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Smadja DM, Chocron R, Rivet N, Ortuno S, Guerin CL, Diehl JL. Platelet Activation and Severe Bleeding During Extracorporeal Carbon Dioxide Removal in Chronic Obstructive Pulmonary Disease Patients. ASAIO J 2024:00002480-990000000-00485. [PMID: 38753545 DOI: 10.1097/mat.0000000000002241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Affiliation(s)
- David M Smadja
- From the Innovative Therapies in Haemostasis, INSERM UMR-S1140 Department, Paris University, Paris, France
- Hematology Department, Georges Pompidou European Hospital, Paris, France
| | - Richard Chocron
- Emergency Department, Georges Pompidou European Hospital, Paris, France
- Paris Centre de Recherche Cardiovasculaire, INSERM UMR-S 970 Department, Paris University, Paris, France
| | - Nadia Rivet
- From the Innovative Therapies in Haemostasis, INSERM UMR-S1140 Department, Paris University, Paris, France
- Hematology Department, Georges Pompidou European Hospital, Paris, France
| | - Sofia Ortuno
- Medical Intensive Care Department, Georges Pompidou European Hospital, Paris, France
| | - Coralie L Guerin
- From the Innovative Therapies in Haemostasis, INSERM UMR-S1140 Department, Paris University, Paris, France
- Flow Cytometry Department, Curie Institute, Paris, France
| | - Jean-Luc Diehl
- From the Innovative Therapies in Haemostasis, INSERM UMR-S1140 Department, Paris University, Paris, France
- Medical Intensive Care Department, Georges Pompidou European Hospital, Paris, France
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2
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Stommel AM, Herkner H, Kienbacher CL, Wildner B, Hermann A, Staudinger T. Effects of extracorporeal CO 2 removal on gas exchange and ventilator settings: a systematic review and meta-analysis. Crit Care 2024; 28:146. [PMID: 38693569 PMCID: PMC11061932 DOI: 10.1186/s13054-024-04927-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/21/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE A systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO2R) on gas exchange and respiratory settings in critically ill adults with respiratory failure. METHODS We conducted a comprehensive database search, including observational studies and randomized controlled trials (RCTs) from January 2000 to March 2022, targeting adult ICU patients undergoing ECCO2R. Primary outcomes were changes in gas exchange and ventilator settings 24 h after ECCO2R initiation, estimated as mean of differences, or proportions for adverse events (AEs); with subgroup analyses for disease indication and technology. Across RCTs, we assessed mortality, length of stay, ventilation days, and AEs as mean differences or odds ratios. RESULTS A total of 49 studies encompassing 1672 patients were included. ECCO2R was associated with a significant decrease in PaCO2, plateau pressure, and tidal volume and an increase in pH across all patient groups, at an overall 19% adverse event rate. In ARDS and lung transplant patients, the PaO2/FiO2 ratio increased significantly while ventilator settings were variable. "Higher extraction" systems reduced PaCO2 and respiratory rate more efficiently. The three available RCTs did not demonstrate an effect on mortality, but a significantly longer ICU and hospital stay associated with ECCO2R. CONCLUSIONS ECCO2R effectively reduces PaCO2 and acidosis allowing for less invasive ventilation. "Higher extraction" systems may be more efficient to achieve this goal. However, as RCTs have not shown a mortality benefit but increase AEs, ECCO2R's effects on clinical outcome remain unclear. Future studies should target patient groups that may benefit from ECCO2R. PROSPERO Registration No: CRD 42020154110 (on January 24, 2021).
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Affiliation(s)
- Alexandra-Maria Stommel
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Calvin Lukas Kienbacher
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Brigitte Wildner
- University Library, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Hermann
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Barbič B, Bianchi C, Madotto F, Sklar MC, Karagiannidis C, Fan E, Brochard L. The Failure of Extracorporeal Carbon Dioxide Removal May Be a Failure of Technology. Am J Respir Crit Care Med 2024; 209:884-887. [PMID: 38190699 DOI: 10.1164/rccm.202309-1628le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 01/03/2024] [Indexed: 01/10/2024] Open
Affiliation(s)
- Beatrice Barbič
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and
- Scuola di Specializzazione in Anestesia, Terapia Intensiva e del Dolore, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Cecilia Bianchi
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and
- Scuola di Specializzazione in Anestesia, Terapia Intensiva e del Dolore, Università degli Studi di Milano, Milan, Italy
| | - Fabiana Madotto
- Dipartimento Area Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Michael C Sklar
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada; and
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and
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4
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Gayen S, Dachert S, Lashari BH, Gordon M, Desai P, Criner GJ, Cardet JC, Shenoy K. Critical Care Management of Severe Asthma Exacerbations. J Clin Med 2024; 13:859. [PMID: 38337552 PMCID: PMC10856115 DOI: 10.3390/jcm13030859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Severe asthma exacerbations, including near-fatal asthma (NFA), have high morbidity and mortality. Mechanical ventilation of patients with severe asthma is difficult due to the complex pathophysiology resulting from severe bronchospasm and dynamic hyperinflation. Life-threatening complications of traditional ventilation strategies in asthma exacerbations include the development of systemic hypotension from hyperinflation, air trapping, and pneumothoraces. Optimizing pharmacologic techniques and ventilation strategies is crucial to treat the underlying bronchospasm. Despite optimal pharmacologic management and mechanical ventilation, the mortality rate of patients with severe asthma in intensive care units is 8%, suggesting a need for advanced non-pharmacologic therapies, including extracorporeal life support (ECLS). This review focuses on the pathophysiology of acute asthma exacerbations, ventilation management including non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV), the pharmacologic management of acute asthma, and ECLS. This review also explores additional advanced non-pharmacologic techniques and monitoring tools for the safe and effective management of critically ill adult asthmatic patients.
