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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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2
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Piquilloud L. Extracorporeal Carbon Dioxide Removal in Chronic Obstructive Pulmonary Disease: It Depends on the Objective! Am J Respir Crit Care Med 2024; 209:472-473. [PMID: 38285549 PMCID: PMC10919107 DOI: 10.1164/rccm.202401-0176ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 01/31/2024] Open
Affiliation(s)
- Lise Piquilloud
- Adult Intensive Care Unit University Hospital of Lausanne and Lausanne University Lausanne, Switzerland
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3
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Zhou Z, Li Z, Liu C, Wang F, Zhang L, Fu P. Extracorporeal carbon dioxide removal for patients with acute respiratory failure: a systematic review and meta-analysis. Ann Med 2023; 55:746-759. [PMID: 36856550 PMCID: PMC9980035 DOI: 10.1080/07853890.2023.2172606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Acute respiratory failure (ARF) is a common clinical critical syndrome with substantial mortality. Extracorporeal carbon dioxide removal (ECCO2R) has been proposed for the treatment of ARF. However, whether ECCO2R could provide a survival advantage for patients with ARF is still controversial. METHODS Electronic databases (PubMed, Embase, Web of Science, and the Cochrane database) were searched from inception to 30 April 2022. Randomized controlled trials (RCTs) and observational studies that examined the following outcomes were included: mortality, length of hospital and ICU stay, intubation and tracheotomy rate, mechanical ventilation days, ventilator-free days (VFDs), respiratory parameters, and reported adverse events. RESULTS Four RCTs and five observational studies including 1173 participants with ARF due to COPD or ARDS were included in this meta-analysis. Pooled analyses of related studies showed no significant difference in overall mortality between ECCO2R and control group, neither in RCTs targeted ARDS or acute hypoxic respiratory failure patients (RR 1.05, 95% CI 0.83 to 1.32, p = 0.70, I2 =0.0%), nor in studies targeted patients with ARF secondary to COPD (RR 0.80, 95% CI 0.58 to 1.11, p = 0.19, I2 =0.0%). A shorter duration of ICU stay in the ECCO2R group was only obtained in observational studies (WMD -4.25, p < 0.01), and ECCO2R was associated with a longer length of hospital stay (p = 0.02). ECCO2R was associated with lower intubation rate (p < 0.01) and tracheotomy rate (p = 0.01), and shorter mechanical ventilation days (p < 0.01) in comparison to control group in ARF patients with COPD. In addition, an improvement in pH (p = 0.01), PaO2 (p = 0.01), respiratory rate (p < 0.01), and PaCO2 (p = 0.04) was also observed in patients with COPD exacerbations by ECCO2R therapy. However, the ECCO2R-related complication rate was high in six of the included studies. CONCLUSIONS Our findings from both RCTs and observational studies did not confirm a significant beneficial effect of ECCO2R therapy on mortality. A shorter length of ICU stay in the ECCO2R group was only obtained in observational studies, and ECCO2R was associated with a longer length of hospital stay. ECCO2R was associated with lower intubation rate and tracheotomy rate, and shorter mechanical ventilation days in ARF patients with COPD. And an improvement in pH, PaO2, respiratory rate and PaCO2 was observed in the ECCO2R group. However, outcomes largely relied on data from observational studies targeted patients with ARF secondary to COPD, thus further larger high-quality RCTs are desirable to strengthen the evidence on the efficacy and benefits of ECCO2R for patients with ARF.Key messagesECCO2R therapy did not confirm a significant beneficial effect on mortality.ECCO2R was associated with lower intubation and tracheotomy rate, and shorter mechanical ventilation days in patients with ARF secondary to COPD.An improvement in pH, PaO2, respiratory rate, and PaCO2 was observed in ECCO2R group in patients with COPD exacerbations.Evidence for the future application of ECCO2R therapy for patients with ARF. The protocol of this meta-analysis was registered on PROSPERO (CRD42022295174).
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Affiliation(s)
- Zhifeng Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Zhengyan Li
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Chen Liu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Fang Wang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
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4
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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: 2] [Impact Index Per Article: 2.0] [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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Extracorporeal Carbon Dioxide Removal: From Pathophysiology to Clinical Applications; Focus on Combined Continuous Renal Replacement Therapy. Biomedicines 2023; 11:biomedicines11010142. [PMID: 36672649 PMCID: PMC9855411 DOI: 10.3390/biomedicines11010142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 01/08/2023] Open
Abstract
Lung-protective ventilation (LPV) with low tidal volumes can significantly increase the survival of patients with acute respiratory distress syndrome (ARDS) by limiting ventilator-induced lung injuries. However, one of the main concerns regarding the use of LPV is the risk of developing hypercapnia and respiratory acidosis, which may limit the clinical application of this strategy. This is the reason why different extracorporeal CO2 removal (ECCO2R) techniques and devices have been developed. They include low-flow or high-flow systems that may be performed with dedicated platforms or, alternatively, combined with continuous renal replacement therapy (CRRT). ECCO2R has demonstrated effectiveness in controlling PaCO2 levels, thus allowing LPV in patients with ARDS from different causes, including those affected by Coronavirus disease 2019 (COVID-19). Similarly, the suitability and safety of combined ECCO2R and CRRT (ECCO2R-CRRT), which provides CO2 removal and kidney support simultaneously, have been reported in both retrospective and prospective studies. However, due to the complexity of ARDS patients and the limitations of current evidence, the actual impact of ECCO2R on patient outcome still remains to be defined. In this review, we discuss the main principles of ECCO2R and its clinical application in ARDS patients, in particular looking at clinical experiences of combined ECCO2R-CRRT treatments.
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6
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Prat NJ, Meyer AD, Scaravilli V, Cannon J, Cancio LC, Cap AP, Batchinsky AI. Regional blood acidification inhibits coagulation during extracorporeal carbon dioxide removal (ECCO 2 R). Artif Organs 2022; 46:1181-1191. [PMID: 35289412 DOI: 10.1111/aor.14233] [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: 12/17/2021] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Consumption of platelets and coagulation factors during extracorporeal carbon dioxide removal (ECCO2 R) increases bleeding complications and associated mortality. Regional infusion of lactic acid enhances ECCO2 R by shifting the chemical equilibrium from bicarbonate to carbon dioxide. Our goal was to test if regional blood acidification during ECCO2 R inhibits platelet function and coagulation. METHODS An ECCO2 R system containing a hemofilter circulated blood at 0.25 L/min in 8 healthy ewes (Ovis aries) for 36 hours. Three of the sheep received ECCO2 R with no recirculation compared to 5 sheep that received ECCO2 R plus 12 hours of regional blood acidification via the hemofilter, placed upstream from the oxygenator, into which 4.4 M lactic acid was infused. Blood gases, platelet count and function, thromboelastography, coagulation-factor activity, and von Willebrand factor activity (vWF:Ag) were measured at baseline, at start of lactic acid infusion, and after 36 hours of extracorporeal circulation. RESULTS Twelve hours of regional acid infusion significantly inhibited platelet aggregation response to adenosine diphosphate; vWF; and platelet expression of P-selectin compared to control. It also significantly reduced consumption of fibrinogen and of coagulation factors V, VII, IX, compared to control. CONCLUSIONS Regional acidification reduces platelet activation and vitamin-K-dependent coagulation-factor consumption during ECCO2 R. This is the first report of a simple method that may enhance effective anticoagulation for ECCO2 R.
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Affiliation(s)
- Nicolas J Prat
- French Armed Forces Biomedical Research Institute (IRBA), Paris, France.,U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew D Meyer
- Division of Critical Care Medicine, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA.,U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Jeremy Cannon
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
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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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Tonetti T, Pisani L, Cavalli I, Vega ML, Maietti E, Filippini C, Nava S, Ranieri VM. Extracorporeal carbon dioxide removal for treatment of exacerbated chronic obstructive pulmonary disease (ORION): study protocol for a randomised controlled trial. Trials 2021; 22:718. [PMID: 34666820 PMCID: PMC8524839 DOI: 10.1186/s13063-021-05692-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 10/07/2021] [Indexed: 02/08/2023] Open
Abstract
Background Hypercapnic exacerbations are severe complications of chronic obstructive pulmonary disease (COPD), characterized by negative impact on prognosis, quality of life and healthcare costs. The present standard of care for acute exacerbations of COPD is non-invasive ventilation; when it fails, the use of invasive mechanical ventilation is inevitable, but is associated with extremely poor prognosis. Extracorporeal circuits designed to remove CO2 (ECCO2R) may enhance the efficacy of NIV to remove CO2 and avoid the worsening of respiratory acidosis, which inevitably leads to failure of non-invasive ventilation. Although the use of ECCO2R for acute exacerbations of COPD is steadily increasing, solid evidence on its efficacy and safety is scarce, thus the need for a randomized controlled trial. Methods multicenter randomized controlled unblinded clinical trial including 284 (142 per arm) patients with acute hypercapnic respiratory failure caused by exacerbation of COPD, requiring respiratory support with NIV. The primary outcome is event free survival at 28 days, a composite outcome defined by survival in absence of prolonged mechanical ventilation, severe hypoxemia, septic shock and second episode of COPD exacerbation. Secondary outcomes are incidence of endotracheal intubation and tracheostomy, intensive care and hospital length-of-stay and 90-day mortality. Discussion Acute exacerbations of COPD represent a significant burden in terms of prognosis, quality of life and healthcare costs. Lack definite evidence despite increasing use of ECCO2R justifies a randomized trial to evaluate whether patients with acute hypercapnic acidosis not responsive to NIV should undergo invasive mechanical ventilation (with all serious related risks) or be treated with ECCO2R to avoid invasive ventilation but be exposed to possible adverse events of ECCO2R. Owing to its pragmatic nature, sample size and composite primary outcome, this trial aims at providing valuable answers to relevant questions for clinical treatment of acute exacerbations of COPD. Trial registration ClinicalTrials.gov, NCT04582799. Registered 12 October 2020, . Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05692-w.
