Extracorporeal carbon dioxide removal (ECCO2R) in COPD and ARDS patients with severe hypercapnic respiratory failure. A retrospective case-control study

Background/aim: Treatment of severe hypercapnic respiratory failure (HRF) has some challenges in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS), especially when lung protective ventilation (LPV) strategies are required. Extracorporeal CO2removal (ECCO2R) therapy is an emerging option to manage hypercapnia while allowing LPV in these cases. However, further data on ECCO2R use is still needed to make clear recommendations. Materials and methods: This study was conducted on patients admitted to intensive care unit (ICU) between January 1st, 2016 to December 31st, 2019. The medical records were retrospectively scanned in institutional software database. Patients who received invasive mechanic ventilation (iMV) support due to severe HRF related to COPD or ARDS were included in the analyses. Patients were grouped according to treatment approaches as that ECCO2R therapy in addition to conventional treatments and conventional treatments alone (controls). Groups were compared for 28-day survival, iMV duration, and length of stay (LOS). Results: ECCO2R therapy was noted in 75 of the cases among included 395 patients (COPD n = 256, ARDS n = 139) out of scanned 1715 medical records. The survival rate of ECCO2R patients was 68% and significantly higher than 58% survival rate of controls (p = 0.025), with relative risk reduction (RRR) = 0.16, absolute risk reduction (ARR)= 0.10, number need to treat (NNT) = 10, and odds ratio (OR) = 1.5. In addition, iMV duration (12.8 ± 2.6 vs. 17.1 ± 4.9 days, p = 0.007) and LOS (16.9 ± 4.1 vs. 18.9 ± 5.5 days, p = 0.032) were significantly shorter than controls. Repeated measure analyses showed that LPV settings were successfully provided by 72 h of ECCO2R therapy. Subgroup analyses according to diagnoses of COPD and ARDS also favored ECCO2R. Conclusion: ECCO2R therapy significantly improved survival, iMV duration and LOS in patients with severe HRF due to COPD or ARDS, and successfully provided LPV approaches. Further studies are needed to assess promising benefits of ECCO2R therapy.Key words: Extracorporeal carbon dioxide removal, ECCO2R, hypercapnic respiratory failure, artificial membranes, survival, intensive care