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Affiliation(s)
- Shameek Gayen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Stephen Dachert
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Bilal H. Lashari
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Matthew Gordon
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Parag Desai
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Gerard J. Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Juan Carlos Cardet
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL 33602, USA;
| | - Kartik Shenoy
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
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Tiruvoipati R, Ludski J, Gupta S, Subramaniam A, Ponnapa Reddy M, Paul E, Haji K. Evaluation of the safety and efficacy of extracorporeal carbon dioxide removal in the critically ill using the PrismaLung+ device. Eur J Med Res 2023; 28:291. [PMID: 37596670 PMCID: PMC10436516 DOI: 10.1186/s40001-023-01269-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/05/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Several extracorporeal carbon dioxide removal (ECCO2R) devices are currently in use with variable efficacy and safety profiles. PrismaLung+ is an ECCO2R device that was recently introduced into clinical practice. It is a minimally invasive, low flow device that provides partial respiratory support with or without renal replacement therapy. Our aim was to describe the clinical characteristics, efficacy, and safety of PrismaLung+ in patients with acute hypercapnic respiratory failure. METHODS All adult patients who required ECCO2R with PrismaLung+ for hypercapnic respiratory failure in our intensive care unit (ICU) during a 6-month period between March and September 2022 were included. RESULTS Ten patients were included. The median age was 55.5 (IQR 41-68) years, with 8 (80%) male patients. Six patients had acute respiratory distress syndrome (ARDS), and two patients each had exacerbations of asthma and chronic obstructive pulmonary disease (COPD). All patients were receiving invasive mechanical ventilation at the time of initiation of ECCO2R. The median duration of ECCO2R was 71 h (IQR 57-219). A significant improvement in pH and PaCO2 was noted within 30 min of initiation of ECCO2R. Nine patients (90%) survived to weaning of ECCO2R, eight (80%) survived to ICU discharge and seven (70%) survived to hospital discharge. The median duration of ICU and hospital stays were 14.5 (IQR 8-30) and 17 (IQR 11-38) days, respectively. There were no patient-related complications with the use of ECCO2R. A total of 18 circuits were used in ten patients (median 2 per patient; IQR 1-2). Circuit thrombosis was noted in five circuits (28%) prior to reaching the expected circuit life with no adverse clinical consequences. CONCLUSION(S) PrismaLung+ rapidly improved PaCO2 and pH with a good clinical safety profile. Circuit thrombosis was the only complication. This data provides insight into the safety and efficacy of PrismaLung+ that could be useful for centres aspiring to introduce ECCO2R into their clinical practice.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia.
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia.