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Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Anesthesia and Intensive Care Medicine, Sant'Orsola Research Hospital, Bologna, Italy
| | - Lara Pisani
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Pneumology and Respiratory Critical Care, Sant'Orsola Research Hospital, Bologna, Italy
| | - Irene Cavalli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Anesthesia and Intensive Care Medicine, Sant'Orsola Research Hospital, Bologna, Italy
| | - Maria Laura Vega
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Pneumology and Respiratory Critical Care, Sant'Orsola Research Hospital, Bologna, Italy
| | - Elisa Maietti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Claudia Filippini
- Dipartimento di Scienze Chirurgiche, Università di Torino, Torino, Italy
| | - Stefano Nava
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Pneumology and Respiratory Critical Care, Sant'Orsola Research Hospital, Bologna, Italy
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy. .,Anesthesia and Intensive Care Medicine, Sant'Orsola Research Hospital, Bologna, Italy.
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9
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Zakhary B, Sheldrake J, Pellegrino V. Extracorporeal membrane oxygenation and V/Q ratios: an ex vivo analysis of CO 2 clearance within the Maquet Quadrox-iD oxygenator. Perfusion 2021; 35:29-33. [PMID: 32397880 DOI: 10.1177/0267659120906767] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
While hypercapnia is typically well treated with modern membrane oxygenators, there are cases where respiratory acidosis persists despite maximal extracorporeal membrane oxygenation support. To better understand the physiology of gas exchange within the membrane oxygenator, CO2 clearance within an adult Maquet Quadrox-iD oxygenator was evaluated at varying blood CO2 tensions and V/Q ratios in an ex vivo extracorporeal membrane oxygenation circuit. A closed blood-primed circuit incorporating two Maquet Quadrox-iD oxygenators in series was attached to a Maquet PLS Rotaflow pump. A varying blend of CO2 and air was connected to the first oxygenator to provide different levels of pre-oxygenator blood CO2 levels (PvCO2) to the second oxygenator. Varying sweep gas flows of 100% O2 were connected to the second oxygenator to provide different V/Q ratios. Exhaust CO2 was directly measured, and then VCO2 and oxygenator dead space fraction (VD/VT) were calculated. VCO2 increased with increasing gas flow rates with plateauing at V/Q ratios greater than 4.0. Exhaust CO2 increased with PvCO2 in a linear fashion with the slope of the line decreasing at high V/Q ratios. Oxygenator dead space fraction varied with V/Q ratio-at lower ratios, dead space fraction was 0.3-0.4 and rose to 0.8-0.9 at ratios greater than 4.0. Within the Maquet Quadrox-iD oxygenator, CO2 clearance is limited at high V/Q ratios and correlated with elevated oxygenator dead space fraction. These findings have important implications for patients requiring high levels of extracorporeal membrane oxygenation support.
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Affiliation(s)
- Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jayne Sheldrake
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
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10
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Giraud R, Banfi C, Assouline B, De Charrière A, Cecconi M, Bendjelid K. The use of extracorporeal CO 2 removal in acute respiratory failure. Ann Intensive Care 2021; 11:43. [PMID: 33709318 PMCID: PMC7951130 DOI: 10.1186/s13613-021-00824-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/04/2021] [Indexed: 12/17/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) exacerbation and protective mechanical ventilation of acute respiratory distress syndrome (ARDS) patients induce hypercapnic respiratory acidosis. Main text Extracorporeal carbon dioxide removal (ECCO2R) aims to eliminate blood CO2 to fight against the adverse effects of hypercapnia and related acidosis. Hypercapnia has deleterious extrapulmonary consequences, particularly for the brain. In addition, in the lung, hypercapnia leads to: lower pH, pulmonary vasoconstriction, increases in right ventricular afterload, acute cor pulmonale. Moreover, hypercapnic acidosis may further damage the lungs by increasing both nitric oxide production and inflammation and altering alveolar epithelial cells. During an exacerbation of COPD, relieving the native lungs of at least a portion of the CO2 could potentially reduce the patient's respiratory work, Instead of mechanically increasing alveolar ventilation with MV in an already hyperinflated lung to increase CO2 removal, the use of ECCO2R may allow a decrease in respiratory volume and respiratory rate, resulting in improvement of lung mechanic. Thus, the use of ECCO2R may prevent noninvasive ventilation failure and allow intubated patients to be weaned off mechanical ventilation. In ARDS patients, ECCO2R may be used to promote an ultraprotective ventilation in allowing to lower tidal volume, plateau (Pplat) and driving pressures, parameters that have identified as a major risk factors for mortality. However, although ECCO2R appears to be effective in improving gas exchange and possibly in reducing the rate of endotracheal intubation and allowing more protective ventilation, its use may have pulmonary and hemodynamic consequences and may be associated with complications. Conclusion In selected patients, ECCO2R may be a promising adjunctive therapeutic strategy for the management of patients with severe COPD exacerbation and for the establishment of protective or ultraprotective ventilation in patients with ARDS without prognosis-threatening hypoxemia.
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Affiliation(s)
- Raphaël Giraud
- Intensive Care Unit, Geneva University Hospitals, 4, Rue Gabrielle Perret-Gentil, 1205, Geneva, Switzerland. .,Faculty of Medicine, University of Geneva, Geneva, Switzerland. .,Geneva Hemodynamic Research Group, Geneva, Switzerland.
| | - Carlo Banfi
- University of Milan, Gruppo Ospedaliero San Donato, Milan, Italy.,Department of Cardio-Thoracic Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Benjamin Assouline
- Intensive Care Unit, Geneva University Hospitals, 4, Rue Gabrielle Perret-Gentil, 1205, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Amandine De Charrière
- Intensive Care Unit, Geneva University Hospitals, 4, Rue Gabrielle Perret-Gentil, 1205, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini, Pieve Emanuele, 20090, Milan, Italy
| | - Karim Bendjelid
- Intensive Care Unit, Geneva University Hospitals, 4, Rue Gabrielle Perret-Gentil, 1205, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
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11
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Bojic A, Schellongowski P, Robak O, Hermann A, Buchtele N, Nagler B, Lamm W, Staudinger T. Long-term Respiratory Extracorporeal Membrane Oxygenation and Prognosis: A Retrospective Analysis. ASAIO J 2021; 67:345-352. [PMID: 33627611 DOI: 10.1097/mat.0000000000001225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The duration of extracorporeal membrane oxygenation (ECMO) treatments increases, however, data presented from prolonged support is limited. We retrospectively analyzed all patients during a 4-year period undergoing respiratory ECMO for duration of therapy, demographics, therapy-associated parameters, and outcome according to ECMO duration (<28 days and ≥28 days = long-term ECMO). Out of 55 patients undergoing ECMO for ARDS or during bridging to lung transplantation, 18 were on ECMO for ≥28 days (33%). In the long-term group, median ECMO run time was 40 days (interquartile range 34-54 days). Hospital survival was not significantly different between the groups (54% in short-term and 50% in long-term ECMO patients). There was a significantly higher proportion of patients suffering from malignancy in the group of long-term nonsurvivors. Recovery occurred after more than 40 days on ECMO in 3 patients. The longest ECMO run time in a hospital survivor was 65 days. Duration of ECMO support alone was no prognostic factor and should not represent a basis for decision-making. In patients suffering from malignancy, long-term ECMO support seems to be a factor of adverse prognosis, if not futile.
