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Pequignot B, Combes A, Lescroart M, Levy B, Koszutski M. Contribution of electrical impedance tomography to personalize positive end-expiratory pressure under ECCO 2R. Crit Care 2024; 28:124. [PMID: 38627745 PMCID: PMC11022412 DOI: 10.1186/s13054-024-04908-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/11/2024] [Indexed: 04/19/2024] Open
Abstract
Extracorporeal Carbon Dioxide Removal (ECCO2R) is used in acute respiratory distress syndrome (ARDS) patients to facilitate lung-protective ventilatory strategies. Electrical Impedance Tomography (EIT) allows individual, non-invasive, real-time, bedside, radiation-free imaging of the lungs, providing global and regional dynamic lung analyses. To provide new insights for future ECCO2R research in ARDS, we propose a potential application of EIT to personalize End-Expiratory Pressure (PEEP) following each reduction in tidal volume (VT), as demonstrated in an illustrative case. A 72-year-old male with COVID-19 was admitted to the ICU for moderate ARDS. Monitoring with EIT was started to determine the optimal PEEP value (PEEPEIT), defined as the intersection of the collapse and overdistention curves, after each reduction in VT during ECCO2R. The identified PEEPEIT values were notably low (< 10 cmH2O). The decrease in VT associated with PEEPEIT levels resulted in improved lung compliance, reduced driving pressure and a more uniform ventilation pattern. Despite current Randomized Controlled Trials showing that ultra-protective ventilation with ECCO2R does not improve survival, the applicability of universal ultra-protective ventilation settings for all patients remains a subject of debate. Inappropriately set PEEP levels can lead to alveolar collapse or overdistension, potentially negating the benefits of VT reduction. EIT facilitates real-time monitoring of derecruitment associated with VT reduction, guiding physicians in determining the optimal PEEP value after each decrease in tidal volume. This original description of using EIT under ECCO2R to adjust PEEP at a level compromising between recruitability and overdistention could be a crucial element for future research on ECCO2R.
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Affiliation(s)
- Benjamin Pequignot
- Service de Médecine Intensive et Réanimation, Université de Lorraine, Hôpital Brabois, CHRU Nancy, 54500, Vandoeuvre Les Nancy, France.
- Faculté de Médecine de Nancy, Université de Lorraine, INSERM UMR_S1116, Vandœuvre-Lès-Nancy, France.
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 47, Boulevard de L'Hôpital, 75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Mickael Lescroart
- Service de Médecine Intensive et Réanimation, Université de Lorraine, Hôpital Brabois, CHRU Nancy, 54500, Vandoeuvre Les Nancy, France
- Faculté de Médecine de Nancy, Université de Lorraine, INSERM UMR_S1116, Vandœuvre-Lès-Nancy, France
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation, Université de Lorraine, Hôpital Brabois, CHRU Nancy, 54500, Vandoeuvre Les Nancy, France
- Faculté de Médecine de Nancy, Université de Lorraine, INSERM UMR_S1116, Vandœuvre-Lès-Nancy, France
| | - Matthieu Koszutski
- Service de Médecine Intensive et Réanimation, Université de Lorraine, Hôpital Brabois, CHRU Nancy, 54500, Vandoeuvre Les Nancy, France
- Faculté de Médecine de Nancy, Université de Lorraine, INSERM UMR_S1116, Vandœuvre-Lès-Nancy, France
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Duggal A, Conrad SA, Barrett NA, Saad M, Cheema T, Pannu S, Romero RS, Brochard L, Nava S, Ranieri VM, May A, Brodie D, Hill NS. Extracorporeal Carbon Dioxide Removal to Avoid Invasive Ventilation During Exacerbations of Chronic Obstructive Pulmonary Disease: VENT-AVOID Trial - A Randomized Clinical Trial. Am J Respir Crit Care Med 2024; 209:529-542. [PMID: 38261630 DOI: 10.1164/rccm.202311-2060oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/23/2024] [Indexed: 01/25/2024] Open
Abstract
Rationale: It is unclear whether extracorporeal CO2 removal (ECCO2R) can reduce the rate of intubation or the total time on invasive mechanical ventilation (IMV) in adults experiencing an exacerbation of chronic obstructive pulmonary disease (COPD). Objectives: To determine whether ECCO2R increases the number of ventilator-free days within the first 5 days postrandomization (VFD-5) in exacerbation of COPD in patients who are either failing noninvasive ventilation (NIV) or who are failing to wean from IMV. Methods: This randomized clinical trial was conducted in 41 U.S. institutions (2018-2022) (ClinicalTrials.gov ID: NCT03255057). Subjects were randomized to receive either standard care with venovenous ECCO2R (NIV stratum: n = 26; IMV stratum: n = 32) or standard care alone (NIV stratum: n = 22; IMV stratum: n = 33). Measurements and Main Results: The trial was stopped early because of slow enrollment and enrolled 113 subjects of the planned sample size of 180. There was no significant difference in the median VFD-5 between the arms controlled by strata (P = 0.36). In the NIV stratum, the median VFD-5 for both arms was 5 days (median shift = 0.0; 95% confidence interval [CI]: 0.0-0.0). In the IMV stratum, the median VFD-5 in the standard care and ECCO2R arms were 0.25 and 2 days, respectively; median shift = 0.00 (95% confidence interval: 0.00-1.25). In the NIV stratum, all-cause in-hospital mortality was significantly higher in the ECCO2R arm (22% vs. 0%, P = 0.02) with no difference in the IMV stratum (17% vs. 15%, P = 0.73). Conclusions: In subjects with exacerbation of COPD, the use of ECCO2R compared with standard care did not improve VFD-5. Clinical trial registered with www.clinicaltrials.gov (NCT03255057).
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Affiliation(s)
- Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Steven A Conrad
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Nicholas A Barrett
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Mohamed Saad
- Division of Pulmonary, Critical Care and Sleep Disorders Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tariq Cheema
- Division of Pulmonary Critical Care, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Sonal Pannu
- Division of Pulmonary Critical Care and Sleep, Department of Medicine, Ohio State University, Columbus, Ohio
| | - Ramiro Saavedra Romero
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stefano Nava
- Respiratory and Critical Care Unit, IRCCS Azienda Hospital, University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Hospital, University of Bologna, Bologna, Italy
| | - Alexandra May
- ALung Technologies, LivaNova PLC, Pittsburgh, Pennsylvania
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
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Ferrer Gómez C, Gabaldón T, Hernández Laforet J. Ultraprotective Ventilation via ECCO2R in Three Patients Presenting an Air Leak: Is ECCO2R Effective? J Pers Med 2023; 13:1081. [PMID: 37511692 PMCID: PMC10381516 DOI: 10.3390/jpm13071081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 07/30/2023] Open
Abstract
Extracorporeal CO2 removal (ECCO2R) is a therapeutic approach that allows protective ventilation in acute respiratory failure by preventing hypercapnia and subsequent acidosis. The main indications for ECCO2R in acute respiratory failure are COPD (chronic obstructive pulmonary disease) exacerbation, acute respiratory distress syndrome (ARDS) and other situations of asthmatics status. However, CO2 removal procedure is not extended to those ARDS patients presenting an air leak. Here, we report three cases of air leaks in patients with an ARDS that were successfully treated using a new ECCO2R device. Case 1 is a polytrauma patient that developed pneumothorax during the hospital stay, case 2 is a patient with a post-surgical bronchial fistula after an Ivor-Lewis esophagectomy, and case 3 is a COVID-19 patient who developed a spontaneous pneumothorax after being hospitalized for a prolonged time. ECCO2R allowed for protective ventilation mitigating VILI (ventilation-induced lung injury) and significantly improved hypercapnia and respiratory acidemia, allowing time for the native lung to heal. Although further investigation is needed, our observations seem to suggest that CO2 removal can be a safe and effective procedure in patients connected to mechanical ventilation with ARDS-associated air leaks.