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| | - Jarryd Ludski
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Intensive Care Medicine, Dandenong Hospital, Dandenong, Australia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- Department of Intensive Care, Calvary Hospital, Canberra, ACT, Australia
| | - Eldho Paul
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Alfred Hospital, Melbourne, VIC, Australia
| | - Kavi Haji
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
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Tiruvoipati R, Akkanti B, Dinh K, Barrett N, May A, Kimmel J, Conrad SA. Extracorporeal Carbon Dioxide Removal With the Hemolung in Patients With Acute Respiratory Failure: A Multicenter Retrospective Cohort Study. Crit Care Med 2023; 51:892-902. [PMID: 36942957 PMCID: PMC10262985 DOI: 10.1097/ccm.0000000000005845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVES Extracorporeal carbon dioxide removal (ECCO 2 R) devices are effective in reducing hypercapnia and mechanical ventilation support but have not been shown to reduce mortality. This may be due to case selection, device performance, familiarity, or the management. The objective of this study is to investigate the effectiveness and safety of a single ECCO 2 R device (Hemolung) in patients with acute respiratory failure and identify variables associated with survival that could help case selection in clinical practice as well as future research. DESIGN Multicenter, multinational, retrospective review. SETTING Data from the Hemolung Registry between April 2013 and June 2021, where 57 ICUs contributed deidentified data. PATIENTS Patients with acute respiratory failure treated with the Hemolung. The characteristics of patients who survived to ICU discharge were compared with those who died. Multivariable logistical regression analysis was used to identify variables associated with ICU survival. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 159 patients included, 65 (41%) survived to ICU discharge. The survival was highest in status asthmaticus (86%), followed by acute respiratory distress syndrome (ARDS) (52%) and COVID-19 ARDS (31%). All patients had a significant reduction in Pa co2 and improvement in pH with reduction in mechanical ventilation support. Patients who died were older, had a lower Pa o2 :F io2 (P/F) and higher use of adjunctive therapies. There was no difference in the complications between patients who survived to those who died. Multivariable regression analysis showed non-COVID-19 ARDS, age less than 65 years, and P/F at initiation of ECCO 2 R to be independently associated with survival to ICU discharge (P/F 100-200 vs <100: odds ratio, 6.57; 95% CI, 2.03-21.33). CONCLUSIONS Significant improvement in hypercapnic acidosis along with reduction in ventilation supports was noted within 4 hours of initiating ECCO 2 R. Non-COVID-19 ARDS, age, and P/F at commencement of ECCO 2 R were independently associated with survival.
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Affiliation(s)
| | - Bindu Akkanti
- Department of Medicine, Division of Critical Care, Pulmonary and Sleep, University of Texas McGovern Medical School, Houston, TX
- Advanced Cardiopulmonary Therapeutics and Transplantation, University of Texas Health-Houston, Houston, TX
| | - Kha Dinh
- Department of Medicine, Division of Critical Care, Pulmonary and Sleep, University of Texas McGovern Medical School, Houston, TX
- Advanced Cardiopulmonary Therapeutics and Transplantation, University of Texas Health-Houston, Houston, TX
| | - Nicholas Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | | | | | - Steven A Conrad
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA
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Lozano-Espinosa M, Antolín-Amérigo D, Riera Del Brío J, Gordo Vidal F, Quirce S, Álvarez Rodríguez J. Extracorporeal membrane oxygenation (ECMO) and beyond in near fatal asthma: A comprehensive review. Respir Med 2023:107246. [PMID: 37245648 DOI: 10.1016/j.rmed.2023.107246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 05/30/2023]
Abstract
The treatment of choice in severe asthma exacerbations with respiratory failure includes ventilatory support, both invasive and/or non-invasive, along with different kinds of asthma medication. Of note, the rate of mortality of patients with asthma has decreased substantially in recent years mainly due to significant advances in pharmacological treatment and other management strategies. However, the risk of death in patients with severe asthma who require invasive mechanical ventilation has been estimated between 6.5% and 10.3%. When conventional measures fail, rescue strategies, such as extracorporeal membrane oxygenation (ECMO) or extracorporeal CO2 removal (ECCO2R) may need to be implemented. While ECMO does not constitute a definitive treatment per se, it can minimize further ventilator associated lung injury (VALI) and can enable diagnostic-therapeutic maneuvers that cannot be performed without ECMO such as bronchoscopy and transfer for diagnostic imaging. Asthma is one of the diseases that is associated with excellent outcomes for patients with refractory respiratory failure requiring ECMO support, as shown by the Extracorporeal Life Support Organization (ELSO) registry. Moreover, in such situations, the use of ECCO2R for rescue has been described and utilized in both children and adults and is more widely spread in different hospitals than ECMO. In this article, we aim to review the evidence for the usefulness of extracorporeal respiratory support measures in the management of severe asthma exacerbations that lead to respiratory failure.
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Affiliation(s)
- María Lozano-Espinosa
- Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - Darío Antolín-Amérigo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain.
| | - Jordi Riera Del Brío
- Servicio de Medicina Intensiva, Hospital Universitari Vall d'Hebron, SODIR, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Federico Gordo Vidal
- Servicio de Medicina Intensiva, Hospital Universitario Henares, Coslada, Madrid, Spain; Grupo de Investigación en Patología Crítica. Universidad Francisco de Vitoria. Pozuelo de Alarcón, Madrid, Spain
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain
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Combes A, Brodie D, Aissaoui N, Bein T, Capellier G, Dalton HJ, Diehl JL, Kluge S, McAuley DF, Schmidt M, Slutsky AS, Jaber S. Extracorporeal carbon dioxide removal for acute respiratory failure: a review of potential indications, clinical practice and open research questions. Intensive Care Med 2022; 48:1308-1321. [PMID: 35943569 DOI: 10.1007/s00134-022-06796-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023]
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) is a form of extracorporeal life support (ECLS) largely aimed at removing carbon dioxide in patients with acute hypoxemic or acute hypercapnic respiratory failure, so as to minimize respiratory acidosis, allowing more lung protective ventilatory settings which should decrease ventilator-induced lung injury. ECCO2R is increasingly being used despite the lack of high-quality evidence, while complications associated with the technique remain an issue of concern. This review explains the physiological basis underlying the use of ECCO2R, reviews the evidence regarding indications and contraindications, patient management and complications, and addresses organizational and ethical considerations. The indications and the risk-to-benefit ratio of this technique should now be carefully evaluated using structured national or international registries and large randomized trials.