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Affiliation(s)
- Andja Bojic
- From the Department of Medicine I, Intensive Care Unit 13.i2, Medical University of Vienna, Vienna General Hospital, Waehringer Guertel, Vienna, Austria
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12
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How to ventilate obstructive and asthmatic patients. Intensive Care Med 2020; 46:2436-2449. [PMID: 33169215 PMCID: PMC7652057 DOI: 10.1007/s00134-020-06291-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/12/2020] [Indexed: 11/11/2022]
Abstract
Exacerbations are part of the natural history of chronic obstructive pulmonary disease and asthma. Severe exacerbations can cause acute respiratory failure, which may ultimately require mechanical ventilation. This review summarizes practical ventilator strategies for the management of patients with obstructive airway disease. Such strategies include non-invasive mechanical ventilation to prevent intubation, invasive mechanical ventilation, from the time of intubation to weaning, and strategies intended to prevent post-extubation acute respiratory failure. The role of tracheostomy, the long-term prognosis, and potential future adjunctive strategies are also discussed. Finally, the physiological background that underlies these strategies is detailed.
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13
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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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14
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Abstract
This review focuses on the use of veno-venous extracorporeal membrane oxygenation for respiratory failure across all blood flow ranges. Starting with a short overview of historical development, aspects of the physiology of gas exchange (i.e., oxygenation and decarboxylation) during extracorporeal circulation are discussed. The mechanisms of phenomena such as recirculation and shunt playing an important role in daily clinical practice are explained.Treatment of refractory and symptomatic hypoxemic respiratory failure (e.g., acute respiratory distress syndrome [ARDS]) currently represents the main indication for high-flow veno-venous-extracorporeal membrane oxygenation. On the other hand, lower-flow extracorporeal carbon dioxide removal might potentially help to avoid or attenuate ventilator-induced lung injury by allowing reduction of the energy load (i.e., driving pressure, mechanical power) transmitted to the lungs during mechanical ventilation or spontaneous ventilation. In the latter context, extracorporeal carbon dioxide removal plays an emerging role in the treatment of chronic obstructive pulmonary disease patients during acute exacerbations. Both applications of extracorporeal lung support raise important ethical considerations, such as likelihood of ultimate futility and end-of-life decision-making. The review concludes with a brief overview of potential technical developments and persistent challenges.
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15
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Diehl JL, Augy JL, Rivet N, Guerin C, Chocron R, Smadja DM. Severity of endothelial dysfunction is associated with the occurrence of hemorrhagic complications in COPD patients treated by extracorporeal CO 2 removal. Intensive Care Med 2020; 46:1950-1952. [PMID: 32519002 DOI: 10.1007/s00134-020-06138-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Jean-Luc Diehl
- Service de Médecine Intensive - Réanimation, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, 20 rue Leblanc, 75015, Paris, France. .,Innovative Therapies in Haemostasis, INSERM UMR-S1140, Paris University, 75006, Paris, France.
| | - Jean Loup Augy
- Service de Médecine Intensive - Réanimation, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, 20 rue Leblanc, 75015, Paris, France
| | - Nadia Rivet
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, Paris University, 75006, Paris, France.,Hematology Department and Biosurgical Research Lab, Georges Pompidou European Hospital, 20 rue Leblanc, 75015, Paris, France
| | - Coralie Guerin
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, Paris University, 75006, Paris, France.,Flow Cytometry Department, Curie Institute, 75006, Paris, France
| | - Richard Chocron
- Emergency Department, Georges Pompidou European Hospital, 20 rue Leblanc, 75015, Paris, France.,Paris Centre de Recherche Cardiovasculaire, INSERM UMR-S 970, Paris University, 75015, Paris, France
| | - David M Smadja
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, Paris University, 75006, Paris, France.,Hematology Department and Biosurgical Research Lab, Georges Pompidou European Hospital, 20 rue Leblanc, 75015, Paris, France
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16
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Scala R, Ciarleglio G, Maccari U, Granese V, Salerno L, Madioni C. Ventilator Support and Oxygen Therapy in Palliative and End-of-Life Care in the Elderly. Turk Thorac J 2020; 21:54-60. [PMID: 32163365 DOI: 10.5152/turkthoracj.2020.201401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022]
Abstract
Elderly patients suffering from chronic cardio-pulmonary diseases commonly experience acute respiratory failure. As in younger patients, a well-known therapeutic approach of noninvasive mechanical ventilation is able to prevent orotracheal intubation in a large number of severe scenarios in elderly patients. In addition, this type of ventilation is frequently applied in elderly patients who refuse intubation for invasive mechanical ventilation. The rate of failure of noninvasive ventilation may be reduced by means of the integration of new technological devices (i.e., high-flow nasal cannula, extracorporeal CO2 removal, cough assistance and high-frequency chest wall oscillation, and fiberoptic bronchoscopy). Ethical issues with end-of-life decisions and the choice of the environment are not clearly defined in the treatment of elderly with acute respiratory insufficiency.
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Affiliation(s)
- Raffaele Scala
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Giuseppina Ciarleglio
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Uberto Maccari
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Valentina Granese
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Laura Salerno
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Chiara Madioni
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
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17
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Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion 2020; 35:492-508. [PMID: 32156179 DOI: 10.1177/0267659120906048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
TECHNOLOGY Extracorporeal carbon dioxide removal means the removal of carbon dioxide from the blood across a gas exchange membrane without substantially improving oxygenation. Carbon dioxide removal is possible with substantially less extracorporeal blood flow than needed for oxygenation. Techniques for extracorporeal carbon dioxide removal include (1) pumpless arterio-venous circuits, (2) low-flow venovenous circuits based on the technology of continuous renal replacement therapy, and (3) venovenous circuits based on extracorporeal membrane oxygenation technology. INDICATIONS Extracorporeal carbon dioxide removal has been shown to enable more protective ventilation in acute respiratory distress syndrome patients, even beyond the so-called "protective" level. Although experimental data suggest a benefit on ventilator induced lung injury, no hard clinical evidence with respect to improved outcome exists. In addition, extracorporeal carbon dioxide removal is a tool to avoid intubation and mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease failing non-invasive ventilation. This concept has been shown to be effective in 56-90% of patients. Extracorporeal carbon dioxide removal has also been used in ventilated patients with hypercapnic respiratory failure to correct acidosis, unload respiratory muscle burden, and facilitate weaning. In patients suffering from terminal fibrosis awaiting lung transplantation, extracorporeal carbon dioxide removal is able to correct acidosis and enable spontaneous breathing during bridging. Keeping these patients awake, ambulatory, and breathing spontaneously is associated with favorable outcome. COMPLICATIONS Complications of extracorporeal carbon dioxide removal are mostly associated with vascular access and deranged hemostasis leading to bleeding. Although the spectrum of complications may differ, no technology offers advantages with respect to rate and severity of complications. So called "high-extraction systems" working with higher blood flows and larger membranes may be more effective with respect to clinical goals.
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Affiliation(s)
- Thomas Staudinger
- Department of Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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18
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Satici C, López-Padilla D, Schreiber A, Kharat A, Swingwood E, Pisani L, Patout M, Bos LD, Scala R, Schultz MJ, Heunks L. ERS International Congress, Madrid, 2019: highlights from the Respiratory Intensive Care Assembly. ERJ Open Res 2020; 6:00331-2019. [PMID: 32166088 PMCID: PMC7061203 DOI: 10.1183/23120541.00331-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/23/2020] [Indexed: 12/19/2022] Open
Abstract
The Respiratory Intensive Care Assembly of the European Respiratory Society is delighted to present the highlights from the 2019 International Congress in Madrid, Spain. We have selected four sessions that discussed recent advances in a wide range of topics: from acute respiratory failure to cough augmentation in neuromuscular disorders and from extra-corporeal life support to difficult ventilator weaning. The subjects are summarised by early career members in close collaboration with the Assembly leadership. We aim to give the reader an update on the most important developments discussed at the conference. Each session is further summarised into a short list of take-home messages.
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Affiliation(s)
- Celal Satici
- Respiratory Medicine, Istanbul Gaziosmanpasa Training and Research Hospital, Health Science University, Istanbul, Turkey
| | - Daniel López-Padilla
- Respiratory Dept, Gregorio Marañón University Hospital, Spanish Sleep Network, Madrid, Spain
| | - Annia Schreiber
- Interdepartmental Division of Critical Care, University of Toronto, Unity Health Toronto (St Michael's Hospital) and the Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Aileen Kharat
- Pulmonology Dept, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Ema Swingwood
- University Hospitals Bristol NHS Foundation Trust, Adult Therapy Services, Bristol Royal Infirmary, Bristol, UK
| | - Luigi Pisani
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Lieuwe D. Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Marcus J. Schultz
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Leo Heunks
- Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
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19
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Lief L, McSparron J. Acute Exacerbation of COPD. EVIDENCE-BASED CRITICAL CARE 2020. [PMCID: PMC7121203 DOI: 10.1007/978-3-030-26710-0_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Mendez Y, Ochoa-Martinez FE, Ambrosii T. Chronic Obstructive Pulmonary Disease and Respiratory Acidosis in the Intensive Care Unit. CURRENT RESPIRATORY MEDICINE REVIEWS 2019. [DOI: 10.2174/1573398x15666181127141410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Chronic obstructive lung disease is a common and preventable disease. One of its
pathophysiological consequences is the presence of carbon dioxide retention due to hypoventilation
and ventilation/perfusion mismatch, which in consequence will cause a decrease in the acid/base
status of the patient. Whenever a patient develops an acute exacerbation, acute respiratory
hypercapnic failure will appear and the necessity of a hospital ward is a must. However, current
guidelines exist to better identify these patients and make an accurate diagnosis by using clinical
skills and laboratory data such as arterial blood gases. Once the patient is identified, rapid treatment
will help to diminish the hospital length and the avoidance of intensive care unit. On the other hand,
if there is the existence of comorbidities such as cardiac failure, gastroesophageal reflux disease,
pulmonary embolism or depression, it is likely that the patient will be admitted to the intensive care
unit with the requirement of intubation and mechanical ventilation.