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Affiliation(s)
- Carolina Ferrer Gómez
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Tania Gabaldón
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Javier Hernández Laforet
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
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Lozano-Espinosa M, Antolín-Amérigo D, Riera Del Brío J, Gordo Vidal F, Quirce S, Álvarez Rodríguez J. Extracorporeal membrane oxygenation (ECMO) and beyond in near fatal asthma: A comprehensive review. Respir Med 2023:107246. [PMID: 37245648 DOI: 10.1016/j.rmed.2023.107246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 05/30/2023]
Abstract
The treatment of choice in severe asthma exacerbations with respiratory failure includes ventilatory support, both invasive and/or non-invasive, along with different kinds of asthma medication. Of note, the rate of mortality of patients with asthma has decreased substantially in recent years mainly due to significant advances in pharmacological treatment and other management strategies. However, the risk of death in patients with severe asthma who require invasive mechanical ventilation has been estimated between 6.5% and 10.3%. When conventional measures fail, rescue strategies, such as extracorporeal membrane oxygenation (ECMO) or extracorporeal CO2 removal (ECCO2R) may need to be implemented. While ECMO does not constitute a definitive treatment per se, it can minimize further ventilator associated lung injury (VALI) and can enable diagnostic-therapeutic maneuvers that cannot be performed without ECMO such as bronchoscopy and transfer for diagnostic imaging. Asthma is one of the diseases that is associated with excellent outcomes for patients with refractory respiratory failure requiring ECMO support, as shown by the Extracorporeal Life Support Organization (ELSO) registry. Moreover, in such situations, the use of ECCO2R for rescue has been described and utilized in both children and adults and is more widely spread in different hospitals than ECMO. In this article, we aim to review the evidence for the usefulness of extracorporeal respiratory support measures in the management of severe asthma exacerbations that lead to respiratory failure.
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Affiliation(s)
- María Lozano-Espinosa
- Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - Darío Antolín-Amérigo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain.
| | - Jordi Riera Del Brío
- Servicio de Medicina Intensiva, Hospital Universitari Vall d'Hebron, SODIR, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Federico Gordo Vidal
- Servicio de Medicina Intensiva, Hospital Universitario Henares, Coslada, Madrid, Spain; Grupo de Investigación en Patología Crítica. Universidad Francisco de Vitoria. Pozuelo de Alarcón, Madrid, Spain
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain
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Abrams D, Fan E. Lower Flow, Higher Costs? Recognizing Tradeoffs on the Spectrum of Extracorporeal Support for ARDS. Am J Respir Crit Care Med 2023; 207:1116-1118. [PMID: 36913243 PMCID: PMC10161738 DOI: 10.1164/rccm.202303-0354ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Affiliation(s)
- Darryl Abrams
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Eddy Fan
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada;
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Nakayama R, Wada K, Bunya N. Discrepancy in units in "In vivo carbon dioxide clearance of a low-flow extracorporeal carbon dioxide removal circuit in patients with acute exacerbations of chronic obstructive pulmonary disease". Perfusion 2022:2676591221096761. [PMID: 35623333 DOI: 10.1177/02676591221096761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryuichi Nakayama
- Department of Emergency Medicine, 13035Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kenshiro Wada
- Department of Emergency Medicine, 13035Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naofumi Bunya
- Department of Emergency Medicine, 13035Sapporo Medical University School of Medicine, Sapporo, Japan
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Ruberto F, Alessandri F, Piazzolla M, Zullino V, Bruno K, Celli P, Diso D, Venuta F, Bilotta F, Pugliese F. Intraoperative use of extracorporeal CO 2 removal (ECCO 2R) and emergency ECMO requirement in patients undergoing lung transplant: a case-matched cohort retrospective study. J Anesth Analg Crit Care 2022; 2:22. [PMID: 37386563 DOI: 10.1186/s44158-022-00050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/10/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND The use of extracorporeal carbon dioxide removal (ECCO2R) is less invasive than extracorporeal membrane oxygenation (ECMO), and intraoperative control of gas exchange could be feasible. The aim of this study in intermediate intraoperative severity patients undergoing LT was to assess the role of intraoperative ECCO2R on emergency ECMO requirement in patients. METHODS Thirty-eight consecutive patients undergoing lung transplantation (LT) with "intermediate" intraoperative severity in the intervals 2007 to 2010 or 2011 to 2014 were analyzed as historical comparison of case-matched cohort retrospective study. The "intermediate" intraoperative severity was defined as the development of intraoperative severe respiratory acidosis with maintained oxygenation function (i.e., pH <7.25, PaCO2 >60 mmHg, and PaO2/FiO2 >150), not associated with hemodynamic instability. Of these 38 patients, twenty-three patients were treated in the 2007-2010 interval by receiving "standard intraoperative treatment," while 15 patients were treated in the 2011-2014 interval by receiving "standard intraoperative treatment + ECCO2R." RESULTS ECMO requirement was more frequent among patients that received "standard intraoperative treatment" alone than in those treated with "standard intraoperative treatment + ECCO2R" (17/23 vs. 3/15; p = 0.004). The use of ECCO2R improved pH and PaCO2 while mean pulmonary artery pressure (mPAP) decreased. CONCLUSION In intermediate intraoperative severity patients, the use of ECCO2R reduces the ECMO requirement.
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Affiliation(s)
- Franco Ruberto
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Alessandri
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Mario Piazzolla
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Veronica Zullino
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Katia Bruno
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paola Celli
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Diso
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Venuta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Bilotta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Pugliese
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Barrett NA, Hart N, Daly KJR, Marotti M, Kostakou E, Carlin C, Lua S, Singh S, Bentley A, Douiri A, Camporota L. A randomised controlled trial of non-invasive ventilation compared with extracorporeal carbon dioxide removal for acute hypercapnic exacerbations of chronic obstructive pulmonary disease. Ann Intensive Care 2022; 12:36. [PMID: 35445986 PMCID: PMC9021560 DOI: 10.1186/s13613-022-01006-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background Patients presenting with acute hypercapnic respiratory failure due to exacerbations of chronic obstructive pulmonary disease (AECOPD) are typically managed with non-invasive ventilation (NIV). The impact of low-flow extracorporeal carbon dioxide removal (ECCO2R) on outcome in these patients has not been explored in randomised trials. Methods Open-label randomised trial comparing NIV (NIV arm) with ECCO2R (ECCO2R arm) in patients with AECOPD at high risk of NIV failure (pH < 7.30 after ≥ 1 h of NIV). The primary endpoint was time to cessation of NIV. Secondary outcomes included device tolerance and complications, changes in arterial blood gases, hospital survival. Results Eighteen patients (median age 67.5, IQR (61.5–71) years; median GOLD stage 3 were enrolled (nine in each arm). Time to NIV discontinuation was shorter with ECCO2R (7:00 (6:18–8:30) vs 24:30 (18:15–49:45) h, p = 0.004). Arterial pH was higher with ECCO2R at 4 h post-randomisation (7.35 (7.31–7.37) vs 7.25 (7.21–7.26), p < 0.001). Partial pressure of arterial CO2 (PaCO2) was significantly lower with ECCO2R at 4 h (6.8 (6.2–7.15) vs 8.3 (7.74–9.3) kPa; p = 0.024). Dyspnoea and comfort both rapidly improved with commencement of ECCO2R. There were no severe or life-threatening complications in the study population. There were no episodes of major bleeding or red blood cell transfusion in either group. ICU and hospital length of stay were longer with ECCO2R, and there was no difference in 90-day mortality or functional outcomes at follow-up. Interpretation There is evidence of benefit associated with ECCO2R with time to improvement in respiratory acidosis, in respiratory physiology and an immediate improvement in patient comfort and dyspnoea with commencement of ECCO2R. In addition, there was minimal clinically significant adverse events associated with ECCO2R use in patients with AECOPD at risk of failing or not tolerating NIV. However, the ICU and hospital lengths of stay were longer in the ECCO2R for similar outcomes. Trial registration The trial is prospectively registered on ClinicalTrials.gov: NCT02086084. Registered on 13th March 2014, https://clinicaltrials.gov/ct2/show/NCT02086084?cond=ecco2r&draw=2&rank=8 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01006-8.