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Affiliation(s)
- Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France. .,Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, boulevard de l'Hôpital, 75013, Paris, France.
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, USA.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York, USA
| | - Nadia Aissaoui
- Assistance publique des hopitaux de Paris (APHP), Cochin Hospital, Intensive Care Medicine, Université de Paris and Paris Cardiovascular Research Center, INSERM U970, Paris, France
| | - Thomas Bein
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | - Gilles Capellier
- CHU Besançon, Réanimation Médicale, 2500, Besançon, France.,Université de Franche Comte, EA, 3920, Besançon, France.,Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive, Care Research Centre, Monash University, Melbourne, Australia
| | - Heidi J Dalton
- Heart and Vascular Institute and Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA, USA
| | - Jean-Luc Diehl
- Medical Intensive Care Unit and Biosurgical Research Lab (Carpentier Foundation), HEGP Hospital, Assistance Publique-Hôpitaux de Paris-Centre (APHP-Centre), Paris, France.,Université de Paris, INSERM, Innovative Therapies in Haemostasis, 75006, Paris, France
| | - Stefan Kluge
- Department of Intensive Care, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel F McAuley
- Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, UK.,Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Matthieu Schmidt
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Samir Jaber
- PhyMedExp, University of Montpellier, Institut National de La Santé Et de La Recherche Médicale (INSERM), Centre National de La Recherche Scientifique (CNRS), Centre Hospitalier Universitaire (CHU) Montpellier, Montpellier, France.,Département d'Anesthésie-Réanimation, Hôpital Saint-Eloi, Montpellier Cedex, France
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Worku E, Brodie D, Ling RR, Ramanathan K, Combes A, Shekar K. Venovenous extracorporeal CO 2 removal to support ultraprotective ventilation in moderate-severe acute respiratory distress syndrome: A systematic review and meta-analysis of the literature. Perfusion 2022:2676591221096225. [PMID: 35656595 DOI: 10.1177/02676591221096225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCO2R) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCO2R in supporting ultra-protective ventilation in moderate-to-severe ARDS. METHODS MEDLINE and EMBASE were interrogated for studies (2000-2021) reporting venovenous ECCO2R use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCO2R, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCO2R therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data. RESULTS Ten studies reporting 421 patients (PaO2:FiO2 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmH2O reduction (95%-CI: 3.22-3.91) in driving pressure from baseline (p < .001) and a 1.89 mL/kg (95%-CI: 1.75-2.02, p < .001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO2:FiO2 ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy. CONCLUSIONS Venovenous ECCO2R permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made.
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Affiliation(s)
- Elliott Worku
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, 12294Columbia University College of Physicians and Surgeons, NY, USA
- Center for Acute Respiratory Failure, 25065New York-Presbyterian Hospital, NY, USA
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Cardiothoracic Intensive Care Unit, 375583National University Heart Centre, National University Hospital, Singapore
| | - Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, 26933Pitié-Salpêtrière Hospital, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane and Bond University, Gold Coast, QLD, Australia
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Zanella A, Pesenti A, Busana M, De Falco S, Di Girolamo L, Scotti E, Protti I, Colombo SM, Scaravilli V, Biancolilli O, Carlin A, Gori F, Battistin M, Dondossola D, Pirrone F, Salerno D, Gatti S, Grasselli G. A Minimally Invasive and Highly Effective Extracorporeal CO2 Removal Device Combined With a Continuous Renal Replacement Therapy. Crit Care Med 2022; 50:e468-e476. [PMID: 35044966 DOI: 10.1097/ccm.0000000000005428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Extracorporeal carbon dioxide removal is used to treat patients suffering from acute respiratory failure. However, the procedure is hampered by the high blood flow required to achieve a significant CO2 clearance. We aimed to develop an ultralow blood flow device to effectively remove CO2 combined with continuous renal replacement therapy (CRRT). DESIGN Preclinical, proof-of-concept study. SETTING An extracorporeal circuit where 200 mL/min of blood flowed through a hemofilter connected to a closed-loop dialysate circuit. An ion-exchange resin acidified the dialysate upstream, a membrane lung to increase Pco2 and promote CO2 removal. PATIENTS Six, 38.7 ± 2.0-kg female pigs. INTERVENTIONS Different levels of acidification were tested (from 0 to 5 mEq/min). Two l/hr of postdilution CRRT were performed continuously. The respiratory rate was modified at each step to maintain arterial Pco2 at 50 mm Hg. MEASUREMENTS AND MAIN RESULTS Increasing acidification enhanced CO2 removal efficiency of the membrane lung from 30 ± 5 (0 mEq/min) up to 145 ± 8 mL/min (5 mEq/min), with a 483% increase, representing the 73% ± 7% of the total body CO2 production. Minute ventilation decreased accordingly from 6.5 ± 0.7 to 1.7 ± 0.5 L/min. No major side effects occurred, except for transient tachycardia episodes. As expected from the alveolar gas equation, the natural lung Pao2 dropped at increasing acidification steps, given the high dissociation between the oxygenation and CO2 removal capability of the device, thus Pao2 decreased. CONCLUSIONS This new extracorporeal ion-exchange resin-based multiple-organ support device proved extremely high efficiency in CO2 removal and continuous renal support in a preclinical setting. Further studies are required before clinical implementation.