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Affiliation(s)
- Yamely Mendez
- Faculty of Medicine “Dr. Alberto Romo Caballero”, Universidad Autonoma de Tamaulipas, Tampico, Mexico
| | - Francisco E. Ochoa-Martinez
- Faculty of Medicine, Universidad Autonoma de Nuevo Leon, University Hospital “Dr. Jose Eleuterio Gonzalez”, Monterrey, Mexico
| | - Tatiana Ambrosii
- Chair of Anesthesiology and Reanimatology “Valeriu Ghereg”, State University of Medicine and Pharmacy “Nicolae Testemitanu”, Chisinau, Moldova, Republic of
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21
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Gross-Hardt S, Hesselmann F, Arens J, Steinseifer U, Vercaemst L, Windisch W, Brodie D, Karagiannidis C. Low-flow assessment of current ECMO/ECCO 2R rotary blood pumps and the potential effect on hemocompatibility. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:348. [PMID: 31694688 PMCID: PMC6836552 DOI: 10.1186/s13054-019-2622-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/23/2019] [Indexed: 01/10/2023]
Abstract
Background Extracorporeal carbon dioxide removal (ECCO2R) uses an extracorporeal circuit to directly remove carbon dioxide from the blood either in lieu of mechanical ventilation or in combination with it. While the potential benefits of the technology are leading to increasing use, there are very real risks associated with it. Several studies demonstrated major bleeding and clotting complications, often associated with hemolysis and poorer outcomes in patients receiving ECCO2R. A better understanding of the risks originating specifically from the rotary blood pump component of the circuit is urgently needed. Methods High-resolution computational fluid dynamics was used to calculate the hemodynamics and hemocompatibility of three current rotary blood pumps for various pump flow rates. Results The hydraulic efficiency dramatically decreases to 5–10% if operating at blood flow rates below 1 L/min, the pump internal flow recirculation rate increases 6–12-fold in these flow ranges, and adverse effects are increased due to multiple exposures to high shear stress. The deleterious consequences include a steep increase in hemolysis and destruction of platelets. Conclusions The role of blood pumps in contributing to adverse effects at the lower blood flow rates used during ECCO2R is shown here to be significant. Current rotary blood pumps should be used with caution if operated at blood flow rates below 2 L/min, because of significant and high recirculation, shear stress, and hemolysis. There is a clear and urgent need to design dedicated blood pumps which are optimized for blood flow rates in the range of 0.5–1.5 L/min.
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Affiliation(s)
- Sascha Gross-Hardt
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Felix Hesselmann
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Jutta Arens
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Leen Vercaemst
- Department of Perfusion, University Hospital Gasthuisberg, Leuven, Belgium
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Center, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Daniel Brodie
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Center, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany.
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23
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Takahashi N, Nakada TA, Sakai T, Kato Y, Moriyama K, Nishida O, Oda S. A CO 2 removal system using extracorporeal lung and renal assist device with an acid and alkaline infusion. J Artif Organs 2019; 23:54-61. [PMID: 31584110 DOI: 10.1007/s10047-019-01136-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/22/2019] [Indexed: 01/04/2023]
Abstract
The patients with respiratory failure need high tidal volume by mechanical ventilation, which lead to the ventilator-induced lung injury. We developed an extracorporeal lung and renal assist device (ELRAD), comprising acid infusion, membrane lung, continuous hemodiafiltration and alkaline infusion. To evaluate this system, we conducted in vivo studies using experimental swine which were connected to the new system. In vivo experiments consist of four protocols; baseline = hemodiafiltration only (no O2 gas flow to membrane lung); membrane lung = "Baseline" plus O2 gas flow to membrane lung; "Acid infusion" = "Membrane lung" plus continuous acid infusion; ELRAD = "Acid infusion" plus continuous alkaline infusion. We changed the ventilatory rate of the mechanical ventilation to maintain PCO2 at 50-55 mmHg during the four protocols. The results showed that there was statistically no significant difference in the levels of pH, HCO3-, and base excess when each study protocol was initiated. The amount of CO2 eliminated by the membrane lung significantly increased by 1.6 times in the acid infusion protocol and the ELRAD protocol compared to the conventional membrane lung protocol. Minute ventilation in the ELRAD protocol significantly decreased by 0.5 times compared with the hemodiafiltration only protocol (P < 0.0001), the membrane lung (P = 0.0006) and acid infusion protocol (P = 0.0017), respectively. In conclusion, a developed CO2 removal system efficiently removed CO2 at low blood flow and reduced minute ventilation, while maintaining acid-base balance within the normal range.
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Affiliation(s)
- Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan.
| | - Toshikazu Sakai
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Yu Kato
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Kazuhiro Moriyama
- Laboratory for Immune Response and Regulatory Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
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24
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Goligher EC, Combes A, Brodie D, Ferguson ND, Pesenti AM, Ranieri VM, Slutsky AS. Determinants of the effect of extracorporeal carbon dioxide removal in the SUPERNOVA trial: implications for trial design. Intensive Care Med 2019; 45:1219-1230. [PMID: 31432216 DOI: 10.1007/s00134-019-05708-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/18/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To describe the variability and determinants of the effect of extracorporeal CO2 removal (ECCO2R) on tidal volume (Vt), driving pressure (ΔP), and mechanical power (PowerRS) and to determine whether highly responsive patients can be identified for the purpose of predictive enrichment in ECCO2R trial design. METHODS Using data from the SUPERNOVA trial (95 patients with early moderate acute respiratory distress syndrome), the independent effects of alveolar dead space fraction (ADF), respiratory system compliance (Crs), hypoxemia (PaO2/FiO2), and device performance (higher vs lower CO2 extraction) on the magnitude of reduction in Vt, ΔP, and PowerRS permitted by ECCO2R were assessed by linear regression. Predicted and observed changes in ΔP were compared by Bland-Altman analysis. Hypothetical trials of ECCO2R, incorporating predictive enrichment and different target CO2 removal rates, were simulated in the SUPERNOVA study population. RESULTS Changes in Vt permitted by ECCO2R were independently associated with ADF and device performance but not PaO2/FiO2. Changes in ΔP and PowerRS were independently associated with ADF, Crs, and device performance but not PaO2/FiO2. The change in ΔP predicted from ADF and Crs was moderately correlated with observed change in ΔP (R2 0.32, p < 0.001); limits of agreement between observed and predicted changes in ΔP were ± 3.9 cmH2O. In simulated trials, restricting enrollment to patients with a larger predicted decrease in ΔP enhanced the average reduction in ΔP, increased predicted mortality benefit, and reduced sample size and screening size requirements. The increase in statistical power obtained by restricting enrollment based on predicted ΔP response varied according to device performance as specified by the target CO2 removal rate. CONCLUSIONS The lung-protective benefits of ECCO2R increase with higher alveolar dead space fraction, lower respiratory system compliance, and higher device performance. ADF and Crs, rather than severity of hypoxemia, should be the primary factors determining whether to enroll patients in clinical trials of ECCO2R.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada. .,Toronto General Hospital Research Institute, 585 University Ave., 11-PMB Room 192, Toronto, ON, M5G 2N2, Canada.
