Extracorporeal carbon dioxide removal for lowering the risk of mechanical ventilation: research questions and clinical potential for the future

Abstract

 Extracorporeal carbon dioxide removal is an emerging therapy for the treatment of acute respiratory failure.  There is limited evidence to support the routine use of ECCO 2 R, outside of clinical trials, in patients with acute respiratory failure.  Future research should focus on veno-venous ECCO 2 R.  Further research is required to optimise the technology and identify if modifications can be made, especially to permit the use of less anticoagulation than is currently needed.  ECCO 2 R may have a role in facilitating lower tidal volume ventilation than the current standard of care in patients with acute hypoxaemic respiratory failure, but further research is required to confirm this.  In patients with acute hypercapnic respiratory failure, ECCO 2 R may be used to prevent endotracheal intubation, facilitate extubation, and act as an adjunct or alternative to non-invasive ventilation.  Clinicians are encouraged to enroll patients into clinical trials investigating the use of ECCO 2 R in acute respiratory failure, and contribute to data registries.

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases

“…It should be noted that although extracorporeal CO 2 removal for lung-protective ventilation is feasible, it is neither evidence-based nor is it universally available. 39 Occasionally, patients develop concomitant or discrete cardiac failure-mainly from myocarditis, myocardial infarction, or sepsis-related cardiomyopathy-and might need venoarterial ECMO. Provision of ECMO in the setting of both pulmonary and cardiac dysfunction is particularly complex and, where possible, requires close liaison with an expert extracorporeal life support centre before ECMO initiation.…”

COVID-19 and ECMO: the interplay between coagulation and inflammation—a narrative review

“…Some studies showed that an early use of V-V ECMO in respiratory distress may minimize respiratory-driven pressure and reduce pulmonary and systemic inflammation as well as severe multiorgan dysfunction [11,12]. Therefore, V-V ECMO is a feasible option in COVID patients not responding to conventional interventions resulting in improved outcome and lung protection [13].…”

Extracorporeal carbon dioxide removal requirements for ultraprotective mechanical ventilation: Mathematical model predictions

“…First, the current model only predicts the relationship between acid‐base chemistry and the ECCO 2 R rate; thus, the current approach is general and not dependent on the performance characteristics of a specific device. In practical clinical applications, the predictions from the current model may require supplementary data relating the ECCO 2 R rate to the blood flow rate for a specific device . Second, the current model is limited by the assumption of steady state conditions.…”

“…There are several ECCO 2 R devices currently available with varying abilities to remove CO 2 depending on the rate of blood flow through the device and the surface area available for transmembrane diffusion. These devices have generally been categorized as lower or higher CO 2 extraction devices with the former containing relatively small membrane surface area using blood flow rates ≤500 mL/min and the latter containing relatively large membrane surface area using blood flow rates >500 mL/min.…”

“…These devices have generally been categorized as lower or higher CO 2 extraction devices with the former containing relatively small membrane surface area using blood flow rates ≤500 mL/min and the latter containing relatively large membrane surface area using blood flow rates >500 mL/min. Improvement in ECCO 2 R technologies has great potential as such devices can be integrated into a continuous renal replacement extracorporeal circuit and their efficacy for CO 2 removal may be increased by using physical principles other than diffusion such as electrodialysis or novel membrane fabrication techniques . However, the ECCO 2 R requirements for achieving adequate blood gas chemistry or normocapnia in lung‐protective strategies have not been quantitatively evaluated except in preclinical studies …”