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11
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Azzi M, Aboab J, Alviset S, Ushmorova D, Ferreira L, Ioos V, Memain N, Issoufaly T, Lermuzeaux M, Laine L, Serbouti R, Silva D. Extracorporeal CO 2 removal in acute exacerbation of COPD unresponsive to non-invasive ventilation. BMJ Open Respir Res 2021; 8:8/1/e001089. [PMID: 34893522 PMCID: PMC8666884 DOI: 10.1136/bmjresp-2021-001089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/02/2021] [Indexed: 11/05/2022] Open
Abstract
Background The gold-standard treatment for acute exacerbation of chronic obstructive pulmonary disease (ae-COPD) is non-invasive ventilation (NIV). However, NIV failures may be observed, and invasive mechanical ventilation (IMV) is required. Extracorporeal CO₂ removal (ECCO₂R) devices can be an alternative to intubation. The aim of the study was to assess ECCO₂R effectiveness and safety. Methods Patients with consecutive ae-COPD who experienced NIV failure were retrospectively assessed over two periods of time: before and after ECCO₂R device implementation in our ICU in 2015 (Xenios AG). Results Both groups (ECCO₂R: n=26, control group: n=25) were comparable at baseline, except for BMI, which was significantly higher in the ECCO₂R group (30 kg/m² vs 25 kg/m²). pH and PaCO₂ significantly improved in both groups. The mean time on ECCO₂R was 5.4 days versus 27 days for IMV in the control group. Four patients required IMV in the ECCO₂R group, of whom three received IMV after ECCO₂R weaning. Seven major bleeding events were observed with ECCO₂R, but only three led to premature discontinuation of ECCO₂R. Eight cases of ventilator-associated pneumonia were observed in the control group. Mean time spent in the ICU and mean hospital stay in the ECCO₂R and control groups were, respectively, 18 vs 30 days, 29 vs 49 days, and the 90-day mortality rates were 15% vs 28%. Conclusions ECCO₂R was associated with significant improvement of pH and PaCO₂ in patients with ae-COPD failing NIV therapy. It also led to avoiding intubation in 85% of cases, with low complication rates. Trial registration number ClinicalTrials.gov, NCT04882410. Date of registration 12 May 2021, retrospectively registered. https://www.clinicaltrials.gov/ct2/show/NCT04882410.