| | - Alain Combes
- APHP Hôpital Pitié-Salpêtrière, Institut de Cardiologie, Institute of Cardio-metabolism and Nutrition, and Service de Médecine Intensive-réanimation, UMRS_1166-ICAN, INSERM, Sorbonne Université, Paris, France
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.,Toronto General Hospital Research Institute, 585 University Ave., 11-PMB Room 192, Toronto, ON, M5G 2N2, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
| | - Antonio M Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - V Marco Ranieri
- Policlinico di Sant'Orsola, Anesthesia and Intensive Care Medicine, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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Augy JL, Aissaoui N, Richard C, Maury E, Fartoukh M, Mekontso-Dessap A, Paulet R, Anguel N, Blayau C, Cohen Y, Chiche JD, Gaudry S, Voicu S, Demoule A, Combes A, Megarbane B, Charpentier E, Haghighat S, Panczer M, Diehl JL. A 2-year multicenter, observational, prospective, cohort study on extracorporeal CO 2 removal in a large metropolis area. J Intensive Care 2019; 7:45. [PMID: 31452899 PMCID: PMC6701003 DOI: 10.1186/s40560-019-0399-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/12/2019] [Indexed: 11/17/2022] Open
Abstract
Background Extracorporeal carbon dioxide removal (ECCO2R) is a promising technique for the management of acute respiratory failure, but with a limited level of evidence to support its use outside clinical trials and/or data collection initiatives. We report a collaborative initiative in a large metropolis. Methods To assess on a structural basis the rate of utilization as well as efficacy and safety parameters of 2 ECCO2R devices in 10 intensive care units (ICU) during a 2-year period. Results Seventy patients were recruited in 10 voluntary and specifically trained centers. The median utilization rate was 0.19 patient/month/center (min 0.04; max 1.20). ECCO2R was started under invasive mechanical ventilation (IMV) in 59 patients and non-invasive ventilation in 11 patients. The Hemolung Respiratory Assist System (Alung) was used in 53 patients and the iLA Activve iLA kit (Xenios Novalung) in 17 patients. Main indications were ultraprotective ventilation for ARDS patients (n = 24), shortening the duration of IMV in COPD patients (n = 21), preventing intubation in COPD patients (n = 9), and controlling hypercapnia and dynamic hyperinflation in mechanically ventilated patients with severe acute asthma (n = 6). A reduction in median VT was observed in ARDS patients from 5.9 to 4.1 ml/kg (p <0.001). A reduction in PaCO2 values was observed in AE-COPD patients from 67.5 to 51 mmHg (p< 0.001). Median duration of ECCO2R was 5 days (IQR 3–8). Reasons for ECCO2R discontinuation were improvement (n = 33), ECCO2R-related complications (n = 18), limitation of life-sustaining therapies or measures decision (n = 10), and death (n = 9). Main adverse events were hemolysis (n = 21), bleeding (n = 17), and lung membrane clotting (n = 11), with different profiles between the devices. Thirty-five deaths occurred during the ICU stay, 3 of which being ECCO2R-related. Conclusions Based on a registry, we report a low rate of ECCO2R device utilization, mainly in severe COPD and ARDS patients. Physiological efficacy was confirmed in these two populations. We confirmed safety concerns such as hemolysis, bleeding, and thrombosis, with different profiles between the devices. Such results could help to design future studies aiming to enhance safety, to demonstrate a still-lacking strong clinical benefit of ECCO2R, and to guide the choice between different devices. Trial registration ClinicalTrials.gov: Identifier: NCT02965079 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT02965079
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Affiliation(s)
- J L Augy
- 1Service de Médecine Intensive Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - N Aissaoui
- 1Service de Médecine Intensive Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - C Richard
- 2Service de Médecine Intensive Réanimation, AP-HP, Hôpital de Bicètre, Le Kremlin Bicètre, France
| | - E Maury
- 3Service de Médecine Intensive Réanimation, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - M Fartoukh
- Service de Réanimation Polyvalente, AP-HP, Hôpital Tenon, Paris, France
| | - A Mekontso-Dessap
- 5Service de Médecine Intensive Réanimation, AP-HP, Hôpital Henri Mondor, Créteil, France
| | - R Paulet
- Service de Réanimation Polyvalente, Centre Hospitalier de Longjumeau, Longjumeau, France
| | - N Anguel
- 2Service de Médecine Intensive Réanimation, AP-HP, Hôpital de Bicètre, Le Kremlin Bicètre, France
| | - C Blayau
- Service de Réanimation Polyvalente, AP-HP, Hôpital Tenon, Paris, France
| | - Y Cohen
- 7Service de Réanimation Polyvalente, AP-HP, Hôpital Avicenne, Bobigny, France
| | - J D Chiche
- 8Service de Médecine Intensive Réanimation, AP-HP, Hôpital Cochin, Paris, France
| | - S Gaudry
- 9Service de Réanimation Polyvalente, AP-HP, Hôpital Louis Mourier, Colombes, France
| | - S Voicu
- 10Service de Médecine Intensive Réanimation, AP-HP, Hôpital Lariboisière, Paris, France
| | - A Demoule
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - A Combes
- 12Service de Médecine Intensive Réanimation, AP-HP, Hôpital Pitié-Salpétrière, Institut de Cardiologie, Paris, France
| | - B Megarbane
- 10Service de Médecine Intensive Réanimation, AP-HP, Hôpital Lariboisière, Paris, France
| | - E Charpentier
- 13AP-HP, Office du Transfert de Technologie et des Partenariats Industriels, Paris, France
| | - S Haghighat
- 14AP-HP, Agence Générale des Equipements et des Produits de Santé, Paris, France
| | - M Panczer
- 14AP-HP, Agence Générale des Equipements et des Produits de Santé, Paris, France
| | - J L Diehl
- 1Service de Médecine Intensive Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France.,15Faculty of Pharmacy, INSERM UMR-S1140, Paris Descartes University, Paris, France
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Practical Clinical Application of an Extracorporeal Carbon Dioxide Removal System in Acute Respiratory Distress Syndrome and Acute on Chronic Respiratory Failure. ASAIO J 2019; 66:691-697. [DOI: 10.1097/mat.0000000000001050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Barrett NA, Kostakou E, Hart N, Douiri A, Camporota L. Extracorporeal carbon dioxide removal for acute hypercapnic exacerbations of chronic obstructive pulmonary disease: study protocol for a randomised controlled trial. Trials 2019; 20:465. [PMID: 31362776 PMCID: PMC6664508 DOI: 10.1186/s13063-019-3548-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/29/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common cause of chronic respiratory failure and its course is punctuated by a series of acute exacerbations which commonly lead to hospital admission. Exacerbations are managed through the application of non-invasive ventilation and, when this fails, tracheal intubation and mechanical ventilation. The need for mechanical ventilation significantly increases the risk of death. An alternative therapy, extracorporeal carbon dioxide removal (ECCO2R), has been shown to be efficacious in removing carbon dioxide from the blood; however, its impact on respiratory physiology and patient outcomes has not been explored. METHODS/DESIGN A randomised controlled open label trial of patients (12 in each arm) with acute exacerbations of COPD at risk of failing conventional therapy (NIV) randomised to either remaining on NIV or having ECCO2R added to NIV with a primary endpoint of time to cessation of NIV. The change in respiratory physiology following the application of ECCO2R and/or NIV will be measured using electrical impedance tomography, oesophageal pressure and parasternal electromyography. Additional outcomes, including patient tolerance, outcomes, need for readmission, changes in blood gases and biochemistry and procedural complications, will be measured. Physiological changes will be compared within one patient over time and between the two groups. Healthcare costs in the UK system will also be compared between the two groups. DISCUSSION COPD is a common disease and exacerbations are a leading cause of hospital admission in the UK and worldwide, with a sizeable mortality. The management of patients with COPD consumes significant hospital and financial resources. This study seeks to understand the feasibility of a novel approach to the management of patients with acute exacerbations of COPD as well as to understand the underlying physiological changes to explain why the approach does or does not assist this patient cohort. Detailed respiratory physiology has not been previously undertaken using this technique and there are no other randomised controlled trials currently in the literature. TRIAL REGISTRATION ClinicalTrials.gov, NCT02086084.
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Affiliation(s)
- Nicholas A. Barrett
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH UK
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Eirini Kostakou
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH UK
| | - Nicholas Hart
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
- Lane Fox Respiratory Unit, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King’s College London, London, WC2R 2LS UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Trust and King’s College London, London, UK
| | - Luigi Camporota
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH UK
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
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Extracorporeal carbon dioxide removal for lowering the risk of mechanical ventilation: research questions and clinical potential for the future. THE LANCET RESPIRATORY MEDICINE 2019; 6:874-884. [PMID: 30484429 DOI: 10.1016/s2213-2600(18)30326-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/28/2018] [Accepted: 07/19/2018] [Indexed: 12/30/2022]
Abstract
As a result of technical improvements, extracorporeal carbon dioxide removal (ECCO2R) now has the potential to play an important role in the management of adults with acute respiratory failure. There is growing interest in the use of ECCO2R for the management of both hypoxaemic and hypercapnic respiratory failure. However, evidence to support its use is scarce and several questions remain about the best way to implement this therapy, which can be associated with serious side-effects. This Review reflects the consensus opinion of an international group of clinician scientists with expertise in managing acute respiratory failure and in using ECCO2R therapies in this setting. We concisely review clinically relevant aspects of ECCO2R, and provide a series of recommendations for clinical practice and future research, covering topics that include the practicalities of ECCO2R delivery, indications for use, and service delivery.