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Affiliation(s)
- Nicholas A Barrett
- Department of Critical Care, NHS Foundation Trust, Guy's and St ThomasWestminster 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, WC2R 2LS, 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, WC2R 2LS, UK.,Lane Fox Respiratory Unit, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK
| | - Kathleen J R Daly
- Department of Critical Care, NHS Foundation Trust, Guy's and St ThomasWestminster Bridge Rd, London, SE1 7EH, UK
| | - Martina Marotti
- Department of Critical Care, NHS Foundation Trust, Guy's and St ThomasWestminster Bridge Rd, London, SE1 7EH, UK
| | - Eirini Kostakou
- Department of Critical Care, NHS Foundation Trust, Guy's and St ThomasWestminster Bridge Rd, London, SE1 7EH, UK
| | - Chris Carlin
- Dept. of Respiratory Medicine, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Stephanie Lua
- Dept. of Respiratory Medicine, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Suveer Singh
- Department of Respiratory and Critical Care Medicine, Chelsea & Westminster Hospital, London, SW10 9NH, UK
| | - Andrew Bentley
- Department of Intensive Care & Respiratory Medicine, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, 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, WC2R 2LS, UK
| | - Luigi Camporota
- Department of Critical Care, NHS Foundation Trust, Guy's and St ThomasWestminster 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, WC2R 2LS, UK
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9
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Leypoldt JK, Kurz J, Echeverri J, Storr M, Harenski K. Targeting arterial partial pressure of carbon dioxide in acute respiratory distress syndrome patients using extracorporeal carbon dioxide removal. Artif Organs 2021; 46:677-687. [PMID: 34817074 DOI: 10.1111/aor.14127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/06/2021] [Accepted: 11/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND A retrospective analysis of SUPERNOVA trial data showed that reductions in tidal volume to ultraprotective levels without significant increases in arterial partial pressure of carbon dioxide (PaCO2 ) for critically ill, mechanically ventilated patients with acute respiratory distress syndrome (ARDS) depends on the rate of extracorporeal carbon dioxide removal (ECCO2 R). METHODS We used a whole-body mathematical model of acid-base balance to quantify the effect of altering carbon dioxide (CO2 ) removal rates using different ECCO2 R devices to achieve target PaCO2 levels in ARDS patients. Specifically, we predicted the effect of using a new, larger surface area PrismaLung+ device instead of the original PrismaLung device on the results from two multicenter clinical studies in critically ill, mechanically ventilated ARDS patients. RESULTS After calibrating model parameters to the clinical study data using the PrismaLung device, model predictions determined optimal extracorporeal blood flow rates for the PrismaLung+ and mechanical ventilation frequencies to obtain target PaCO2 levels of 45 and 50 mm Hg in mild and moderate ARDS patients treated at a tidal volume of 3.98 ml/kg predicted body weight (PW). Comparable model predictions showed that reductions in tidal volumes below 6 ml/kg PBW may be difficult for acidotic highly severe ARDS patients with acute kidney injury and high CO2 production rates using a PrismaLung+ device in-series with a continuous venovenous hemofiltration device. CONCLUSIONS The described model provides guidance on achieving target PaCO2 levels in mechanically ventilated ARDS patients using protective and ultraprotective tidal volumes when increasing CO2 removal rates from ECCO2 R devices.
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Affiliation(s)
- John K Leypoldt
- Department IV-Modeling and Supporting of Internal Functions, Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Warsaw, Poland
| | - Jörg Kurz
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Jorge Echeverri
- Medical Affairs, Baxter Healthcare Corporation, Deerfield, Illinois, USA
| | - Markus Storr
- Research and Development, Baxter International, Hechingen, Germany
| | - Kai Harenski
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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İnal V, Efe S. Extracorporeal carbon dioxide removal (ECCO2R) in COPD and ARDS patients with severe hypercapnic respiratory failure. A retrospective case-control study. Turk J Med Sci 2021; 51:2127-2135. [PMID: 33932971 PMCID: PMC8569780 DOI: 10.3906/sag-2012-151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 05/01/2021] [Indexed: 02/05/2023] Open
Abstract
Background/aim Treatment of severe hypercapnic respiratory failure (HRF) has some challenges in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS), especially when lung protective ventilation (LPV) strategies are required. Extracorporeal CO2 removal (ECCO2R) therapy is an emerging option to manage hypercapnia while allowing LPV in these cases. However, further data on ECCO2R use is still needed to make clear recommendations. Materials and methods This study was conducted on patients admitted to intensive care unit (ICU) between January 1st, 2016 to December 31st, 2019. The medical records were retrospectively scanned in institutional software database. Patients who received invasive mechanic ventilation (iMV) support due to severe HRF related to COPD or ARDS were included in the analyses. Patients were grouped according to treatment approaches as that ECCO2R therapy in addition to conventional treatments and conventional treatments alone (controls). Groups were compared for 28-day survival, iMV duration, and length of stay (LOS). Results ECCO2R therapy was noted in 75 of the cases among included 395 patients (COPD n = 256, ARDS n = 139) out of scanned 1715 medical records. The survival rate of ECCO2R patients was 68% and significantly higher than 58% survival rate of controls (p = 0.025), with relative risk reduction (RRR) = 0.16, absolute risk reduction (ARR)= 0.10, number need to treat (NNT) = 10, and odds ratio (OR) = 1.5. In addition, iMV duration (12.8 ± 2.6 vs. 17.1 ± 4.9 days, p = 0.007) and LOS (16.9 ± 4.1 vs. 18.9 ± 5.5 days, p = 0.032) were significantly shorter than controls. Repeated measure analyses showed that LPV settings were successfully provided by 72 h of ECCO2R therapy. Subgroup analyses according to diagnoses of COPD and ARDS also favored ECCO2R. Conclusion ECCO2R therapy significantly improved survival, iMV duration and LOS in patients with severe HRF due to COPD or ARDS, and successfully provided LPV approaches. Further studies are needed to assess promising benefits of ECCO2R therapy.
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Affiliation(s)
- Volkan İnal
- Department of Internal Medicine Division of Critical Care, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Serdar Efe
- Department of Internal Medicine Division of Critical Care, Faculty of Medicine, Trakya University, Edirne, Turkey
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12
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Schwärzel LS, Jungmann AM, Schmoll N, Caspari S, Seiler F, Muellenbach RM, Bewarder M, Dinh QT, Bals R, Lepper PM, Omlor AJ. Comparison of Circular and Parallel-Plated Membrane Lungs for Extracorporeal Carbon Dioxide Elimination. Membranes (Basel) 2021; 11:398. [PMID: 34072067 DOI: 10.3390/membranes11060398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 11/17/2022]
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) is an important technique to treat critical lung diseases such as exacerbated chronic obstructive pulmonary disease (COPD) and mild or moderate acute respiratory distress syndrome (ARDS). This study applies our previously presented ECCO2R mock circuit to compare the CO2 removal capacity of circular versus parallel-plated membrane lungs at different sweep gas flow rates (0.5, 2, 4, 6 L/min) and blood flow rates (0.3 L/min, 0.9 L/min). For both designs, two low-flow polypropylene membrane lungs (Medos Hilte 1000, Quadrox-i Neonatal) and two mid-flow polymethylpentene membrane lungs (Novalung Minilung, Quadrox-iD Pediatric) were compared. While the parallel-plated Quadrox-iD Pediatric achieved the overall highest CO2 removal rates under medium and high sweep gas flow rates, the two circular membrane lungs performed relatively better at the lowest gas flow rate of 0.5 L/min. The low-flow Hilite 1000, although overall better than the Quadrox i-Neonatal, had the most significant advantage at a gas flow of 0.5 L/min. Moreover, the circular Minilung, despite being significantly less efficient than the Quadrox-iD Pediatric at medium and high sweep gas flow rates, did not show a significantly worse CO2 removal rate at a gas flow of 0.5 L/min but rather a slight advantage. We suggest that circular membrane lungs have an advantage at low sweep gas flow rates due to reduced shunting as a result of their fiber orientation. Efficiency for such low gas flow scenarios might be relevant for possible future portable ECCO2R devices.
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13
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Leypoldt JK, Kurz J, Echeverri J, Storr M, Harenski K. Modeling acid-base balance for in-series extracorporeal carbon dioxide removal and continuous venovenous hemofiltration devices. Artif Organs 2021; 45:1036-1049. [PMID: 33909323 DOI: 10.1111/aor.13969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/10/2021] [Accepted: 04/02/2021] [Indexed: 01/03/2023]
Abstract
Patients with acute respiratory distress syndrome and acute kidney injury (AKI) treated by kidney replacement therapy may also require treatment with extracorporeal carbon dioxide removal (ECCO2 R) devices to permit protective or ultraprotective mechanical ventilation. We developed a mathematical model of acid-base balance during extracorporeal therapy using ECCO2 R and continuous venovenous hemofiltration (CVVH) devices applied in series for the treatment of mechanically ventilated AKI patients. Published data from clinical studies of mechanically ventilated AKI patients treated by CVVH at known infusion rates of substitution fluid without ECCO2 R were used to adjust the model parameters to fit plasma levels of arterial partial pressure of carbon dioxide (PaCO2 ), arterial plasma bicarbonate concentration ([HCO3 ]), and plasma pH (as well as certain other unmeasured physiological variables). The effects of applying ECCO2 R at an unchanged and a reduced tidal volume on PaCO2 , [HCO3 ] and plasma pH were then simulated assuming carbon dioxide removal rates from the ECCO2 R device measured in the clinical studies. Agreement of such model predictions with clinical data was good whether the ECCO2 R device was positioned proximal or distal to the CVVH device in the extracorporeal circuit. Although carbon dioxide removal rates from the ECCO2 R device measured in one previous clinical study were higher when it was placed proximal to the CVVH device, suggesting that such in-series positioning was optimal, the current mathematical model demonstrates that proximal positioning of the ECCO2 R device also results in lower bicarbonate (and, therefore, total carbon dioxide) removal from the distal CVVH device. Thus, the removal of total carbon dioxide by such extracorporeal circuits is relatively independent of the position of the in-series devices. It is concluded that the described mathematical model has quantitative accuracy; these results suggest that the overall acid-base balance when using ECCO2 R and CVVH devices in a single extracorporeal circuit will be similar, independent of their in-series position.
