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Extracorporeal CO2 removal.
Contrib Nephrol. 2010; 165:185-196.CN

Abstract

The extracorporeal carbon dioxide removal (ECCO(2)R) concept, used as an integrated tool with conventional ventilation, plays a role in adjusting respiratory acidosis consequent to tidal volume (Vt) reduction in a protective ventilation setting. This concept arises from the extracorporeal membrane oxygenation (ECMO) experience. Kolobow and Gattinoni were the first to introduce extracorporeal support, with the intent to separate carbon dioxide removal from oxygen uptake; they hypothesized that to allow the lung to 'rest' oxygenation via mechanical ventilation could be dissociated from decarboxylation via extracorporeal carbon dioxide removal. Carbon dioxide is removed by a pump-driven modified ECMO machine with veno-venous bypass, while oxygenation is accomplished by high levels of positive end-expiratory pressure, with a respiratory rate of 3-5 breaths/min. The focus was that, in case of acute respiratory failure, CO(2) extraction facilitates a reduction in ventilatory support and oxygenation is maintained by simple diffusion across the patient's alveoli, called 'apneic oxygenation'. Concerns have been raised regarding the standard use of extracorporeal support because of the high incidence of serious complications: hemorrhage; hemolysis, and neurological impairments. Due to the negative results of a clinical trial, the extensive resources required and the high incidence of side effects, low frequency positive pressure ventilation ECCO(2)R was restricted to a 'rescue' therapy for the most severe case of acute respiratory distress syndrome (ARDS). Technological improvement led to the implementation of two different CO(2) removal approaches: the iLA called 'pumpless arteriovenous ECMO' and the veno-venous ECCO(2)R. They enable consideration of extracorporeal support as something more than mere rescue therapy; both of them are indicated in more protective ventilation settings in case of severe ARDS, and as a support to the spontaneous breathing/lung function in bridge to lung transplant. The future development of more and more efficient devices capable of removing a substantial amount of carbon dioxide production (30-100%) with blood flows of 250-500 ml/min is foreseeable. Moreover, in the future ARDS management should include a minimally invasive ECCO(2)R circuit associated with noninvasive ventilation. This would embody the modern mechanical ventilation philosophy: avoid tracheal tubes; minimize sedation, and prevent ventilator-induced acute lung injury and nosocomial infections.

Authors

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Pub Type(s)

Journal Article

Language

eng

PubMed ID

20427969

Citation

Terragni, Pier Paolo, et al. "Extracorporeal CO2 Removal." Contributions to Nephrology, vol. 165, 2010, pp. 185-196.
Terragni PP, Birocco A, Faggiano C, et al. Extracorporeal CO2 removal. Contrib Nephrol. 2010;165:185-196.
Terragni, P. P., Birocco, A., Faggiano, C., & Ranieri, V. M. (2010). Extracorporeal CO2 removal. Contributions to Nephrology, 165, 185-196. https://doi.org/10.1159/000313758
Terragni PP, et al. Extracorporeal CO2 Removal. Contrib Nephrol. 2010;165:185-196. PubMed PMID: 20427969.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Extracorporeal CO2 removal. AU - Terragni,Pier Paolo, AU - Birocco,Alberto, AU - Faggiano,Chiara, AU - Ranieri,V Marco, Y1 - 2010/04/20/ PY - 2010/4/30/entrez PY - 2010/4/30/pubmed PY - 2010/7/8/medline SP - 185 EP - 196 JF - Contributions to nephrology JO - Contrib Nephrol VL - 165 N2 - The extracorporeal carbon dioxide removal (ECCO(2)R) concept, used as an integrated tool with conventional ventilation, plays a role in adjusting respiratory acidosis consequent to tidal volume (Vt) reduction in a protective ventilation setting. This concept arises from the extracorporeal membrane oxygenation (ECMO) experience. Kolobow and Gattinoni were the first to introduce extracorporeal support, with the intent to separate carbon dioxide removal from oxygen uptake; they hypothesized that to allow the lung to 'rest' oxygenation via mechanical ventilation could be dissociated from decarboxylation via extracorporeal carbon dioxide removal. Carbon dioxide is removed by a pump-driven modified ECMO machine with veno-venous bypass, while oxygenation is accomplished by high levels of positive end-expiratory pressure, with a respiratory rate of 3-5 breaths/min. The focus was that, in case of acute respiratory failure, CO(2) extraction facilitates a reduction in ventilatory support and oxygenation is maintained by simple diffusion across the patient's alveoli, called 'apneic oxygenation'. Concerns have been raised regarding the standard use of extracorporeal support because of the high incidence of serious complications: hemorrhage; hemolysis, and neurological impairments. Due to the negative results of a clinical trial, the extensive resources required and the high incidence of side effects, low frequency positive pressure ventilation ECCO(2)R was restricted to a 'rescue' therapy for the most severe case of acute respiratory distress syndrome (ARDS). Technological improvement led to the implementation of two different CO(2) removal approaches: the iLA called 'pumpless arteriovenous ECMO' and the veno-venous ECCO(2)R. They enable consideration of extracorporeal support as something more than mere rescue therapy; both of them are indicated in more protective ventilation settings in case of severe ARDS, and as a support to the spontaneous breathing/lung function in bridge to lung transplant. The future development of more and more efficient devices capable of removing a substantial amount of carbon dioxide production (30-100%) with blood flows of 250-500 ml/min is foreseeable. Moreover, in the future ARDS management should include a minimally invasive ECCO(2)R circuit associated with noninvasive ventilation. This would embody the modern mechanical ventilation philosophy: avoid tracheal tubes; minimize sedation, and prevent ventilator-induced acute lung injury and nosocomial infections. SN - 1662-2782 UR - https://www.unboundmedicine.com/medline/citation/20427969/Extracorporeal_CO2_removal_ L2 - https://www.karger.com?DOI=10.1159/000313758 DB - PRIME DP - Unbound Medicine ER -