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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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Tonetti T, Zanella A, Pérez-Torres D, Grasselli G, Ranieri VM. Current knowledge gaps in extracorporeal respiratory support. Intensive Care Med Exp 2023; 11:77. [PMID: 37962702 PMCID: PMC10645840 DOI: 10.1186/s40635-023-00563-x] [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: 01/18/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction ("ultra-protective ventilation") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.
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Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
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Ruberto F, Alessandri F, Piazzolla M, Zullino V, Bruno K, Celli P, Diso D, Venuta F, Bilotta F, Pugliese F. Intraoperative use of extracorporeal CO 2 removal (ECCO 2R) and emergency ECMO requirement in patients undergoing lung transplant: a case-matched cohort retrospective study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:22. [PMID: 37386563 DOI: 10.1186/s44158-022-00050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/10/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND The use of extracorporeal carbon dioxide removal (ECCO2R) is less invasive than extracorporeal membrane oxygenation (ECMO), and intraoperative control of gas exchange could be feasible. The aim of this study in intermediate intraoperative severity patients undergoing LT was to assess the role of intraoperative ECCO2R on emergency ECMO requirement in patients. METHODS Thirty-eight consecutive patients undergoing lung transplantation (LT) with "intermediate" intraoperative severity in the intervals 2007 to 2010 or 2011 to 2014 were analyzed as historical comparison of case-matched cohort retrospective study. The "intermediate" intraoperative severity was defined as the development of intraoperative severe respiratory acidosis with maintained oxygenation function (i.e., pH <7.25, PaCO2 >60 mmHg, and PaO2/FiO2 >150), not associated with hemodynamic instability. Of these 38 patients, twenty-three patients were treated in the 2007-2010 interval by receiving "standard intraoperative treatment," while 15 patients were treated in the 2011-2014 interval by receiving "standard intraoperative treatment + ECCO2R." RESULTS ECMO requirement was more frequent among patients that received "standard intraoperative treatment" alone than in those treated with "standard intraoperative treatment + ECCO2R" (17/23 vs. 3/15; p = 0.004). The use of ECCO2R improved pH and PaCO2 while mean pulmonary artery pressure (mPAP) decreased. CONCLUSION In intermediate intraoperative severity patients, the use of ECCO2R reduces the ECMO requirement.
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Affiliation(s)
- Franco Ruberto
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Alessandri
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Mario Piazzolla
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Veronica Zullino
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Katia Bruno
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paola Celli
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Diso
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Venuta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Bilotta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Pugliese
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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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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Schwärzel LS, Jungmann AM, Schmoll N, Seiler F, Muellenbach RM, Schenk J, Dinh QT, Bals R, Lepper PM, Omlor AJ. A mock circulation loop to test extracorporeal CO 2 elimination setups. Intensive Care Med Exp 2020; 8:52. [PMID: 32915322 PMCID: PMC7484925 DOI: 10.1186/s40635-020-00341-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/02/2020] [Indexed: 01/01/2023] Open
Abstract
Background Extracorporeal carbon dioxide removal (ECCO2R) is a promising yet limited researched therapy for hypercapnic respiratory failure in acute respiratory distress syndrome and exacerbated chronic obstructive pulmonary disease. Herein, we describe a new mock circuit that enables experimental ECCO2R research without animal models. In a second step, we use this model to investigate three experimental scenarios of ECCO2R: (I) the influence of hemoglobin concentration on CO2 removal. (II) a potentially portable ECCO2R that uses air instead of oxygen, (III) a low-flow ECCO2R that achieves effective CO2 clearance by recirculation and acidification of the limited blood volume of a small dual lumen cannula (such as a dialysis catheter). Results With the presented ECCO2R mock, CO2 removal rates comparable to previous studies were obtained. The mock works with either fresh porcine blood or diluted expired human packed red blood cells. However, fresh porcine blood was preferred because of better handling and availability. In the second step of this work, hemoglobin concentration was identified as an important factor for CO2 removal. In the second scenario, an air-driven ECCO2R setup showed only a slightly lower CO2 wash-out than the same setup with pure oxygen as sweep gas. In the last scenario, the low-flow ECCO2R, the blood flow at the test membrane lung was successfully raised with a recirculation channel without the need to increase cannula flow. Low recirculation ratios resulted in increased efficiency, while high recirculation ratios caused slightly reduced CO2 removal rates. Acidification of the CO2 depleted blood in the recirculation channel caused an increase in CO2 removal rate. Conclusions We demonstrate a simple and cost effective, yet powerful, “in-vitro” ECCO2R model that can be used as an alternative to animal experiments for many research scenarios. Moreover, in our approach parameters such as hemoglobin level can be modified more easily than in animal models.