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Affiliation(s)
- John K Leypoldt
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Jörg Kurz
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Jorge Echeverri
- Medical Affairs, Baxter Healthcare Corporation, Deerfield, IL, USA
| | - Markus Storr
- Research and Development, Baxter International, Hechingen, Germany
| | - Kai Harenski
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
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14
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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: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Schöps M, Groß-Hardt SH, Schmitz-Rode T, Steinseifer U, Brodie D, Clauser JC, Karagiannidis C. Hemolysis at low blood flow rates: in-vitro and in-silico evaluation of a centrifugal blood pump. J Transl Med 2021; 19:2. [PMID: 33402176 PMCID: PMC7784380 DOI: 10.1186/s12967-020-02599-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/30/2020] [Indexed: 01/03/2023] Open
Abstract
Background Treating severe forms of the acute respiratory distress syndrome and cardiac failure, extracorporeal membrane oxygenation (ECMO) has become an established therapeutic option. Neonatal or pediatric patients receiving ECMO, and patients undergoing extracorporeal CO2 removal (ECCO2R) represent low-flow applications of the technology, requiring lower blood flow than conventional ECMO. Centrifugal blood pumps as a core element of modern ECMO therapy present favorable operating characteristics in the high blood flow range (4 L/min–8 L/min). However, during low-flow applications in the range of 0.5 L/min–2 L/min, adverse events such as increased hemolysis, platelet activation and bleeding complications are reported frequently. Methods In this study, the hemolysis of the centrifugal pump DP3 is evaluated both in vitro and in silico, comparing the low-flow operation at 1 L/min to the high-flow operation at 4 L/min. Results Increased hemolysis occurs at low-flow, both in vitro and in silico. The in-vitro experiments present a sixfold higher relative increased hemolysis at low-flow. Compared to high-flow operation, a more than 3.5-fold increase in blood recirculation within the pump head can be observed in the low-flow range in silico. Conclusions This study highlights the underappreciated hemolysis in centrifugal pumps within the low-flow range, i.e. during pediatric ECMO or ECCO2R treatment. The in-vitro results of hemolysis and the in-silico computational fluid dynamic simulations of flow paths within the pumps raise awareness about blood damage that occurs when using centrifugal pumps at low-flow operating points. These findings underline the urgent need for a specific pump optimized for low-flow treatment. Due to the inherent problems of available centrifugal pumps in the low-flow range, clinicians should use the current centrifugal pumps with caution, alternatively other pumping principles such as positive displacement pumps may be discussed in the future.![]()
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Affiliation(s)
- Malte Schöps
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Pauwelstrasse 20, 52074, Aachen, Germany.
| | - Sascha H Groß-Hardt
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Pauwelstrasse 20, 52074, Aachen, Germany
| | - Thomas Schmitz-Rode
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Pauwelstrasse 20, 52074, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Pauwelstrasse 20, 52074, Aachen, Germany
| | - Daniel Brodie
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Johanna C Clauser
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Pauwelstrasse 20, 52074, Aachen, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany
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16
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Braune S, Bojes P, Mecklenburg A, Angriman F, Soeffker G, Warnke K, Westermann D, Blankenberg S, Kubik M, Reichenspurner H, Kluge S. Feasibility, safety, and resource utilisation of active mobilisation of patients on extracorporeal life support: a prospective observational study. Ann Intensive Care 2020; 10:161. [PMID: 33259044 PMCID: PMC7708587 DOI: 10.1186/s13613-020-00776-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 11/20/2020] [Indexed: 11/29/2022] Open
Abstract
Background There is scarce evidence on the feasibility, safety and resource utilisation of active mobilisation in critically ill patients on extracorporeal life support (ECLS). Methods This prospective observational single-centre study included all consecutive critically ill patients on ECLS admitted to an academic centre in Germany over a time period of one year. The level of mobilisation was categorised according to the ICU Mobility Scale (IMS). Primary outcome was complications during mobilisation. Results During the study period, active mobilisation with an activity level on the IMS of ≥ 3 was performed at least on one occasion in 43 out of 115 patients (37.4%). A total of 332 mobilisations with IMS ≥ 3 were performed during 1242 ECLS days (26.7%). ECLS configurations applied were va-ECMO (n = 63), vv-ECMO (n = 26), vv-ECCO2R (n = 12), av-ECCO2R (n = 10), and RVAD (n = 4). Femoral cannulation had been in place in 108 patients (93.9%). The median duration of all mobilisation activities with IMS ≥ 3 was 130 min (IQR 44–215). All mobilisations were undertaken by a multi-professional ECLS team with a median number of 3 team members involved (IQR 3–4). Bleeding from cannulation site requiring transfusion and/or surgery occurred in 6.9% of actively mobilised patients and in 15.3% of non-mobilised patients. During one mobilisation episode, accidental femoral cannula displacement occurred with immediate and effective recannulation. Sedation was the major reason for non-mobilisation. Conclusions Active mobilisation (IMS ≥ 3) of ECLS patients undertaken by an experienced multi-professional team was feasible, and complications were infrequent and managed successfully. Larger prospective multicentre studies are needed to further evaluate early goal directed sedation and mobilisation bundles in patients on ECLS.
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Affiliation(s)
- Stephan Braune
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Patrick Bojes
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Anne Mecklenburg
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Federico Angriman
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Gerold Soeffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Katja Warnke
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dirk Westermann
- Department of Interventional and General Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Interventional and General Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Mathias Kubik
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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17
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Schwärzel LS, Jungmann AM, Schmoll N, Seiler F, Muellenbach RM, Schenk J, Dinh QT, Bals R, Lepper PM, Omlor AJ. A mock circulation loop to test extracorporeal CO 2 elimination setups. Intensive Care Med Exp 2020; 8:52. [PMID: 32915322 PMCID: PMC7484925 DOI: 10.1186/s40635-020-00341-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/02/2020] [Indexed: 01/01/2023] Open
Abstract
Background Extracorporeal carbon dioxide removal (ECCO2R) is a promising yet limited researched therapy for hypercapnic respiratory failure in acute respiratory distress syndrome and exacerbated chronic obstructive pulmonary disease. Herein, we describe a new mock circuit that enables experimental ECCO2R research without animal models. In a second step, we use this model to investigate three experimental scenarios of ECCO2R: (I) the influence of hemoglobin concentration on CO2 removal. (II) a potentially portable ECCO2R that uses air instead of oxygen, (III) a low-flow ECCO2R that achieves effective CO2 clearance by recirculation and acidification of the limited blood volume of a small dual lumen cannula (such as a dialysis catheter). Results With the presented ECCO2R mock, CO2 removal rates comparable to previous studies were obtained. The mock works with either fresh porcine blood or diluted expired human packed red blood cells. However, fresh porcine blood was preferred because of better handling and availability. In the second step of this work, hemoglobin concentration was identified as an important factor for CO2 removal. In the second scenario, an air-driven ECCO2R setup showed only a slightly lower CO2 wash-out than the same setup with pure oxygen as sweep gas. In the last scenario, the low-flow ECCO2R, the blood flow at the test membrane lung was successfully raised with a recirculation channel without the need to increase cannula flow. Low recirculation ratios resulted in increased efficiency, while high recirculation ratios caused slightly reduced CO2 removal rates. Acidification of the CO2 depleted blood in the recirculation channel caused an increase in CO2 removal rate. Conclusions We demonstrate a simple and cost effective, yet powerful, “in-vitro” ECCO2R model that can be used as an alternative to animal experiments for many research scenarios. Moreover, in our approach parameters such as hemoglobin level can be modified more easily than in animal models.