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Morales-Quinteros L, Del Sorbo L, Artigas A. Extracorporeal carbon dioxide removal for acute hypercapnic respiratory failure. Ann Intensive Care 2019; 9:79. [PMID: 31267300 PMCID: PMC6606679 DOI: 10.1186/s13613-019-0551-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/24/2019] [Indexed: 02/11/2023] Open
Abstract
In the past, the only treatment of acute exacerbations of obstructive diseases with hypercapnic respiratory failure refractory to medical treatment was invasive mechanical ventilation (IMV). Considerable technical improvements transformed extracorporeal techniques for carbon dioxide removal in an attractive option to avoid worsening respiratory failure and respiratory acidosis, and to potentially prevent or shorten the duration of IMV in patients with exacerbation of COPD and asthma. In this review, we will present a summary of the pathophysiological rationale and evidence of ECCO2R in patients with severe exacerbations of these pathologies.
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Affiliation(s)
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Antonio Artigas
- Intensive Care Unit, Hospital Universitario Sagrado Corazón, Barcelona, Spain.,Critical Care Center, ParcTaulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Tramarin J, Cortegiani A, Gregoretti C, Vitale F, Palmeri C, Iozzo P, Forfori F, Giarratano A. Regional anticoagulation with heparin of an extracorporeal CO 2 removal circuit: a case report. J Med Case Rep 2019; 13:123. [PMID: 31046832 PMCID: PMC6498662 DOI: 10.1186/s13256-019-2051-6] [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: 12/03/2018] [Accepted: 03/13/2019] [Indexed: 11/15/2022] Open
Abstract
Background Extracorporeal carbon dioxide removal is an increasingly used respiratory support technique. As is true of all extracorporeal techniques, extracorporeal carbon dioxide removal needs proper anticoagulation. We report a case of a patient at risk of bleeding complications who was treated with extracorporeal carbon dioxide removal and anticoagulated with a regional technique. Case presentation A 56-year-old Caucasian man with a history of chronic obstructive pulmonary disease exacerbation required extracorporeal carbon dioxide removal for severe hypercapnia and acidosis despite mechanical ventilation. The extracorporeal circuit was anticoagulated using a regional heparin technique to limit the patient’s risk of bleeding due to a low platelet count. The patient underwent 96 h of effective extracorporeal carbon dioxide removal without any adverse events. He was successfully weaned from extracorporeal carbon dioxide removal. During the treatment, no bleeding complications or unexpected circuit clotting was observed. Conclusions The use of regional heparin anticoagulation technique seems to be feasible and safe during extracorporeal carbon dioxide removal.
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Affiliation(s)
- Jacopo Tramarin
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Filippo Vitale
- Department of Anesthesia and Intensive Care, University of Palermo, Palermo, Italy
| | - Cesira Palmeri
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Pasquale Iozzo
- Department of Anesthesia and Intensive Care, University of Palermo, Palermo, Italy
| | - Francesco Forfori
- Department of Anesthesia and Intensive Care, University of Pisa, Pisa, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
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[Current techniques for extracorporeal decarboxylation]. Med Klin Intensivmed Notfmed 2019; 114:733-740. [PMID: 31020339 DOI: 10.1007/s00063-019-0567-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/13/2019] [Indexed: 02/06/2023]
Abstract
The widespread use of extracorporeal lung assist (ECLA) in recent years has led to the introduction of different decarboxylation systems into clinical practice. Due to the large CO2 transport capacity of the blood such systems require considerably lower extracorporeal blood flows and therefore allow for effective decarboxylation with reduced invasiveness and complexity. While systems derived from classical lung assist are mainly used to control severe acute hypercapnic respiratory failure, recently a growing number of therapies based on renal replacement platforms have become available ("respiratory dialysis"). Such low-flow systems still allow for effective partial CO2 elimination and can control respiratory acidosis as well as facilitate or even enable protective and ultraprotective ventilation strategies in acute lung failure (ARDS). While the use of extracorporeal CO2 elimination (ECCO2R) has been shown to decrease ventilator-induced lung injury (VILI), positive effects on hard clinical endpoints such as mortality or duration of mechanical ventilation are still unproven. In light of limited evidence, ECCO2R must be regarded as an experimental procedure. Its use should therefore at present be restricted to centers with appropriate experience.
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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: 18] [Impact Index Per Article: 3.6] [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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Fisser C, Spoletini G, Soe AK, Livesey A, Schreiber A, Swingwood E, Bos LD, Dreher M, Schultz MJ, Heunks L, Scala R. European Respiratory Society International Congress 2018: highlights from Assembly 2 on respiratory intensive care. ERJ Open Res 2019; 5:00198-2018. [PMID: 30847349 PMCID: PMC6397914 DOI: 10.1183/23120541.00198-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/28/2019] [Indexed: 12/14/2022] Open
Abstract
The respiratory intensive care Assembly of the European Respiratory Society is proud to present a summary of several important sessions held at the International Congress in Paris in 2018. For the highly esteemed reader who may have missed the Congress, a concise review was written on three topics: the state-of-the-art session on respiratory critical care, hot topics in weaning and the best abstracts in noninvasive ventilation. The respiratory intensive care Assembly of the European Respiratory Society is proud to present a summary of several important sessions from the 2018 #ERSCongress in Parishttp://ow.ly/6Du830nFESK
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Affiliation(s)
- Christoph Fisser
- Dept of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.,Dept of Pneumology, Hospital Donaustauf, Donaustauf, Germany
| | - Giulia Spoletini
- Respiratory Dept, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Aung Kyaw Soe
- Dept of Hospital Therapy, Pediatric Faculty, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Alana Livesey
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Annia Schreiber
- Dept of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
| | - Ema Swingwood
- Physiotherapy Dept - Adult Therapy Services, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Lieuwe D Bos
- Dept of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Michael Dreher
- Dept of Pneumology and Intensive Care Medicine, University Hospital Aachen, Germany
| | - Marcus J Schultz
- Dept of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Leo Heunks
- Dept of Intensive Care, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
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Fichtner F, Moerer O, Laudi S, Weber-Carstens S, Nothacker M, Kaisers U. Mechanical Ventilation and Extracorporeal Membrane Oxygena tion in Acute Respiratory Insufficiency. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:840-847. [PMID: 30722839 PMCID: PMC6375070 DOI: 10.3238/arztebl.2018.0840] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 06/18/2018] [Accepted: 09/12/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Mechanical ventilation is life-saving for patients with acute respiratory insufficiency. In a German prevalence study, 13.6% of patients in intensive care units received mechanical ventilation for more than 12 hours; 20% of these patients received mechanical ventilation as treatment for acute respiratory distress syndrome (ARDS). The new S3 guideline is the first to contain recommendations for the entire process of treatment in these groups of patients (indications, ventilation modes/parameters, ac- companying measures, treatments for refractory impairment of gas exchange, weaning, and follow-up care). METHODS This guideline was developed according to the GRADE methods. Pertinent publications were identified by a systematic search of the literature, the quality of the evidence was evaluated, a risk/benefit assessment was conducted, and recommendations were issued by interdisciplinary consensus. RESULTS Mechanical ventilation is recommended as primary treatment for patients with severe ARDS. In other patient groups, non-in- vasive ventilation can lower mortality. If mechanical ventilation is needed, ventilation modes allowing spontaneous breathing seem beneficial (quality of evidence [QoE]: very low). Protective ventilation (high positive end-expiratory pressure, low tidal volume, limited peak pressure) improve the survival of ARDS patients (QoE: high). If a severe impairment of gas exchange is present, prone posi- tioning lessens mortality (QoE: high). Veno-venous extracorporeal membrane oxygenation (vvECMO) has not unequivocally been shown to improve survival. Early mobilization and weaning protocols can shorten the duration of ventilation (QoE: moderate). CONCLUSION Recommendations for patients undergoing mechanical ventilation include lung-protective ventilation, early sponta- neous breathing and mobilization, weaning protocols, and, for those with severe impairment of gas exchange, prone positioning. It is further recommended that patients with ARDS and refractory impairment of gas exchange should be transferred to an ARDS/ECMO center, where extracorporeal methods should be applied only after application of all other therapeutic options.
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Affiliation(s)
- Falk Fichtner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig
| | - Onnen Moerer
- Center for Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen
| | - Sven Laudi
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicin, Charité–Universitätsklinikum Berlin
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management (AWMF-IMWi), AWMF office Berlin
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Bourke SC, Piraino T, Pisani L, Brochard L, Elliott MW. Beyond the guidelines for non-invasive ventilation in acute respiratory failure: implications for practice. THE LANCET RESPIRATORY MEDICINE 2018; 6:935-947. [DOI: 10.1016/s2213-2600(18)30388-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/31/2022]
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Abstract
Extracorporeal gas exchange is increasingly used for various indications. Among these are refractory acute respiratory failure, including the acute respiratory distress syndrome (ARDS), and the avoidance of ventilator-induced lung injury (VILI) by enabling lung-protective ventilation. Additionally, extracorporeal gas exchange allows the treatment of hypercapnic respiratory failure while helping to unload the respiratory muscles and avoid intubation and invasive ventilation, as well as facilitating weaning from the ventilator. These indications are based on a reasonable physiologic rationale but must be weighed against the costs and complications associated with the technique. This article summarizes current evidence and indications for extracorporeal gas exchange.
