Extracorporeal carbon dioxide removal for patients with acute respiratory failure secondary to the acute respiratory distress syndrome: a systematic review

Abstract

Acute respiratory distress syndrome (ARDS) continues to have significant mortality and morbidity. The only intervention proven to reduce mortality is the use of lung-protective mechanical ventilation strategies, although such a strategy may lead to problematic hypercapnia. Extracorporeal carbon dioxide removal (ECCO2R) devices allow uncoupling of ventilation from oxygenation, thereby removing carbon dioxide and facilitating lower tidal volume ventilation. We performed a systematic review to assess efficacy, complication rates, and utility of ECCO2R devices. We included randomised controlled trials (RCTs), case–control studies and case series with 10 or more patients. We searched MEDLINE, Embase, LILACS (Literatura Latino Americana em Ciências da Saúde), and ISI Web of Science, in addition to grey literature and clinical trials registries. Data were independently extracted by two reviewers against predefined criteria and agreement was reached by consensus. Outcomes of interest included mortality, intensive care and hospital lengths of stay, respiratory parameters and complications. The review included 14 studies with 495 patients (two RCTs and 12 observational studies). Arteriovenous ECCO2R was used in seven studies, and venovenous ECCO2R in seven studies. Available evidence suggests no mortality benefit to ECCO2R, although post hoc analysis of data from the most recent RCT showed an improvement in ventilator-free days in more severe ARDS. Organ failure-free days or ICU stay have not been shown to decrease with ECCO2R. Carbon dioxide removal was widely demonstrated as feasible, facilitating the use of lower tidal volume ventilation. Complication rates varied greatly across the included studies, representing technological advances. There was a general paucity of high-quality data and significant variation in both practice and technology used among studies, which confounded analysis. ECCO2R is a rapidly evolving technology and is an efficacious treatment to enable protective lung ventilation. Evidence for a positive effect on mortality and other important clinical outcomes is lacking. Rapid technological advances have led to major changes in these devices and together with variation in study design have limited applicability of analysis. Further well-designed adequately powered RCTs are needed.

Patient Selection and Timing of Continuous Renal Replacement Therapy

“…A recent systematic review of 2 RCTs and 12 observational studies concluded that robust data was still lacking, especially since the only 2 RCTs were terminated early for futility [58] . The results of an ongoing active study aimed at evaluating the safety and efficacy of combining ECCO2R and CRRT are awaited (ClinicalTrials.gov; NCT01239966) [59] .…”

Évaluation des dispositifs médicaux d’épuration sélective du CO2 : principe de fonctionnement, aspects techniques et données d’évaluation clinique

“…Une autre étude publiée sur 10 patients a montré la faisabilité d'un système d'épuration du CO 2 couplé à un circuit d'épuration rénale [13]. Une revue systémique de la littérature, incluant les études portant sur tout type de système d'ECCO2R (récent/ancien, artério-veineux/veinoveineux) a conclu en la faisabilité technique des dispositifs tout en soulignant le grand manque de données d'évalua-tion clinique de bonne qualité [14]. Dans ce contexte, les recommandations de la Société de réanimation de langue française sont de ne proposer l'ECCO2R dans le SDRA que dans le cadre d'essais cliniques [15].…”

Coronavirus Epidemic and Extracorporeal Therapies in Intensive Care: si vis pacem para bellum

“…The most important technique in these cases is the ECMO mostly applied in venovenous mode [21][22][23]. Furthermore, extracorporeal CO 2 removal is another option that can be performed in less severe cases to facilitate a less invasive and traumatic mechanical ventilation [24]. Although acute kidney injury in these patients is not common, continuous renal replacement therapies may offer in conditions of mild to severe kidney dysfunction a significant support for solute and fluid control.…”