in patients during ECCO 2 R treatment: ΔP < 14 cmH 2 O, Pplat < 25 cmH 2 O, and respiratory rate of 20–25 breaths/min. Indications for starting ECCO 2 R include ΔP > 15–20 cmH 2 O, Pplat > 30–35 cmH 2 O, PaCO 2 ≥ 60 mmHg, pH < 7.25, respiratory rate > 20–30 breaths/min, PaO 2 /FiO 2 < 150, PEEP > 8–15 cmH 2 O [86] .…”

“…Whereas low-flow systems such as ECCO 2 R (0.5–1.5 L/min) provide adequate flow both for oxygenation and CO 2 removal, high-flow systems such as ECMO (2–4 l/min) provide too much flow for targeting minimal oxygenation and CO 2 removal (low blood flow is needed) [86] , 87 , [88] . Criteria for using ECMO in the EOLIA trial included patients already pronated who did not improve enough.…”