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Affiliation(s)
- Mathilde Azzi
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Jerome Aboab
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Sophie Alviset
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Daria Ushmorova
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Luis Ferreira
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Vincent Ioos
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Nathalie Memain
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Tazime Issoufaly
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Mathilde Lermuzeaux
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Laurent Laine
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Rita Serbouti
- Medical Affairs, Fresenius Medical Care France SAS, Fresnes, Île-de-France, France
| | - Daniel Silva
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
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12
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Yu TZ, Tatum RT, Saxena A, Ahmad D, Yost CC, Maynes EJ, O'Malley TJ, Massey HT, Swol J, Whitson BA, Tchantchaleishvili V. Utilization and outcomes of extracorporeal CO 2 removal (ECCO 2 R): Systematic review and meta-analysis of arterio-venous and veno-venous ECCO 2 R approaches. Artif Organs 2021; 46:763-774. [PMID: 34897748 DOI: 10.1111/aor.14130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/25/2021] [Accepted: 11/09/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Extracorporeal carbon dioxide removal (ECCO2 R) provides respiratory support to patients suffering from hypercapnic respiratory failure by utilizing an extracorporeal shunt and gas exchange membrane to remove CO2 from either the venous (VV-ECCO2 R) or arterial (AV-ECCO2 R) system before return into the venous site. AV-ECCO2 R relies on the patient's native cardiac function to generate pressures needed to deliver blood through the extracorporeal circuit. VV-ECCO2 R utilizes a mechanical pump and can be used to treat patients with inadequate native cardiac function. We sought to evaluate the existing evidence comparing the subgroups of patients supported on VV and AV-ECCO2 R devices. METHODS A literature search was performed to identify all relevant studies published between 2000 and 2019. Demographic information, medical indications, perioperative variables, and clinical outcomes were extracted for systematic review and meta-analysis. RESULTS Twenty-five studies including 826 patients were reviewed. 60% of patients (497/826) were supported on VV-ECCO2 R. The most frequent indications were acute respiratory distress syndrome (ARDS) [69%, (95%CI: 53%-82%)] and chronic obstructive pulmonary disease (COPD) [49%, (95%CI: 37%-60%)]. ICU length of stay was significantly shorter in patients supported on VV-ECCO2 R compared to AV-ECCO2 R [15 (95%CI: 7-23) vs. 42 (95%CI: 17-67) days, p = 0.05]. In-hospital mortality was not significantly different [27% (95%CI: 18%-38%) vs. 36% (95%CI: 24%-51%), p = 0.26]. CONCLUSION Both VV and AV-ECCO2 R provided clinically meaningful CO2 removal with comparable mortality.
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Affiliation(s)
- Tiffany Z Yu
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert T Tatum
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Abhiraj Saxena
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Danial Ahmad
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin C Yost
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth J Maynes
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas J O'Malley
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard T Massey
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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13
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Chen Y, Wang S, Huang J, Fu Y, Wen J, Zhou C, Fu Y, Liu L. Application of extracorporeal carbon dioxide removal combined with continuous blood purification therapy in ARDS with hypercapnia in patients with critical COVID-19. Clin Hemorheol Microcirc 2021; 78:199-207. [PMID: 33554895 DOI: 10.3233/ch-201080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Coronavirus disease-19 (COVID-19) is a new type of epidemic pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The population is generally susceptible to COVID-19, which mainly causes lung injury. Some cases may develop severe acute respiratory distress syndrome (ARDS). Currently, ARDS treatment is mainly mechanical ventilation, but mechanical ventilation often causes ventilator-induced lung injury (VILI) accompanied by hypercapnia in 14% of patients. Extracorporeal carbon dioxide removal (ECCO2R) can remove carbon dioxide from the blood of patients with ARDS, correct the respiratory acidosis, reduce the tidal volume and airway pressure, and reduce the incidence of VILI. CASE REPORT Two patients with critical COVID-19 combined with multiple organ failure undertook mechanical ventilation and suffered from hypercapnia. ECCO2R, combined with continuous renal replacement therapy (CRRT), was conducted concomitantly. In both cases (No. 1 and 2), the tidal volume and positive end-expiratory pressure (PEEP) were down-regulated before the treatment and at 1.5 hours, one day, three days, five days, eight days, and ten days after the treatment, together with a noticeable decrease in PCO2 and clear increase in PO2, while FiO2 decreased to approximately 40%. In case No 2, compared with the condition before treatment, the PCO2 decreased significantly with down-regulation in the tidal volume and PEEP and improvement in the pulmonary edema and ARDS after the treatment. CONCLUSION ECCO2R combined with continuous blood purification therapy in patients with COVID-19 who are criti-cally ill and have ARDS and hypercapnia might gain both time and opportunity in the treatment, down-regulate the ventilator parameters, reduce the incidence of VILI and achieve favorable therapeutic outcomes.
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Affiliation(s)
- Ye Chen
- Department of Hemopurification Center, National Clinical Research Center for Infectious Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Shouhong Wang
- Department of Critical Care Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jianrong Huang
- Department of Hemopurification Center, National Clinical Research Center for Infectious Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Yingyun Fu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Juanmin Wen
- Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, Guangdong, China
| | - Chengbin Zhou
- Department of Cardiovascular Surgery, Guangdong Provincial Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yang Fu
- School of Medicine, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Lei Liu
- National Clinical Research Center for Infectious Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
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14
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Alkaline Liquid Ventilation of the Membrane Lung for Extracorporeal Carbon Dioxide Removal (ECCO 2R): In Vitro Study. MEMBRANES 2021; 11:membranes11070464. [PMID: 34206672 PMCID: PMC8306443 DOI: 10.3390/membranes11070464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 11/16/2022]
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) is a promising strategy to manage acute respiratory failure. We hypothesized that ECCO2R could be enhanced by ventilating the membrane lung with a sodium hydroxide (NaOH) solution with high CO2 absorbing capacity. A computed mathematical model was implemented to assess NaOH–CO2 interactions. Subsequently, we compared NaOH infusion, named “alkaline liquid ventilation”, to conventional oxygen sweeping flows. We built an extracorporeal circuit with two polypropylene membrane lungs, one to remove CO2 and the other to maintain a constant PCO2 (60 ± 2 mmHg). The circuit was primed with swine blood. Blood flow was 500 mL × min−1. After testing the safety and feasibility of increasing concentrations of aqueous NaOH (up to 100 mmol × L−1), the CO2 removal capacity of sweeping oxygen was compared to that of 100 mmol × L−1 NaOH. We performed six experiments to randomly test four sweep flows (100, 250, 500, 1000 mL × min−1) for each fluid plus 10 L × min−1 oxygen. Alkaline liquid ventilation proved to be feasible and safe. No damages or hemolysis were detected. NaOH showed higher CO2 removal capacity compared to oxygen for flows up to 1 L × min−1. However, the highest CO2 extraction power exerted by NaOH was comparable to that of 10 L × min−1 oxygen. Further studies with dedicated devices are required to exploit potential clinical applications of alkaline liquid ventilation.