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Affiliation(s)
- Leonie S Schwärzel
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Anna M Jungmann
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Nicole Schmoll
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Frederik Seiler
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Ralf M Muellenbach
- Department of Anaesthesiology and Critical Care, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Joachim Schenk
- Department of Transfusion Medicine and Hemostaseology, University Hospital of Saarland, Homburg, Germany
| | - Quoc Thai Dinh
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Robert Bals
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany.
| | - Albert J Omlor
- Department of Internal Medicine V - Pneumology and Intensive Care Medicine, University Hospital of Saarland, Kirrbergerstr. 1, 66421, Homburg, Germany
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18
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Combes A, Auzinger G, Capellier G, du Cheyron D, Clement I, Consales G, Dabrowski W, De Bels D, de Molina Ortiz FJG, Gottschalk A, Hilty MP, Pestaña D, Sousa E, Tully R, Goldstein J, Harenski K. ECCO 2R therapy in the ICU: consensus of a European round table meeting. Crit Care 2020; 24:490. [PMID: 32768001 PMCID: PMC7412288 DOI: 10.1186/s13054-020-03210-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/28/2020] [Indexed: 01/19/2023]
Abstract
Background With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO2 removal (ECCO2R). However, current evidence in these indications is limited. A European ECCO2R Expert Round Table Meeting was convened to further explore the potential for this treatment approach. Methods A modified Delphi-based method was used to collate European experts’ views to better understand how ECCO2R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus. Results Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO2R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO2R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO2R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO2 levels. Driving pressure (≥ 14 cmH2O) followed by plateau pressure (Pplat; ≥ 25 cmH2O) was considered the most important criteria for ECCO2R initiation. Key treatment targets for patients with ARDS undergoing ECCO2R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH2O) and Pplat (< 25 cmH2O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO2 and no decrease in respiratory rate were key criteria for initiating ECCO2R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30–7.35), respiratory rate (< 20–25 breaths/min), decrease of PaCO2 (by 10–20%), weaning from NIV, decrease in HCO3− and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group. Conclusions Insights from this group of experienced physicians suggest that ECCO2R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, Boulevard de l'Hôpital, F-75013, Paris, France. .,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, F-75013, Paris, France.
| | - Georg Auzinger
- Department of Critical Care, King's College Hospital, London, SE5 9RS, UK.,Department of Critical Care, Cleveland Clinic, London, SW1Y 7AW, UK
| | - Gilles Capellier
- Service de Médecine Intensive-Réanimation CHRU Besançon, EA 3920 University of Franche Comte, Besançon, France.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Damien du Cheyron
- Service de Médecine Intensive-Réanimation, Caen University Hospital, 14000, Caen, France
| | - Ian Clement
- Critical Care Unit, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - Guglielmo Consales
- Department Emergency and Critical Care, Prato Hospital, Azienda Toscana Centro, Prato, Italy
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Jaczewskiego Street 8, 20-954, Lublin, Poland
| | - David De Bels
- Service des Soins Intensifs Médico-chirurgicaux, CHU Brugmann, 4 Place A Van Gehuchten, 1020, Brussels, Belgium
| | - Francisco Javier González de Molina Ortiz
- Department of Critical Care, University Hospital Mútua Terrassa, Universitat de Barcelona, Terrassa, Barcelona, Spain.,Department of Critical Care, University Hospital Quirón Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antje Gottschalk
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - David Pestaña
- Department of Anesthesiology and Surgical Critical Care, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Viejo km 9, 28034, Madrid, Spain.,Universidad de Alcalá de Henares, Madrid, Spain
| | - Eduardo Sousa
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-075, Coimbra, Portugal
| | - Redmond Tully
- Department of Intensive Care, Royal Oldham Hospital, Northern Care Alliance, Oldham, OL1 2JH, UK
| | - Jacques Goldstein
- Baxter World Trade SPRL, Acute Therapies Global, Braine-l'Alleud, Belgium
| | - Kai Harenski
- Baxter, Baxter Deutschland GmbH, Unterschleissheim, Germany
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Barrett NA, Hart N, Camporota L. In vivo carbon dioxide clearance of a low-flow extracorporeal carbon dioxide removal circuit in patients with acute exacerbations of chronic obstructive pulmonary disease. Perfusion 2020; 35:436-441. [PMID: 31928313 DOI: 10.1177/0267659119896531] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Veno-venous extracorporeal carbon dioxide removal allows clearance of CO2 from the blood and is becoming popular to enhance protective mechanical ventilation and assist in the management of acute exacerbations of chronic obstructive pulmonary disease, including the prevention of intubation. The main factor determining CO2 transfer across a membrane lung for any given blood flow rate and venous CO2 content is the sweep gas flow rate. The in vivo characteristics of CO2 clearance using ultra-low blood flow devices in patients with acute exacerbations of chronic obstructive pulmonary disease has not been previously described. METHODS Patients commenced on extracorporeal carbon dioxide removal for acute exacerbations of chronic obstructive pulmonary disease recruited to a randomized controlled trial of non-invasive ventilation versus extracorporeal carbon dioxide removal had pre- and post-membrane circuit gases measured after each increment of sweep gas flow to allow calculation of the transmembrane CO2 clearance. This was compared with the clearance reported by the device and also corrected to inlet PCO2 to allow characterization of the CO2 clearance of the device at different sweep gas flow rates. RESULTS CO2 clearance was calculated using both the transmembrane CO2 whole-blood content difference and CO2 clearance reported by the device. The two methods demonstrated a linear relationship and agreement with a bias of 14 mL/minute (SD = ±10) and an R2 of 0.92. The membrane CO2 clearance was non-linear with nearly two thirds of total clearance achieved with sweep gas flow below 2 L/minute (VCO2 of 40 ± 16.7 mL/minute) and a plateau above 5 L/minute sweep gas flow (VCO2 64 ± 1 2.4 mL/minute). CONCLUSION The extracorporeal carbon dioxide removal device used in the study provides efficient clearance of CO2 at low sweep flow rates which then plateaus. This has implications for how the device may be used in clinical practice, particularly during the weaning phase where the final discontinuation of the device may take longer than anticipated. (ClinicalTrials.gov: NCT02086084, registered 13 March 2014, https://clinicaltrials.gov/ct2/show/NCT02086084 ).
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Affiliation(s)
- Nicholas A Barrett
- Centre for Human & Applied Physiological Sciences (CHAPS) and School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.,Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Hart
- Centre for Human & Applied Physiological Sciences (CHAPS) and 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, London, UK
| | - Luigi Camporota
- Centre for Human & Applied Physiological Sciences (CHAPS) and School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.,Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
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20
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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. Crit Care 2019; 23:348. [PMID: 31694688 PMCID: PMC6836552 DOI: 10.1186/s13054-019-2622-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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Perez Ruiz de Garibay A, Kellum JA, Honigschnabel J, Kreymann B. Respiratory and metabolic acidosis correction with the ADVanced Organ Support system. Intensive Care Med Exp 2019; 7:56. [PMID: 31535309 PMCID: PMC6751235 DOI: 10.1186/s40635-019-0269-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/09/2019] [Indexed: 01/23/2023] Open
Abstract
Background The lung, the kidney, and the liver are major regulators of acid-base balance. Acidosis due to the dysfunction of one or more organs can increase mortality, especially in critically ill patients. Supporting compensation by increasing ventilation or infusing bicarbonate is often ineffective. Therefore, direct removal of acid may represent a novel therapeutic approach. This can be achieved with the ADVanced Organ Support (ADVOS) system, an enhanced renal support therapy based on albumin dialysis. Here, we demonstrate proof of concept for this technology. Methods An ex vivo model of either hypercapnic (i.e., continuous CO2 supply) or lactic acidosis (i.e., lactic acid infusion) using porcine blood was subjected to hemodialysis with ADVOS. A variety of operational parameters including blood and dialysate flows, different dialysate pH settings, and acid and base concentrate compositions were tested. Comparisons with standard continuous veno-venous hemofiltration (CVVH) using high bicarbonate substitution fluid and continuous veno-venous hemodialysis (CVVHD) were also performed. Results Sixty-one milliliters per minute (2.7 mmol/min) of CO2 was removed using a blood flow of 400 ml/min and a dialysate pH of 10 without altering blood pCO2 and HCO3− (36 mmHg and 20 mmol/l, respectively). Up to 142 ml/min (6.3 mmol/min) of CO2 was eliminated if elevated pCO2 (117 mmHg) and HCO3− (63 mmol/l) were allowed. During continuous lactic acid infusion, an acid load of up to 3 mmol/min was compensated. When acidosis was triggered, ADVOS multi normalized pH and bicarbonate levels within 1 h, while neither CVVH nor CVVHD could. The major determinants to correct blood pH were blood flow, dialysate composition, and initial acid-base status. Conclusions In conclusion, ADVOS was able to remove more than 50% of the amount of CO2 typically produced by an adult human. Blood pH was maintained stable within the physiological range through compensation of a metabolic acid load by albumin dialysate. These in vitro results will require confirmation in patients.