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Affiliation(s)
- Leonie S Schwärzel
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Anna M Jungmann
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Nicole Schmoll
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Frederik Seiler
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Ralf M Muellenbach
- Department of Anaesthesiology and Critical Care, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Joachim Schenk
- Department of Transfusion Medicine and Hemostaseology, University Hospital of Saarland, Homburg, Germany
| | - Quoc Thai Dinh
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Robert Bals
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany.
| | - Albert J Omlor
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
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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: 30] [Impact Index Per Article: 7.5] [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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Gattinoni L, Vassalli F, Romitti F, Vasques F, Pasticci I, Duscio E, Quintel M. Extracorporeal gas exchange: when to start and how to end? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:203. [PMID: 31200746 PMCID: PMC6570632 DOI: 10.1186/s13054-019-2437-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/15/2019] [Indexed: 12/18/2022]
Affiliation(s)
- L Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - F Vassalli
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - F Romitti
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - F Vasques
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - I Pasticci
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - E Duscio
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - M Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
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Karagiannidis C, Strassmann S, Schwarz S, Merten M, Fan E, Beck J, Sinderby C, Windisch W. Control of respiratory drive by extracorporeal CO 2 removal in acute exacerbation of COPD breathing on non-invasive NAVA. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:135. [PMID: 31014366 PMCID: PMC6480839 DOI: 10.1186/s13054-019-2404-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/21/2019] [Indexed: 01/19/2023]
Abstract
Background Veno-venous extracorporeal CO2 removal (vv-ECCO2R) and non-invasive neurally adjusted ventilator assist (NIV-NAVA) are two promising techniques which may prevent complications related to prolonged invasive mechanical ventilation in patients with acute exacerbation of COPD. Methods A physiological study of the electrical activity of the diaphragm (Edi) response was conducted with varying degrees of extracorporeal CO2 removal to control the respiratory drive in patients with severe acute exacerbation of COPD breathing on NIV-NAVA. Results Twenty COPD patients (SAPS II 37 ± 5.6, age 57 ± 9 years) treated with vv-ECCO2R and supported by NIV-NAVA were studied during stepwise weaning of vv-ECCO2R. Based on dyspnea, tolerance, and blood gases, weaning from vv-ECCO2R was successful in 12 and failed in eight patients. Respiratory drive (measured via the Edi) increased to 19 ± 10 μV vs. 56 ± 20 μV in the successful and unsuccessful weaning groups, respectively, resulting in all patients keeping their CO2 and pH values stable. Edi was the best predictor for vv-ECCO2R weaning failure (ROC analysis AUC 0.95), whereas respiratory rate, rapid shallow breathing index, and tidal volume had lower predictive values. Eventually, 19 patients were discharged home, while one patient died. Mortality at 90 days and 180 days was 15 and 25%, respectively. Conclusions This study demonstrates for the first time the usefulness of the Edi signal to monitor and guide patients with severe acute exacerbation of COPD on vv-ECCO2R and NIV-NAVA. The Edi during vv-ECCO2R weaning was found to be the best predictor of tolerance to removing vv-ECCO2R. Electronic supplementary material The online version of this article (10.1186/s13054-019-2404-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Stephan Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Sarah Schwarz
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Michaela Merten
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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10
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Pettenuzzo T, Fan E, Del Sorbo L. Extracorporeal carbon dioxide removal in acute exacerbations of chronic obstructive pulmonary disease. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:31. [PMID: 29430448 PMCID: PMC5799148 DOI: 10.21037/atm.2017.12.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/30/2017] [Indexed: 01/15/2023]
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) has been proposed as an adjunctive intervention to avoid worsening respiratory acidosis, thereby preventing or shortening the duration of invasive mechanical ventilation (IMV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD). This review will present a comprehensive summary of the pathophysiological rationale and clinical evidence of ECCO2R in patients suffering from severe COPD exacerbations.
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Affiliation(s)
- Tommaso Pettenuzzo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- The Extracorporeal Life Support Program and Department of Medicine, University Health Network, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- The Extracorporeal Life Support Program and Department of Medicine, University Health Network, Toronto, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- The Extracorporeal Life Support Program and Department of Medicine, University Health Network, Toronto, Canada
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