Reduction of ventilator settings allowed by intravenous oxygenator (IVOX) in ARDS patients

Evaluation of fiber bundle rotation for enhancing gas exchange in a respiratory assist catheter

Supplemental oxygenation and carbon dioxide removal through an intravenous respiratory assist catheter can be used as a means of treating patients with acute respiratory failure. We are beginning development efforts toward a new respiratory assist catheter with an insertional size <25F, which can be inserted percutaneously. In this study, we evaluated fiber bundle rotation as an improved mechanism for active mixing and enhanced gas exchange in intravenous respiratory assist catheters. Using a simple test apparatus of a rotating densely packed bundle of hollow fiber membranes, water and blood gas exchange levels were evaluated at various rotation speeds in a mock vena cava. At 12,000 RPM, maximum CO2 gas exchange rates were 449 and 523 mL/min per m2, water and blood, respectively, but the rate of increase with increasing rotation rate diminished beyond 7500 RPM. These levels of gas exchange efficiency are two- to threefold greater than achieved in our previous respiratory catheters using balloon pulsation for active mixing. In preliminary hemolysis tests, which monitored plasma-free hemoglobin levels in vitro over a period of 6 hours, we established that the rotating fiber bundle per se did not cause significant blood hemolysis compared with an intra-aortic balloon pump. Accordingly, fiber bundle rotation appears to be a potential mechanism for increasing gas exchange and reducing insertional size in respiratory catheters.

Investigating the effects of random balloon pulsation on gas exchange in a respiratory assist catheter

We are developing an intravenous respiratory assist catheter, which uses hollow-fiber membranes wrapped around a pulsating balloon that increases oxygenation and CO2 removal with increased balloon pulsation. Our current pulsation system operates with a constant rate of pulsation and delivered balloon volume. This study examined the hypothesis that random balloon pulsation would disrupt fluid entrainment within the fiber bundle and increase our overall gas exchange. We implemented two different modes for random (rates and delivered volume) versus constant pulsation. The impact on gas exchange was measured in a 3 l/min water flow loop at 37 degrees C. CO2 gas exchange for randomized beat rate mode was comparable to its corresponding average constant pulsation (e.g., constant 286 beats/min versus randomized 200-400 beats/min was 299.5+/-0.9 and 302.2+/-1.4 ml/min/m, respectively). Random volume mode CO2 exchange was also comparable to constant delivered balloon volume (100% inflation and deflation) (e.g., 294.3+/-0.6 and 301.1+/-1.7 ml/min/m, random 50-100% inflation and constant, respectively). Greater active mixing was seen with constant pulsation as compared with randomly changing the parameters of balloon pulsation.

Evaluation of local gas exchange in a pulsating respiratory support catheter

An intravenous respiratory support catheter, the next generation of artificial lungs, is being developed in our laboratory to potentially support acute respiratory failure or patients with chronic obstructive pulmonary disease with acute exacerbations. A rapidly pulsating 25 ml balloon inside a bundle of hollow fiber membranes facilitates supplemental oxygenation and CO2 removal. In this study, we hypothesized that non-uniform gas exchange in different regions of this fiber bundle was present because of asymmetric balloon collapse and the interaction of longitudinal flow. Four quarter regions and two rings around the central balloon were selectively perfused to evaluate local gas exchange in a 3.18 cm test section using helium as the sweep gas. Quarter region CO2 exchange rates at 400 beats per minute were 156.8 +/- 0.8, 162.5 +/- 1.8, 157.2 +/- 0.2, and 196.6 +/- 0.8 ml/min/m2 (top, front, bottom, and back, respectively). The back section, adjacent to convex balloon collapse, had 17-20% higher exchange than the other sections caused by higher relative velocities past its stationary fibers. Inner and outer ring maximum pulsation gas exchange rates were 174.4 +/- 1.8 and 174.6 +/- 0.9 ml/min/m2, respectively, showing that fluid flow was equally distributed throughout the fiber bundle.

Adjuncts to mechanical ventilation

Adjunctive ventilatory strategies have been developed to improve oxygenation and carbon dioxide (CO2) removal during mechanical ventilation of critically ill patients. These techniques allow clinicians to attain their clinical goals at lower levels of ventilatory support. In this article, the authors discuss extracorporeal CO2 removal, venovenous intravena caval oxygenator, and tracheal gas insufflation as adjuncts to CO2 removal and nitric oxide, surfactant replacement therapy, perfluorocarbon-associated gas exchange, and prone positioning as adjuncts to oxygenation.

Clinical strategies in intravascular gas exchange

Specific therapies in the management of acute pulmonary failure remain elusive, with attention being focused instead on novel supportive measures. The benefits of extracorporeal gas exchange support remain uncertain, and the perceived simplicity of intravascular gas exchange has, therefore, attracted much interest. Initial clinical experience with the intravascular oxygenator (IVOX) device confirms its safety and simplicity, but estimated mean gas-transfer values represent only 25% of basal gas-exchange requirements. The inherent limitations of IVOX as an oxygenator are discussed, providing a rationale for considering IVOX as primarily a CO2 removal device. Reappraisal of the clinical place of intravascular gas exchange and the identification of specific applications most likely to yield benefit to patients are suggested. Design modifications enhancing efficacy are anticipated, further strengthening the potential of intravascular gas-exchange devices in selected patients with pulmonary failure.