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15
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Martin AK, Ramakrishna H. Extracorporeal Carbon Dioxide Removal (ECCO 2R): A Potential Perioperative Tool in End-Stage Lung Disease. J Cardiothorac Vasc Anesth 2021; 35:2245-2248. [PMID: 33994317 DOI: 10.1053/j.jvca.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/10/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Medicine, Jacksonville, FL
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Medicine, Rochester, MN
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Goursaud S, Valette X, Dupeyrat J, Daubin C, du Cheyron D. Ultraprotective ventilation allowed by extracorporeal CO 2 removal improves the right ventricular function in acute respiratory distress syndrome patients: a quasi-experimental pilot study. Ann Intensive Care 2021; 11:3. [PMID: 33411146 PMCID: PMC7788545 DOI: 10.1186/s13613-020-00784-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
Background Right ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS). RV failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. Veno-venous extracorporeal CO2 removal (ECCO2R) might allow ultraprotective ventilation with lower tidal volume (VT) and plateau pressure (Pplat). This study investigated whether ECCO2R therapy could affect RV function. Methods This was a quasi-experimental prospective observational pilot study performed in a French medical ICU. Patients with moderate-to-severe ARDS with PaO2/FiO2 ratio between 80 and 150 mmHg were enrolled. An ultraprotective ventilation strategy was used with VT at 4 mL/kg of predicted body weight during the 24 h following the start of a low-flow ECCO2R device. RV function was assessed by transthoracic echocardiography (TTE) during the study protocol. Results The efficacy of ECCO2R facilitated an ultraprotective strategy in all 18 patients included. We observed a significant improvement in RV systolic function parameters. Tricuspid annular plane systolic excursion (TAPSE) increased significantly under ultraprotective ventilation compared to baseline (from 22.8 to 25.4 mm; p < 0.05). Systolic excursion velocity (S’ wave) also increased after the 1-day protocol (from 13.8 m/s to 15.1 m/s; p < 0.05). A significant improvement in the aortic velocity time integral (VTIAo) under ultraprotective ventilation settings was observed (p = 0.05). There were no significant differences in the values of systolic pulmonary arterial pressure (sPAP) and RV preload. Conclusion Low-flow ECCO2R facilitates an ultraprotective ventilation strategy thatwould improve RV function in moderate-to-severe ARDS patients. Improvement in RV contractility appears to be mainly due to a decrease in intrathoracic pressure allowed by ultraprotective ventilation, rather than a reduction of PaCO2.
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Affiliation(s)
- Suzanne Goursaud
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France. .,Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000, Caen, France.