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Affiliation(s)
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA
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Abstract
INTRODUCTION Extracorporeal gas exchange requires the passage of oxygen and carbon dioxide (CO2) across an artificial membrane. Current European Union regulations do not require the transfer to be assessed in models using clinically relevant haemoglobin, making it difficult for clinicians to understand the CO2 clearance of a membrane, and how it changes in relation to sweep gas flow through the membrane. The characteristics of membrane CO2 clearance are described using a single membrane at different sweep gas flows in an in vitro model with clinically relevant haemoglobin concentrations using three separate methods of calculating CO2 clearance. METHODS To define the CO2 removal characteristics of the extra-corporeal CO2 removal (ECCO2R) device, we devised an in-vitro gas exchange circuit formed by a dedicated ECCO2R circuit (ALung, Pittsburgh, USA) in series with two membrane oxygenators. The system was primed with donated expired human red cells provided by the local blood bank. The experimental set-up allowed constant CO2 input (via one membrane oxygenator) with variable removal from a portion of the blood in a manner which was analogous to that seen in vivo. Blood gases were measured from different ports in the circuit in order to measure the experimental membrane CO2 clearance (VCO2). RESULTS Results demonstrate that the relationship between VCO2 and gas flow at a constant blood flow of 0.4 L/minute with a haemoglobin of 7 g/dL increases sharply from a gas flow of 0 to 2 L/min but plateaus at gas flows >4 L/minute. VCO2, calculated using three different methods, showed a strong linear correlation with minimal bias. CONCLUSIONS The CO2 clearance of the membrane used in this bench test is non-linear. This has implications for clinical practice, especially during the weaning phase of the device.
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Affiliation(s)
- Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, 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, London, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, 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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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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. Electronic supplementary material The online version of this article (10.1186/s13063-019-3548-4) contains supplementary material, which is available to authorized users.
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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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Introduction End-of-life decisions are often time consuming and difficult for everyone involved. In some of these cases extracorporeal life support systems could potentially be used not only as a bridge to treatment but as a tool to buy time to allow patient's participation in decision making and to avoid further futile invasive procedures. Case report A previously healthy 53-year-old female patient presented with respiratory failure of unknown cause. In the course of treatment her condition was deemed irreversible and the only option for any chance of long-term survival was a lung transplant. During this whole time the patient's condition was managed with extracorporeal carbon dioxide removal system (ECCO2R). She remained compos mentis and expressed the wish to stop all the treatment as the option of lung transplant was not acceptable to her. Treatment was withdrawn and she passed away. Discussion In cases of end-of-life decisions, time can play an essential role. Even though extracorporeal life support systems have been conceptualised to be a bridge to treatment, they could be beneficial in a situation when time is needed to make a decision. ECCO2R has been used as a treatment method in different settings, however, in this case it served as a tool to maintain the patient alive and conscious for a sufficient time for her to participate in decision making. Conclusions Our case report demonstrated that ECCO2R could serve as a bridge to decision in situations when time is limited and the decisions that need to be made are difficult.
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Affiliation(s)
- Lina Grauslytė
- Department of Anaesthesiology, Kauno Klinikos Hospital of the Lithuanian University of Health Sciences, Kaunas, Lithuania.,Queen's Hospital, Barking, Havering and Redbridge University Hospitals Trust NHS London, United Kingdom
| | - Gonzalo De La Cerda
- Queen's Hospital, Barking, Havering and Redbridge University Hospitals Trust NHS London, United Kingdom
| | - Tomas Jovaiša
- Queen's Hospital, Barking, Havering and Redbridge University Hospitals Trust NHS London, United Kingdom.,Department of Anaesthesiology Lithuanian University of Health Sciences, Kaunas, Lithuania
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Strassmann S, Merten M, Schäfer S, de Moll J, Brodie D, Larsson A, Windisch W, Karagiannidis C. Impact of sweep gas flow on extracorporeal CO 2 removal (ECCO 2R). Intensive Care Med Exp 2019; 7:17. [PMID: 30911910 PMCID: PMC6434004 DOI: 10.1186/s40635-019-0244-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/14/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Veno-venous extracorporeal carbon dioxide (CO2) removal (vv-ECCO2R) is increasingly being used in the setting of acute respiratory failure. Blood flow rates range in clinical practice from 200 mL/min to more than 1500 mL/min, and sweep gas flow rates range from less than 1 to more than 10 L/min. The present porcine model study was aimed at determining the impact of varying sweep gas flow rates on CO2 removal under different blood flow conditions and membrane lung surface areas. METHODS Two different membrane lungs, with surface areas of 0.4 and 0.8m2, were used in nine pigs with experimentally-induced hypercapnia. During each experiment, the blood flow was increased stepwise from 300 to 900 mL/min, with further increases up to 1800 mL/min with the larger membrane lung in steps of 300 mL/min. Sweep gas was titrated under each condition from 2 to 8 L/min in steps of 2 L/min. Extracorporeal CO2 elimination was normalized to a PaCO2 of 45 mmHg before the membrane lung. RESULTS Reversal of hypercapnia was only feasible when blood flow rates above 900 mL/min were used with a membrane lung surface area of at least 0.8m2. The membrane lung with a surface of 0.4m2 allowed a maximum normalized CO2 elimination rate of 41 ± 6 mL/min with 8 L/min sweep gas flow and 900 mL blood flow/min. The increase in sweep gas flow from 2 to 8 L/min increased normalized CO2 elimination from 35 ± 5 to 41 ± 6 with 900 mL blood flow/min, whereas with lower blood flow rates, any increase was less effective, levelling out at 4 L sweep gas flow/min. The membrane lung with a surface area of 0.8m2 allowed a maximum normalized CO2 elimination rate of 101 ± 12 mL/min with increasing influence of sweep gas flow. The delta of normalized CO2 elimination increased from 4 ± 2 to 26 ± 7 mL/min with blood flow rates being increased from 300 to 1800 mL/min, respectively. CONCLUSIONS The influence of sweep gas flow on the CO2 removal capacity of ECCO2R systems depends predominantly on blood flow rate and membrane lung surface area. In this model, considerable CO2 removal occurred only with the larger membrane lung surface of 0.8m2 and when blood flow rates of ≥ 900 mL/min were used.
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Affiliation(s)
- 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
| | - 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
| | - Simone Schäfer
- 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
| | - Jonas de Moll
- 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
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Anders Larsson
- Hedenstierna Laboratory, Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - 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
| | - 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.
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Takahashi N, Nakada TA, Oda S. Efficient CO 2 removal using extracorporeal lung and renal assist device. J Artif Organs 2018; 21:427-434. [PMID: 29980955 DOI: 10.1007/s10047-018-1058-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 06/25/2018] [Indexed: 12/01/2022]
Abstract
We developed a novel system comprising acid infusion, membrane lung, and a continuous renal replacement therapy console for efficient CO2 removal at a low blood flow. To evaluate the new system, we used an ex vivo experimental model using swine blood. A liter of aliquoted blood adjusted to pH 7.25 and pCO2 65 mm Hg was mixed with acid (0, 10, or 20 mL of lactic or hydrochloric acid [1 mol/L]) and was immediately delivered to the system in a single pass. We collected blood samples at each point of the circuit and calculated the amount of CO2 eliminated by the membrane lung. The new system removed 13.2 ± 0.8, 32.0 ± 2.1, and 51.6 ± 3.7 mL/min of CO2 (with 0, 10, and 20 mEq/L of lactic acid) and 21.2 ± 1.2, 27.3 ± 0.3, and 42.0 ± 1.3 mL/min (with 0, 10, and 20 mEq/L of hydrochloric acid), respectively. The levels of lactate and Cl- ions for acid-base equilibrium were restored after continuous hemodiafiltration. Thus, the amount of CO2 eliminated by the membrane lung was 3.9 times higher with lactic acid and 2.0 times higher with hydrochloric acid compared with non-acid controls. In conclusion, this easy-to-setup CO2 removal system was safe, effective, and removed CO2 at a low blood flow.