PDF

___

1. Davidson C, Banham S, Elliott M, Kennedy D, Gelder C et al. BTS ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016; 71 (Suppl 2): 1-35. doi: 10.1136/thoraxjnl-2015-208209
2. Combes A, Hajage D, Capellier G, Demoule A, Lavoue S et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. New England Journal of Medicine 2018; 378 (21): 1965-1975. doi: 10.1056/ NEJMoa1800385
3. Nin N, Muriel A, Penuelas O, Brochard L, Lorente JA et al. Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome. Intensive Care Medicine 2017; 43 (2): 200-208. doi: 10.1007/s00134-016-4611-1
4. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT et al. ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New England Journal of Medicine 2000; 342 (18): 1301-1308. doi: 10.1056/ NEJM200005043421801
5. Romay E, Ferrer R. Extracorporeal CO2 removal: technical and physiological fundaments and principal indications. Medicina Intensiva 2016; 40 (1): 33-38. doi: 10.1016/j.medin.2015.06.001
6. Barrett NA, Hart N, Camporota L. In vivo carbon dioxide clearance of a low-flow extracorporeal carbon dioxide removal circuit in patients with acute exacerbations of chronic obstructive pulmonary disease. Perfusion 2020; 35 (5): 436-441. doi: 10.1177/0267659119896531
7. Taccone FS, Malfertheiner MV, Ferrari F, Di Nardo M, Swol J et al. Extracorporeal CO2 removal in critically ill patients: a systematic review. Minerva Anestesiologica 2017; 83 (7): 762-772. doi: 10.23736/S0375-9393.17.11835-3
8. Kolobow T, Gattinoni L, Tomlinson TA, Pierce JE. Control of breathing using an extracorporeal membrane lung. Anesthesiology 1977; 46 (2): 138-141. doi: 10.1097/00000542-197702000-00012
9. Patel B, Chatterjee S, Davignon S, Herlihy JP. Extracorporeal membrane oxygenation as rescue therapy for severe hypoxemic respiratory failure. Journal of Thoracic Diseases 2019; 11 (Suppl 14): 1688-1697. doi: 10.21037/jtd.2019.05.73
10. Davies A, Jones D, Bailey M, Beca J, Bellomo R et al. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. The Journal of the American Medical Association 2009; 302 (17): 1888-1895. doi: 10.1001/ jama.2009.1535
11. Terragni PP, Del Sorbo L, Mascia L, Urbino R, Martin EL et al. Tidal volume lower than 6 ml/kg enhances lung protection role of extracorporeal carbon dioxide removal. Anesthesiology 2009; 111 (4): 826–835. doi: 10.1097/ALN.0b013e3181b764d2
12. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet 2009; 374 (9698): 1351-1363. doi: 10.1016/ S0140-6736(09)61069-2
13. Combes A, Fanelli V, Pham T, Ranieri VM. Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Medicine 2019; 45 (5): 592-600. doi: 10.1007/ s00134-019-05567-4
14. Schmidt M, Jaber S, Zogheib E, Godet T, Capellier G et al. Feasibility and safety of low-flow extracorporeal CO2 removal managed with a renal replacement platform to enhance lungprotective ventilation of patients with mild-to-moderate ARDS. Critical Care 2018; 22 (1):122-129. doi: 10.1186/ s13054-018-2038-5
15. Braune S, Sieweke A, Brettner F, Staudinger T, Joannidis M et al. The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicenter case-control study. Intensive Care Medicine 2016; 42 (9): 1437-1444. doi: 10.1007/s00134-016- 4452-y
16. Fanelli V, Ranieri MV, Mancebo J, Moerer O, Quintel M et al. Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress syndrome. Critical Care 2016; 20: 36-42. doi: 10.1186/s13054-016-1211-y
17. Morelli A, Del Sorbo L, Pesenti A, Ranieri VM, Fan E. Extracorporeal carbon dioxide removal (ECCO2R) in patients with acute respiratory failure. Intensive Care Medicine 2017; 43 (4): 519-530. doi: 10.1007/s00134-016-4673-0
18. Combes A, Auzinger G, Capellier G, Du Cheyron D, Clement I et al. ECCO2R therapy in the ICU: consensus of a European round table meeting. Critical Care 2020; 24 (1): 490-499. doi: 10.1186/s13054-020-03210-z
19. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E et al. Acute respiratory distress syndrome: the Berlin definition. The Journal of the American Medical Association 2012; 307 (23): 2526-2533. doi: 10.1001/jama.2012.5669
20. Singh D, Agusti A, Anzueto A, Barnes PJ, Bourbeau J et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the gold science committee report 2019. The European Respiratory Journal 2019; 53 (5): 1900164. doi: 10.1183/13993003.00164-2019
21. Morimont P, Batchinsky A, Lambermont B. Update on the role of extracorporeal CO(2) removal as an adjunct to mechanical ventilation in ARDS. Critical Care 2015; 19: 117. doi: 10.1186/ s13054-015-0799-7
22. Baker A, Richardson D, Craig G. Extracorporeal carbon dioxide removal (ECCO2R) in respiratory failure: an overview, and where next? Journal of Intensive Care Society 2012; 13 (3): 232-237. doi: 10.1177/175114371201300313
23. Fitzgerald M, Millar J, Blackwood B, Davies A, Brett SJ et al. Extracorporeal carbon dioxide removal for patients with acute respiratory failure secondary to the acute respiratory distress syndrome: a systematic review. Critical Care 2014; 18 (3): 222. doi: 10.1186/cc13875
24. Sklar MC, Beloncle F, Katsios CM, Brochard L, Friedrich JO. Extracorporeal carbon dioxide removal in patients with chronic obstructive pulmonary disease: a systematic review. Intensive Care Medicine 2015; 41(10): 1752-1762. doi: 10.1007/ s00134-015-3921-z
25. Hilty MP, Riva T, Cottini SR, Kleinert EM, Maggiorini A et al. Low flow veno-venous extracorporeal CO2 removal for acute hypercapnic respiratory failure. Minerva Anestesiologica 2017; 83 (8): 812-823. doi: 10.23736/S0375-9393.17.11524-5
26. Moss CE, Galtrey EJ, Camporota L, Meadows C, Gillon S et al. A retrospective observational case series of low-flow venovenous extracorporeal carbon dioxide removal use in patients with respiratory failure. American Society for Artificial Internal Organs Journal 2016; 62 (4): 458-462. doi: 10.1097/MAT.0000000000000386
27. Cummins C, Bentley A, McAuley DF, McNamee JJ, Patrick H et al. A United Kingdom Register study of in-hospital outcomes of patients receiving extracorporeal carbon dioxide removal. Journal of the Intensive Care Society 2018; 19 (2): 114-121. doi: 10.1177/1751143717739816
28. Grasselli G, Castagna L, Bottino N, Scaravilli V, Corcione N et al. practical clinical application of an extracorporeal carbon dioxide removal system in acute respiratory distress syndrome and acute on chronic respiratory failure. American Society for Artificial Internal Organs Journal 2020; 66 (6): 691-697. doi: 10.1097/ MAT0000000000001050