| | - Xavier Valette
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France
| | - Julien Dupeyrat
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France
| | - Cédric Daubin
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France
| | - Damien du Cheyron
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France
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17
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Physiological effects of adding ECCO 2R to invasive mechanical ventilation for COPD exacerbations. Ann Intensive Care 2020; 10:126. [PMID: 32990836 PMCID: PMC7523267 DOI: 10.1186/s13613-020-00743-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background Extracorporeal CO2 removal (ECCO2R) could be a valuable additional modality for invasive mechanical ventilation (IMV) in COPD patients suffering from severe acute exacerbation (AE). We aimed to evaluate in such patients the effects of a low-to-middle extracorporeal blood flow device on both gas exchanges and dynamic hyperinflation, as well as on work of breathing (WOB) during the IMV weaning process. Study design and methods Open prospective interventional study in 12 deeply sedated IMV AE-COPD patients studied before and after ECCO2R initiation. Gas exchange and dynamic hyperinflation were compared after stabilization without and with ECCO2R (Hemolung, Alung, Pittsburgh, USA) combined with a specific adjustment algorithm of the respiratory rate (RR) designed to improve arterial pH. When possible, WOB with and without ECCO2R was measured at the end of the weaning process. Due to study size, results are expressed as median (IQR) and a non-parametric approach was adopted. Results An improvement in PaCO2, from 68 (63; 76) to 49 (46; 55) mmHg, p = 0.0005, and in pH, from 7.25 (7.23; 7.29) to 7.35 (7.32; 7.40), p = 0.0005, was observed after ECCO2R initiation and adjustment of respiratory rate, while intrinsic PEEP and Functional Residual Capacity remained unchanged, from 9.0 (7.0; 10.0) to 8.0 (5.0; 9.0) cmH2O and from 3604 (2631; 4850) to 3338 (2633; 4848) mL, p = 0.1191 and p = 0.3013, respectively. WOB measurements were possible in 5 patients, indicating near-significant higher values after stopping ECCO2R: 11.7 (7.5; 15.0) versus 22.6 (13.9; 34.7) Joules/min., p = 0.0625 and 1.1 (0.8; 1.4) versus 1.5 (0.9; 2.8) Joules/L, p = 0.0625. Three patients died in-ICU. Other patients were successfully hospital-discharged. Conclusions Using a formalized protocol of RR adjustment, ECCO2R permitted to effectively improve pH and diminish PaCO2 at the early phase of IMV in 12 AE-COPD patients, but not to diminish dynamic hyperinflation in the whole group. A trend toward a decrease in WOB was also observed during the weaning process. Trial registration ClinicalTrials.gov: Identifier: NCT02586948.
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18
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Combes A, Auzinger G, Capellier G, du Cheyron D, Clement I, Consales G, Dabrowski W, De Bels D, de Molina Ortiz FJG, Gottschalk A, Hilty MP, Pestaña D, Sousa E, Tully R, Goldstein J, Harenski K. ECCO 2R therapy in the ICU: consensus of a European round table meeting. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:490. [PMID: 32768001 PMCID: PMC7412288 DOI: 10.1186/s13054-020-03210-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/28/2020] [Indexed: 01/19/2023]
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 CO2 removal (ECCO2R). However, current evidence in these indications is limited. A European ECCO2R 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 ECCO2R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus. Results Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO2R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO2R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO2R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO2 levels. Driving pressure (≥ 14 cmH2O) followed by plateau pressure (Pplat; ≥ 25 cmH2O) was considered the most important criteria for ECCO2R initiation. Key treatment targets for patients with ARDS undergoing ECCO2R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH2O) and Pplat (< 25 cmH2O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO2 and no decrease in respiratory rate were key criteria for initiating ECCO2R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30–7.35), respiratory rate (< 20–25 breaths/min), decrease of PaCO2 (by 10–20%), weaning from NIV, decrease in HCO3− and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group. Conclusions Insights from this group of experienced physicians suggest that ECCO2R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, Boulevard de l'Hôpital, F-75013, Paris, France. .,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, F-75013, Paris, France.
| | - Georg Auzinger
- Department of Critical Care, King's College Hospital, London, SE5 9RS, UK.,Department of Critical Care, Cleveland Clinic, London, SW1Y 7AW, UK
| | - Gilles Capellier
- Service de Médecine Intensive-Réanimation CHRU Besançon, EA 3920 University of Franche Comte, Besançon, France.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Damien du Cheyron
- Service de Médecine Intensive-Réanimation, Caen University Hospital, 14000, Caen, France
| | - Ian Clement
- Critical Care Unit, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - Guglielmo Consales
- Department Emergency and Critical Care, Prato Hospital, Azienda Toscana Centro, Prato, Italy
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Jaczewskiego Street 8, 20-954, Lublin, Poland
| | - David De Bels
- Service des Soins Intensifs Médico-chirurgicaux, CHU Brugmann, 4 Place A Van Gehuchten, 1020, Brussels, Belgium
| | - Francisco Javier González de Molina Ortiz
- Department of Critical Care, University Hospital Mútua Terrassa, Universitat de Barcelona, Terrassa, Barcelona, Spain.,Department of Critical Care, University Hospital Quirón Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antje Gottschalk
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - David Pestaña
- Department of Anesthesiology and Surgical Critical Care, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Viejo km 9, 28034, Madrid, Spain.,Universidad de Alcalá de Henares, Madrid, Spain
| | - Eduardo Sousa
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-075, Coimbra, Portugal
| | - Redmond Tully
- Department of Intensive Care, Royal Oldham Hospital, Northern Care Alliance, Oldham, OL1 2JH, UK
| | - Jacques Goldstein
- Baxter World Trade SPRL, Acute Therapies Global, Braine-l'Alleud, Belgium
| | - Kai Harenski
- Baxter, Baxter Deutschland GmbH, Unterschleissheim, Germany
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