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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.
| | - 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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Schneider TM, Bence T, Brettner F. "Awake" ECCO 2R superseded intubation in a near-fatal asthma attack. J Intensive Care 2017; 5:53. [PMID: 28808576 PMCID: PMC5549394 DOI: 10.1186/s40560-017-0247-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Near-fatal asthma attacks are life threatening events that often require mechanical ventilation. Extracorporeal carbon dioxide removal (ECCO2R) is, beside extracorporeal membrane oxygenation (ECMO), a well-established rescue option whenever ventilation gets to its limits. But there seems to be very rare experience with those techniques in avoiding mechanical ventilation in severe asthma attacks. CASE PRESENTATION A 67-year-old man with a near-fatal asthma attack deteriorated under non-invasive ventilation conditions. Beside pharmacological treatment, the intensivists decided to use an extracorporeal carbon dioxide removal system (ECCO2R) to avoid sedation and intubation. Within only a few hours, there was a breakthrough and the patient's status improved continuously. One and a half days later, weaning from ECCO2R was already completed. CONCLUSIONS The discussion deals with several advantages of extracorporeal lung support in acute asthma, the potential of avoiding intubation and sedation, as well as the benefits of a conscious and spontaneously breathing patient. Extracorporeal membrane oxygenation (ECMO) in general and ECCO2R in particular is a highly effective method for the treatment of an acute near-fatal asthma attack. Pathophysiological aspects favor the "awake" approach, without sedation, intubation, and mechanical ventilation. Therefore, experienced clinicians might consider "awake" ECCO2R in similar cases.
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Affiliation(s)
- Thomas-Michael Schneider
- Department of intensive care medicine, Krankenhaus Barmherzige Brueder Munich, Muenchen, Germany
| | - Tibor Bence
- Department of intensive care medicine, Krankenhaus Barmherzige Brueder Munich, Muenchen, Germany
| | - Franz Brettner
- Department of intensive care medicine, Krankenhaus Barmherzige Brueder Munich, Muenchen, Germany
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29
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Karagiannidis C, Strassmann S, Brodie D, Ritter P, Larsson A, Borchardt R, Windisch W. Impact of membrane lung surface area and blood flow on extracorporeal CO 2 removal during severe respiratory acidosis. Intensive Care Med Exp 2017; 5:34. [PMID: 28766276 PMCID: PMC5539069 DOI: 10.1186/s40635-017-0147-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 07/18/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Veno-venous extracorporeal CO2 removal (vv-ECCO2R) is increasingly being used in the setting of acute respiratory failure. Blood flow rates through the device range from 200 ml/min to more than 1500 ml/min, and the membrane surface areas range from 0.35 to 1.3 m2. The present study in an animal model with similar CO2 production as an adult patient was aimed at determining the optimal membrane lung surface area and technical requirements for successful vv-ECCO2R. METHODS Four different membrane lungs, with varying lung surface areas of 0.4, 0.8, 1.0, and 1.3m2 were used to perform vv-ECCO2R in seven anesthetized, mechanically ventilated, pigs with experimentally induced severe respiratory acidosis (pH 7.0-7.1) using a 20Fr double-lumen catheter with a sweep gas flow rate of 8 L/min. During each experiment, the blood flow was increased stepwise from 250 to 1000 ml/min. RESULTS Amelioration of severe respiratory acidosis was only feasible when blood flow rates from 750 to 1000 ml/min were used with a membrane lung surface area of at least 0.8 m2. Maximal CO2 elimination was 150.8 ml/min, with pH increasing from 7.01 to 7.30 (blood flow 1000 ml/min; membrane lung 1.3 m2). The membrane lung with a surface of 0.4 m2 allowed a maximum CO2 elimination rate of 71.7 mL/min, which did not result in the normalization of pH, even with a blood flow rate of 1000 ml/min. Also of note, an increase of the surface area above 1.0 m2 did not result in substantially higher CO2 elimination rates. The pressure drop across the oxygenator was considerably lower (<10 mmHg) in the largest membrane lung, whereas the smallest revealed a pressure drop of more than 50 mmHg with 1000 ml blood flow/min. CONCLUSIONS In this porcine model, vv-ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 ml/min, with a membrane lung surface of at least 0.8 m2. In contrast, low blood flow rates (250-500 ml/min) were not sufficient to completely correct severe respiratory acidosis, irrespective of the surface area of the membrane lung being used. The converse was also true, low surface membrane lungs (0.4 m2) were not capable of completely correcting severe respiratory acidosis across the range of blood flows used in this study.
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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
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York City, NY, USA
| | | | - Anders Larsson
- Hedenstierna Laboratory, Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - 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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30
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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31
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Redwan B, Biancosino C, Giebel F, Woebker G, Eberlein M, Bölükbas S. Perioperative single-site veno-venous extracorporeal CO 2 removal for minimally invasive giant bulla resection. Perfusion 2017. [PMID: 28621588 DOI: 10.1177/0267659117716758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Giant pulmonary bullae are rare and surgical management of patients with severe emphysema and advanced chronic obstructive lung disease (COPD) presenting with giant bullae can be very challenging. Previously, perioperative, two-site, high-flow, veno-venous extracorporeal membrane oxygenation (ECMO) was successfully utilized during giant bulla resection. Here we report the perioperative application of single-site, low-flow extracorporeal CO2 removal (ECCO2R) for minimally invasive thoracoscopic giant bulla resection. This approach of low-flow, veno-venous ECCO2R, which is less invasive than conventional ECLS approaches, has enabled the safe performance of surgery and facilitated protective intraoperative single-lung ventilation while avoiding possible complications of aggressive mechanical ventilation.
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Affiliation(s)
- Bassam Redwan
- 1 Department of Thoracic Surgery, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
| | - Christian Biancosino
- 1 Department of Thoracic Surgery, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
| | - Felix Giebel
- 2 Intensive Care Medicine, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
| | - Gabriele Woebker
- 2 Intensive Care Medicine, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
| | - Michael Eberlein
- 3 Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Servet Bölükbas
- 1 Department of Thoracic Surgery, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
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32
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May AG, Sen A, Cove ME, Kellum JA, Federspiel WJ. Extracorporeal CO 2 removal by hemodialysis: in vitro model and feasibility. Intensive Care Med Exp 2017; 5:20. [PMID: 28390055 PMCID: PMC5383917 DOI: 10.1186/s40635-017-0132-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/30/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Critically ill patients with acute respiratory distress syndrome and acute exacerbations of chronic obstructive pulmonary disease often develop hypercapnia and require mechanical ventilation. Extracorporeal carbon dioxide removal can manage hypercarbia by removing carbon dioxide directly from the bloodstream. Respiratory hemodialysis uses traditional hemodialysis to remove CO2 from the blood, mainly as bicarbonate. In this study, Stewart's approach to acid-base chemistry was used to create a dialysate that would maintain blood pH while removing CO2 as well as determine the blood and dialysate flow rates necessary to remove clinically relevant CO2 volumes. METHODS Bench studies were performed using a scaled down respiratory hemodialyzer in bovine or porcine blood. The scaling factor for the bench top experiments was 22.5. In vitro dialysate flow rates ranged from 2.2 to 24 mL/min (49.5-540 mL/min scaled up) and blood flow rates were set at 11 and 18.7 mL/min (248-421 mL/min scaled up). Blood inlet CO2 concentrations were set at 50 and 100 mmHg. RESULTS Results are reported as scaled up values. The CO2 removal rate was highest at intermittent hemodialysis blood and dialysate flow rates. At an inlet pCO2 of 50 mmHg, the CO2 removal rate increased from 62.6 ± 4.8 to 77.7 ± 3 mL/min when the blood flow rate increased from 248 to 421 mL/min. At an inlet pCO2 of 100 mmHg, the device was able to remove up to 117.8 ± 3.8 mL/min of CO2. None of the test conditions caused the blood pH to decrease, and increases were ≤0.08. CONCLUSIONS When the bench top data is scaled up, the system removes a therapeutic amount of CO2 standard intermittent hemodialysis flow rates. The zero bicarbonate dialysate did not cause acidosis in the post-dialyzer blood. These results demonstrate that, with further development, respiratory hemodialysis can be a minimally invasive extracorporeal carbon dioxide removal treatment option.