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Intermittent extracorporeal CO2 removal in chronic obstructive pulmonary disease patients: a fiction or an option. Curr Opin Crit Care 2018; 24:29-34. [PMID: 29135616 DOI: 10.1097/mcc.0000000000000471] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Aim of this article is to review evidence recently generated on the application of extracorporeal carbon dioxide removal (ECCO2R) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation (invasive and non invasive) for hypercapnic respiratory failure. RECENT FINDINGS To date, the paucity of evidences on ECCO2R to decrease the rate of noninvasive ventilation (NIV) failure and to wean hypercapnic patients from invasive mechanical ventilation (IMV) precludes to systematically apply this technology to COPD patients. SUMMARY Although several efforts have been made to reduce invasiveness and to improve the efficiency of extracorporeal systems, further randomized studies are needed to assess the effects of this technique on both short-term and long-term clinical outcomes.
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Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which recipe for success? Eur Respir Rev 2018; 27:27/149/180029. [DOI: 10.1183/16000617.0029-2018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 12/12/2022] Open
Abstract
Noninvasive positive-pressure ventilation (NPPV) to treat acute respiratory failure has expanded tremendously over the world in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals.The turning point for the successful expansion of NPPV is its ability to achieve the same physiological effects as invasive mechanical ventilation with the avoidance of the life-threatening risks correlated with the use of an artificial airway.Cardiorespiratory arrest, extreme psychomotor agitation, severe haemodynamic instability, nonhypercapnic coma and multiple organ failure are absolute contraindications for NPPV. Moreover, pitfalls of NPPV reduce its rate of success; consistently, a clear plan of what to do in case of NPPV failure should be considered, especially for patients managed in unprotected setting. NPPV failure is likely to be reduced by the application of integrated therapeutic tools in selected patients handled by expert teams.In conclusion, NPPV has to be considered as a rational art and not just as an application of science, which requires the ability of clinicians to both choose case-by-case the best “ingredients” for a “successful recipe” (i.e.patient selection, interface, ventilator, interface,etc.) and to avoid a delayed intubation if the ventilation attempt fails.
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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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40
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Cummins C, Bentley A, McAuley DF, McNamee JJ, Patrick H, Barrett NA. A United Kingdom Register study of in-hospital outcomes of patients receiving extracorporeal carbon dioxide removal. J Intensive Care Soc 2017; 19:114-121. [PMID: 29796067 DOI: 10.1177/1751143717739816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Extracorporeal membrane carbon dioxide removal may have a role in treatment of patients with hypercapnic respiratory failure and refractory hypoxaemia and/or hypercapnia. Methods We report on the use, outcomes and complications in United Kingdom intensive care units reporting patients on the Extracorporal Life Support Organisation register. Results Of 60 patients, 42 (70%) had primarily hypoxic respiratory failure and 18 (30%) primarily hypercapnic respiratory failure. Use of veno-venous procedures increased compared to arterio-venous procedures. Following extracorporeal membrane carbon dioxide removal, ventilatory and blood gas parameters improved at 24 h. Twenty-seven (45%) of patients died before ICU discharge, while 27 (45%) of patients were discharged alive. The most common complications related to thrombosis or haemorrhage. Discussion There is limited use of extracorporeal membrane carbon dioxide removal in UK clinical practice and outcomes reflect variability in indications and the technology used. Usage is likely to increase with the availability of new, simpler, technology. Further high quality evidence is needed.
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Affiliation(s)
- Carole Cummins
- Institute of Applied Health Research, University of Birmingham, UK
| | - Andrew Bentley
- 2Acute Intensive Care Unit, University Hospital of South Manchester NHS Foundation Trust, UK
| | - Daniel F McAuley
- 3Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK.,Regional Intensive Care Unit, Belfast Health and Social Care Trust, UK
| | - James J McNamee
- 3Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK.,Regional Intensive Care Unit, Belfast Health and Social Care Trust, UK
| | - Hannah Patrick
- 5Observational Data Unit, National Institute for Health and Care Excellence, London, UK
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Goligher EC, Amato MBP, Slutsky AS. Applying Precision Medicine to Trial Design Using Physiology. Extracorporeal CO 2 Removal for Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017. [PMID: 28636403 DOI: 10.1164/rccm.201701-0248cp] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In clinical trials of therapies for acute respiratory distress syndrome (ARDS), the average treatment effect in the study population may be attenuated because individual patient responses vary widely. This inflates sample size requirements and increases the cost and difficulty of conducting successful clinical trials. One solution is to enrich the study population with patients most likely to benefit, based on predicted patient response to treatment (predictive enrichment). In this perspective, we apply the precision medicine paradigm to the emerging use of extracorporeal CO2 removal (ECCO2R) for ultraprotective ventilation in ARDS. ECCO2R enables reductions in tidal volume and driving pressure, key determinants of ventilator-induced lung injury. Using basic physiological concepts, we demonstrate that dead space and static compliance determine the effect of ECCO2R on driving pressure and mechanical power. This framework might enable prediction of individual treatment responses to ECCO2R. Enriching clinical trials by selectively enrolling patients with a significant predicted treatment response can increase treatment effect size and statistical power more efficiently than conventional enrichment strategies that restrict enrollment according to the baseline risk of death. To support this claim, we simulated the predicted effect of ECCO2R on driving pressure and mortality in a preexisting cohort of patients with ARDS. Our computations suggest that restricting enrollment to patients in whom ECCO2R allows driving pressure to be decreased by 5 cm H2O or more can reduce sample size requirement by more than 50% without increasing the total number of patients to be screened. We discuss potential implications for trial design based on this framework.
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Affiliation(s)
- Ewan C Goligher
- 1 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,2 Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Marcelo B P Amato
- 3 Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; and
| | - Arthur S Slutsky
- 1 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,4 Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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43
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Habran S, Desaive T, Morimont P, Lambermont B, Dauby P. Mathematical modeling of extracorporeal CO 2 removal therapy : A validation carried out on ten pigs. Med Biol Eng Comput 2017; 56:421-434. [PMID: 28795334 DOI: 10.1007/s11517-017-1694-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
Abstract
The extracorporeal CO2 removal device (ECCO2RD) is used in clinics to treat patients suffering from respiratory failures like acute respiratory distress syndrome (ARDS) or chronic obstructive pulmonary disease (COPD). The aim of this device is to decarboxylate blood externally with low blood flow. A mathematical model is proposed to describe protective ventilation, ARDS, and an extracorporeal CO2 removal therapy (ECCO2RT). The simulations are compared with experimental data carried out on ten pigs. The results show a good agreement between the mathematical simulations and the experimental data, which provides a nice validation of the model. This model is thus able to predict the decrease of PCO2 during ECCO2RT for different blood flows across the extracorporeal lung support.
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Affiliation(s)
- Simon Habran
- GIGA - In Silico Medicine, University of Liege, Liege, Belgium.
| | - Thomas Desaive
- GIGA - In Silico Medicine, University of Liege, Liege, Belgium
| | | | | | - Pierre Dauby
- GIGA - In Silico Medicine, University of Liege, Liege, Belgium
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44
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Seiler F, Trudzinski FC, Kredel M, Lotz C, Lepper PM, Muellenbach RM. [Update: acute hypercapnic respiratory failure]. Med Klin Intensivmed Notfmed 2017; 114:234-239. [PMID: 28707030 DOI: 10.1007/s00063-017-0318-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/17/2017] [Accepted: 06/04/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hypercapnic respiratory failure is a frequent problem in critical care and mainly affects patients with acute exacerbation of COPD (AECOPD) and acute respiratory distress syndrome (ARDS). In recent years, the usage of extracorporeal CO2 removal (ECCO2R) has been increasing. OBJECTIVE Summarizing the state of the art in the management of hypercapnic respiratory failure with special regard to the role of ECCO2R. METHODS Review based on a selective literature search and the clinical and scientific experience of the authors. RESULTS Noninvasive ventilation (NIV) is the therapy of choice in hypercapnic respiratory failure due to AECOPD, enabling stabilization in the majority of cases and generally improving prognosis. Patients in whom NIV fails have an increased mortality. In these patients, ECCO2R may be sufficient to avoid intubation or to shorten time on invasive ventilation; however, corresponding evidence is sparse or even missing when it comes to hard endpoints. Lung-protective ventilation according to the ARDS network is the standard therapy of ARDS. In severe ARDS, low tidal volume ventilation may result in critical hypercapnia. ECCO2R facilitates compensation of respiratory acidosis even under "ultra-protective" ventilator settings. Yet, no positive prognostic effects could be demonstrated so far. CONCLUSION Optimized use of NIV and lung-protective ventilation remains standard of care in the management of hypercapnic respiratory failure. Currently, ECCO2R has to be considered an experimental approach, which should only be provided by experienced centers or in the context of clinical trials.
