Daily use of extracorporeal CO2 removal in a critical care unit: indications and results

Hadrien Winiszewski,Nicolas Belin,Jean-Christophe Navellou,Guylaine Labro,François Belon,Claire Chaignat,Cyrille Patry,Elise David,Gilles Capellier,Cecilia Clermont,Gaël Piton,François Aptel

doi:10.1186/s40560-018-0304-x

Abstract

BackgroundWhile outcome improvement with extracorporeal CO2 removal (ECCO2R) is not demonstrated, a strong pathophysiological rational supports its use in the setting of acute respiratory distress syndrome (ARDS) and COPD exacerbation. We aimed to describe our single-center experience of ECCO2R indications and outcome.MethodsPatients treated with ECCO2R in our medial ICU, from March 2014 to November 2017, were retrospectively enrolled. Primary end point was evolution of ventilator settings during the two first days following ECCO2R start.ResultsThirty-three patients received ECCO2R. Seventeen were managed with Hemolung®, 10 with Prismalung®, 4 with ILA®, and 2 with Cardiohelp®. Indications for ECCO2R were mild or moderate ARDS (n = 16), COPD exacerbation (n = 11), or uncontrolled hypercapnia due to other causes (n = 6). Four patients were not intubated at the time of ECCO2R start. Median duration of ECCO2R treatment was 7 days [5–10]. In ARDS patients, between baseline and day 2, median tidal volume and driving pressure decreased from 5.3 [4.4–5.9] mL/kg and 10 [8–15] to 3.8 [3.3–4.1] mL/kg and 9 [8–11], respectively. Prone positioning was performed in 10 of the 16 patients, without serious adverse event. In COPD patients, between baseline and day 2, median ventilation minute and PaCO2 decreased significantly from respectively 7.6 [6.6–8.7] L/min and 9.4 [8.4–10.1] kPa to 5.8 [4.9–6.2] L/min and 6 [5.3–6.8] kPa. Four out of 11 COPD patients were extubated while on ECCO2R. Device thrombosis occurred in 5 patients (15%). Hemolysis was documented in 16 patients (48%). One patient died of intracranial hemorrhage, while on ECCO2R. Twenty-four patients were discharged from ICU alive. Twenty-eight day mortality was 31% in ARDS, 9% in COPD patients, and 50% in other causes of refractory hypercapnic respiratory failure.ConclusionECCO2R was useful to apply ultra-protective ventilation among ARDS patients and improved PaCO2, pH, and minute ventilation in COPD patients.

Highlights

While outcome improvement with extracorporeal CO2 removal (ECCO2R) is not demonstrated, a strong pathophysiological rational supports its use in the setting of acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD) exacerbation
In the setting of acute respiratory distress syndrome (ADRS), it is well established that low tidal volume and limited plateau pressure are associated with better survival [1]
We have found that ECCO2R system allowed ultra-protective ventilation in ARDS patients by decreasing tidal volume

Summary

Introduction

While outcome improvement with extracorporeal CO2 removal (ECCO2R) is not demonstrated, a strong pathophysiological rational supports its use in the setting of acute respiratory distress syndrome (ARDS) and COPD exacerbation. There is not yet enough data to make strong recommendation about extracorporeal CO2 removal (ECCO2R) devices, as the benefits-risks ratio is not established. In the setting of acute respiratory distress syndrome (ADRS), it is well established that low tidal volume and limited plateau pressure are associated with better survival [1]. Recent guidelines recommend to aim for tidal volume of 4–8 mL/kg of predicted body weight (PBW) and plateau pressure less than 30 cmH2O [2]. Because some data suggest that decreasing plateau pressure, even if it is < 30 cmH2O, might be associated with reduced mortality [4], using tidal volume lower than 6 mL/kg has been proposed [5]. Three studies have showed the feasibility and safety of ultra-protective ventilation, with 4 mL/kg

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