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Affiliation(s)
- Alexandra G May
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, PA, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ayan Sen
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA.,Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Matthew E Cove
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA.,Division of Respiratory and Critical Care Medicine, Department of Medicine, National University of Singapore, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - John A Kellum
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - William J Federspiel
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, PA, USA. .,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA. .,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
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33
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Plein T, Thiebes AL, Finocchiaro N, Hesselmann F, Schmitz-Rode T, Jockenhoevel S, Cornelissen CG. Towards a Biohybrid Lung Assist Device: N-Acetylcysteine Reduces Oxygen Toxicity and Changes Endothelial Cells' Morphology. Cell Mol Bioeng 2016; 10:153-161. [PMID: 31719857 DOI: 10.1007/s12195-016-0473-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 11/21/2016] [Indexed: 11/28/2022] Open
Abstract
The development of an endothelialized membrane oxygenator requires solution strategies combining the knowledge of oxygenators with endothelial cells' biology. Since it is well known that exposing cells towards pure oxygen causes oxidative stress, this aspect has to be taken into account in the development of a biohybrid oxygenator system. N-Acetylcysteine (NAC) is known for its antioxidant properties in cells. We tested its applicability for the development of an endothelialized oxygenator model. Cultivating human umbilical vein derived endothelial cells (HUVEC) up to 6 days with increasing concentrations of NAC from 1 to 30 mM revealed NAC toxicity at concentrations from 20 mM. Cell density clearly decreased after radical oxygen species exposure in non-NAC pretreated cells compared to 20 mM NAC precultured HUVEC after 3 and 6 days. Also the survival rate after ROS treatment could be restored by incubation with NAC from 15 to 25 mM for all time points. NAC treated cells changed their morphology from typical endothelial cells' cobblestone pattern to a fusiform, elongated configuration. Transformed cells were still positive for typical endothelial cell markers. Our present results show the potential of NAC for the protection of an endothelial cell layer in an endothelialized membrane oxygenator due to its antioxidative properties. Moreover, NAC induces a morphological change in HUVEC similar to dynamic cultivation procedures.
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Affiliation(s)
- Tobias Plein
- 1Department of Biohybrid & Medical Textiles (BioTex) at AME-Helmholtz Institute for Biomedical Engineering, ITA-Institut für Textiltechnik, RWTH Aachen University, Pauwelsstraße 20, 52074 Aachen, Germany.,4Aachen-Maastricht-Institute for Biobased Materials (AMIBM), Brightlands Chemelot Campus, Maastricht University, Urmonderbaan 22, 6167 RD Geleen, The Netherlands
| | - Anja Lena Thiebes
- 1Department of Biohybrid & Medical Textiles (BioTex) at AME-Helmholtz Institute for Biomedical Engineering, ITA-Institut für Textiltechnik, RWTH Aachen University, Pauwelsstraße 20, 52074 Aachen, Germany.,4Aachen-Maastricht-Institute for Biobased Materials (AMIBM), Brightlands Chemelot Campus, Maastricht University, Urmonderbaan 22, 6167 RD Geleen, The Netherlands
| | - Nicole Finocchiaro
- 1Department of Biohybrid & Medical Textiles (BioTex) at AME-Helmholtz Institute for Biomedical Engineering, ITA-Institut für Textiltechnik, RWTH Aachen University, Pauwelsstraße 20, 52074 Aachen, Germany.,4Aachen-Maastricht-Institute for Biobased Materials (AMIBM), Brightlands Chemelot Campus, Maastricht University, Urmonderbaan 22, 6167 RD Geleen, The Netherlands
| | - Felix Hesselmann
- 2Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Pauwelsstraße 20, 52074 Aachen, Germany
| | - Thomas Schmitz-Rode
- 1Department of Biohybrid & Medical Textiles (BioTex) at AME-Helmholtz Institute for Biomedical Engineering, ITA-Institut für Textiltechnik, RWTH Aachen University, Pauwelsstraße 20, 52074 Aachen, Germany.,2Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Pauwelsstraße 20, 52074 Aachen, Germany.,4Aachen-Maastricht-Institute for Biobased Materials (AMIBM), Brightlands Chemelot Campus, Maastricht University, Urmonderbaan 22, 6167 RD Geleen, The Netherlands
| | - Stefan Jockenhoevel
- 1Department of Biohybrid & Medical Textiles (BioTex) at AME-Helmholtz Institute for Biomedical Engineering, ITA-Institut für Textiltechnik, RWTH Aachen University, Pauwelsstraße 20, 52074 Aachen, Germany.,4Aachen-Maastricht-Institute for Biobased Materials (AMIBM), Brightlands Chemelot Campus, Maastricht University, Urmonderbaan 22, 6167 RD Geleen, The Netherlands
| | - Christian G Cornelissen
- 1Department of Biohybrid & Medical Textiles (BioTex) at AME-Helmholtz Institute for Biomedical Engineering, ITA-Institut für Textiltechnik, RWTH Aachen University, Pauwelsstraße 20, 52074 Aachen, Germany.,3Department for Internal Medicine - Section for Pneumology, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany.,4Aachen-Maastricht-Institute for Biobased Materials (AMIBM), Brightlands Chemelot Campus, Maastricht University, Urmonderbaan 22, 6167 RD Geleen, The Netherlands
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Abstract
In the past the only option for the treatment of respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease (aeCOPD) was invasive mechanical ventilation. In recent decades, the potential for extracorporeal carbon dioxide (CO2) removal has been realized. We review the various types of extracorporeal CO2 removal, outline the optimal use of these therapies for aeCOPD, and make suggestions for future controlled trials. We also describe the advantages and requirements for an ideal long-term ambulatory CO2 removal system for palliation of COPD.
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Affiliation(s)
- John M Trahanas
- 1 Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA.,2 Department of Surgery, Section of General Surgery, Columbia University Medical Center, New York, NY, USA
| | - William R Lynch
- 1 Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA.,3 Department of Surgery, Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert H Bartlett
- 1 Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
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35
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Liu Z, Duarte RV, Bayliss S, Bramley G, Cummins C. Adverse effects of extracorporeal carbon dioxide removal ( ECCO2R) for acute respiratory failure: a systematic review protocol. Syst Rev 2016; 5:98. [PMID: 27267600 PMCID: PMC4897878 DOI: 10.1186/s13643-016-0270-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/25/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The extracorporeal membrane carbon dioxide removal (ECCO2R) system is primarily designed for the purpose of removing CO2 from the body for patients with potentially reversible severe acute hypercapnic respiratory failure or being considered for lung transplantation. Systematic reviews have focused on the effectiveness of ECCO2R. To the author's best knowledge, this is the first systematic review to focus on the adverse effects of this procedure. METHODS We will conduct a systematic review of procedure-related adverse effects of ECCO2R systems. A high sensitivity search strategy will be employed in Cochrane Library, MEDLINE, EMBASE, Web of Science and product regulatory databases and ongoing trial registers to identify citations. Reference lists of relevant studies and grey literature will also be searched. Screening of the results will be performed by two reviewers independently using pre-defined inclusion and exclusion criteria. Clinical trials and observational studies will be included. Data will be extracted using a purposefully developed extraction form. Appropriateness for statistical pooling of the results will be determined and carried out if heterogeneity is low to moderate. The GRADE framework will be employed to grade the overall quality of the evidence. DISCUSSION In the UK, the current access to the use of ECCO2R is possible only with special arrangements for clinical governance, consent and for audit or research. Current evidence on ECCO2R suggests that there are a number of well-recognised complications which vary greatly across studies. This systematic review will consolidate the existing knowledge on adverse effects resulting from the use of ECCO2R. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023503 .
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Affiliation(s)
- Zulian Liu
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Room 137, B15 2TT, Birmingham, UK
| | - Rui V Duarte
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Room 137, B15 2TT, Birmingham, UK
| | - Sue Bayliss
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Room 137, B15 2TT, Birmingham, UK
| | - George Bramley
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Room 137, B15 2TT, Birmingham, UK
| | - Carole Cummins
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Room 137, B15 2TT, Birmingham, UK.
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36
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Brenner K, Abrams DC, Agerstrand CL, Brodie D. Extracorporeal carbon dioxide removal for refractory status asthmaticus: experience in distinct exacerbation phenotypes. Perfusion 2013; 29:26-8. [PMID: 23842616 DOI: 10.1177/0267659113494964] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) may be indicated for refractory status asthmaticus when severe dynamic hyperinflation or life-threatening respiratory acidosis persists despite optimal medical and ventilator management. Most prior reports describe the application of ECCO2R to rapid-onset asthma exacerbation, requiring a short duration of extracorporeal support. We report two patients with refractory status asthmaticus managed with ECCO2R, emphasizing the use of modern extracorporeal technology, cannulation technique and management protocols, which may improve the risk-to-benefit profile of this strategy. This report highlights the challenges in managing patients with distinct asthma exacerbation phenotypes. The potential need for prolonged device support may alter provider expectations and offers a new perspective of the role of ECCO2R for status asthmaticus.
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Affiliation(s)
- K Brenner
- Columbia University College of Physicians and Surgeons, Division of Pulmonary, Allergy and Critical Care, New York, USA
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