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Affiliation(s)
- F Seiler
- Klinik für Innere Medizin V - Pneumologie, Allergologie, Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 100, 66421, Homburg/Saar, Deutschland. .,ECLS Center Saar, 66421, Homburg, Deutschland.
| | - F C Trudzinski
- Klinik für Innere Medizin V - Pneumologie, Allergologie, Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 100, 66421, Homburg/Saar, Deutschland.,ECLS Center Saar, 66421, Homburg, Deutschland
| | - M Kredel
- Universitätsklinikum Würzburg, Klinik und Poliklinik für Anästhesiologie, 97080, Würzburg, Deutschland
| | - C Lotz
- Universitätsklinikum Würzburg, Klinik und Poliklinik für Anästhesiologie, 97080, Würzburg, Deutschland
| | - P M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie, Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 100, 66421, Homburg/Saar, Deutschland.,ECLS Center Saar, 66421, Homburg, Deutschland
| | - R M Muellenbach
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Kassel GmbH, 34125, Kassel, Deutschland
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45
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Braune S, Sieweke A, Jarczak D, Kluge S. [Extracorporeal lung support]. Med Klin Intensivmed Notfmed 2017; 112:426-436. [PMID: 28555443 DOI: 10.1007/s00063-017-0304-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 01/28/2023]
Abstract
Systems for extracorporeal lung support have recently undergone significant technological improvements leading to more effective and safe treatment. Despite limited scientific evidence these systems are increasingly used in the intensive care unit for treatment of different types of acute respiratory failure. In general two types of systems can be differentiated: devices for extracorporeal carbon dioxide removal (ECCO2R) for ventilatory insufficiency and devices for extracorporeal membrane oxygenation (ECMO) for severe hypoxemic failure. Despite of all technological developments extracorporeal lung support remains an invasive and a potentially dangerous form of treatment with bleeding and vascular injury being the two main complications. For this reason indications and contraindications should always be critically considered and extracorporeal lung support should only be carried out in centers with appropriate experience and expertise.
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Affiliation(s)
- S Braune
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- IV. Medizinische Klinik, Internistische Intensivmedizin und Notaufnahme, St. Franziskus-Hospital, 48145, Münster, Deutschland
| | - A Sieweke
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - D Jarczak
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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[The role of extracorporeal removal of CO 2 (ECCO 2R) in the management of respiratory diseases]. Rev Mal Respir 2017; 34:598-606. [PMID: 28506729 DOI: 10.1016/j.rmr.2017.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 10/21/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The aim of extracorporeal removal of CO2 (ECCO2R) is to ensure the removal of CO2 without any significant effect on oxygenation. ECCO2R makes use of low to moderate extracorporeal blood flow rates, whereas extracorporeal membrane oxygenation (ECMO) requires high blood flows. STATE OF THE ART For each ECCO2R device it is important to consider not only performance in terms of CO2 removal, but also cost and safety, including the incidence of hemolysis and of hemorrhagic and thrombotic complications. In addition, it is possible that the benefits of such techniques may extend beyond simple removal of CO2. There have been preliminary reports of benefits in terms of reduced respiratory muscle workload. Mobilization of endothelial progenitor cells could also occur, in analogy to the data reported with ECMO, with a potential benefit in term of pulmonary repair. The most convincing clinical experience has been reported in the context of the acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (COPD), especially in patients at high risk of failure of non-invasive ventilation. PERSPECTIVES Preliminary results prompt the initiation of randomized controlled trials in these two main indications. Finally, the development of these technologies opens new perspectives in terms of long-term ventilatory support.
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In Vivo Testing of Extracorporeal Membrane Ventilators: iLA-Activve Versus Prototype I-Lung. ASAIO J 2017; 63:185-192. [DOI: 10.1097/mat.0000000000000465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Morelli A, Del Sorbo L, Pesenti A, Ranieri VM, Fan E. Extracorporeal carbon dioxide removal (ECCO 2R) in patients with acute respiratory failure. Intensive Care Med 2017; 43:519-530. [PMID: 28132075 DOI: 10.1007/s00134-016-4673-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 12/29/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE To review the available knowledge related to the use of ECCO2R as adjuvant strategy to mechanical ventilation (MV) in various clinical settings of acute respiratory failure (ARF). METHODS Expert opinion and review of the literature. RESULTS ECCO2R may be a promising adjuvant therapeutic strategy for the management of patients with severe exacerbations of COPD and for the achievement of protective or ultra-protective ventilation in patients with ARDS without life-threatening hypoxemia. Given the observational nature of most of the available clinical data and differences in technical features and performances of current devices, the balance of risks and benefits for or against ECCO2R in such patient populations remains unclear CONCLUSIONS: ECCO2R is currently an experimental technique rather than an accepted therapeutic strategy in ARF-its safety and efficacy require confirmation in clinical trials.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, Policlinico Umberto 1, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, 585 University Avenue, PMB 11-123, Toronto, ON, M5G 2N2, Canada
| | - Antonio Pesenti
- Fondazione IRCCS Ca' Granda, Ospendale Maggiore Policlinico and Department of Pathophysiology and Transplantation, Universita degli Studi di Milano, Milan, Italy
| | - V Marco Ranieri
- Department of Anesthesiology and Intensive Care, Policlinico Umberto 1, Sapienza University of Rome, Rome, Italy
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Extracorporeal Life Support Program, Toronto General Hospital, 585 University Avenue, PMB 11-123, Toronto, ON, M5G 2N2, Canada.
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Vallabhajosyula S, Haddad TM, Sundaragiri PR, Ahmed AA, Nawaz MS, Rayes HAA, Devineni HC, Kanmanthareddy A, McCann DA, Wichman CS, Modrykamien AM, Morrow LE. Role of B-Type Natriuretic Peptide in Predicting In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease With Preserved Left Ventricular Function: A 5-Year Retrospective Analysis. J Intensive Care Med 2016; 33:635-644. [PMID: 27913775 DOI: 10.1177/0885066616682232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). METHODS This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. RESULTS Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. CONCLUSION Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,2 Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Toufik Mahfood Haddad
- 3 Division of Cardiovascular Diseases, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Pranathi R Sundaragiri
- 4 Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anas A Ahmed
- 5 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Muhammad Sarfraz Nawaz
- 6 Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Hamza A A Rayes
- 7 Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Harish C Devineni
- 7 Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Arun Kanmanthareddy
- 3 Division of Cardiovascular Diseases, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Dustin A McCann
- 8 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Christopher S Wichman
- 9 Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, USA
| | - Ariel M Modrykamien
- 10 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Lee E Morrow
- 8 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA.,11 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
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50
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Challenges on non-invasive ventilation to treat acute respiratory failure in the elderly. BMC Pulm Med 2016; 16:150. [PMID: 27846872 PMCID: PMC5111281 DOI: 10.1186/s12890-016-0310-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 11/07/2016] [Indexed: 01/26/2023] Open
Abstract
Acute respiratory failure is a frequent complication in elderly patients especially if suffering from chronic cardio-pulmonary diseases. Non-invasive mechanical ventilation constitutes a successful therapeutic tool in the elderly as, like in younger patients, it is able to prevent endotracheal intubation in a wide range of acute conditions; moreover, this ventilator technique is largely applied in the elderly in whom invasive mechanical ventilation is considered not appropriated. Furthermore, the integration of new technological devices, ethical issues and environment of treatment are still largely debated in the treatment of acute respiratory failure in the elderly. This review aims at reporting and critically analyzing the peculiarities in the management of acute respiratory failure in elderly people, the role of noninvasive mechanical ventilation, the potential advantages of applying alternative or integrated therapeutic tools (i.e. high-flow nasal cannula oxygen therapy, non-invasive and invasive cough assist devices and low-flow carbon-dioxide extracorporeal systems), drawbacks in physician’s communication and “end of life” decisions. As several areas of this topic are not supported by evidence-based data, this report takes in account also “real-life” data as well as author’s experience. The choice of the setting and of the timing of non-invasive mechanical ventilation in elderly people with advanced cardiopulmonary disease should be carefully evaluated together with the chance of using integrated or alternative supportive devices. Last but not least, economic and ethical issues may often challenges the behavior of the physicians towards elderly people who are hospitalized for acute respiratory failure at the end stage of their cardiopulmonary and neoplastic diseases.
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