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Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress sindrome.
Crit Care. 2016 Feb 10; 20:36.CC

Abstract

BACKGROUND

Mechanical ventilation with a tidal volume (VT) of 6 mL/kg/predicted body weight (PBW), to maintain plateau pressure (Pplat) lower than 30 cmH2O, does not completely avoid the risk of ventilator induced lung injury (VILI). The aim of this study was to evaluate safety and feasibility of a ventilation strategy consisting of very low VT combined with extracorporeal carbon dioxide removal (ECCO2R).

METHODS

In fifteen patients with moderate ARDS, VT was reduced from baseline to 4 mL/kg PBW while PEEP was increased to target a plateau pressure--(Pplat) between 23 and 25 cmH2O. Low-flow ECCO2R was initiated when respiratory acidosis developed (pH < 7.25, PaCO2 > 60 mmHg). Ventilation parameters (VT, respiratory rate, PEEP), respiratory compliance (CRS), driving pressure (DeltaP = VT/CRS), arterial blood gases, and ECCO2R system operational characteristics were collected during the period of ultra-protective ventilation. Patients were weaned from ECCO2R when PaO2/FiO2 was higher than 200 and could tolerate conventional ventilation settings. Complications, mortality at day 28, need for prone positioning and extracorporeal membrane oxygenation, and data on weaning from both MV and ECCO2R were also collected.

RESULTS

During the 2 h run in phase, VT reduction from baseline (6.2 mL/kg PBW) to approximately 4 mL/kg PBW caused respiratory acidosis (pH < 7.25) in all fifteen patients. At steady state, ECCO2R with an average blood flow of 435 mL/min and sweep gas flow of 10 L/min was effective at correcting pH and PaCO2 to within 10 % of baseline values. PEEP values tended to increase at VT of 4 mL/kg from 12.2 to 14.5 cmH2O, but this change was not statistically significant. Driving pressure was significantly reduced during the first two days compared to baseline (from 13.9 to 11.6 cmH2O; p < 0.05) and there were no significant differences in the values of respiratory system compliance. Rescue therapies for life threatening hypoxemia such as prone position and ECMO were necessary in four and two patients, respectively. Only two study-related adverse events were observed (intravascular hemolysis and femoral catheter kinking).

CONCLUSIONS

The low-flow ECCO2R system safely facilitates a low volume, low pressure ultra-protective mechanical ventilation strategy in patients with moderate ARDS.

Authors+Show Affiliations

Department of Anesthesia and Critical Care - AOU Città della Salute e della Scienza di Torino, University of Turin, Corso Dogliotti 14, 10126, Torino, Italy. vito.fanelli@unito.it.Dipartimento di Anestesia e Rianimazione, Ospedale Policlinico Umberto I, Sapienza Università di Roma, Rome, Italy.Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain.Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany.Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany.ALung Technologies, Pittsburgh, USA.Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain.Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain.Department of Anesthesia and Critical Care - AOU Città della Salute e della Scienza di Torino, University of Turin, Corso Dogliotti 14, 10126, Torino, Italy.Department of Anesthesia and Critical Care - AOU Città della Salute e della Scienza di Torino, University of Turin, Corso Dogliotti 14, 10126, Torino, Italy.Service de Réanimation Médicale, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

26861596

Citation

Fanelli, Vito, et al. "Feasibility and Safety of Low-flow Extracorporeal Carbon Dioxide Removal to Facilitate Ultra-protective Ventilation in Patients With Moderate Acute Respiratory Distress Sindrome." Critical Care (London, England), vol. 20, 2016, p. 36.
Fanelli V, Ranieri MV, Mancebo J, et al. Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress sindrome. Crit Care. 2016;20:36.
Fanelli, V., Ranieri, M. V., Mancebo, J., Moerer, O., Quintel, M., Morley, S., Moran, I., Parrilla, F., Costamagna, A., Gaudiosi, M., & Combes, A. (2016). Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress sindrome. Critical Care (London, England), 20, 36. https://doi.org/10.1186/s13054-016-1211-y
Fanelli V, et al. Feasibility and Safety of Low-flow Extracorporeal Carbon Dioxide Removal to Facilitate Ultra-protective Ventilation in Patients With Moderate Acute Respiratory Distress Sindrome. Crit Care. 2016 Feb 10;20:36. PubMed PMID: 26861596.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress sindrome. AU - Fanelli,Vito, AU - Ranieri,Marco V, AU - Mancebo,Jordi, AU - Moerer,Onnen, AU - Quintel,Michael, AU - Morley,Scott, AU - Moran,Indalecio, AU - Parrilla,Francisco, AU - Costamagna,Andrea, AU - Gaudiosi,Marco, AU - Combes,Alain, Y1 - 2016/02/10/ PY - 2015/09/28/received PY - 2016/01/31/accepted PY - 2016/2/11/entrez PY - 2016/2/11/pubmed PY - 2016/9/27/medline SP - 36 EP - 36 JF - Critical care (London, England) JO - Crit Care VL - 20 N2 - BACKGROUND: Mechanical ventilation with a tidal volume (VT) of 6 mL/kg/predicted body weight (PBW), to maintain plateau pressure (Pplat) lower than 30 cmH2O, does not completely avoid the risk of ventilator induced lung injury (VILI). The aim of this study was to evaluate safety and feasibility of a ventilation strategy consisting of very low VT combined with extracorporeal carbon dioxide removal (ECCO2R). METHODS: In fifteen patients with moderate ARDS, VT was reduced from baseline to 4 mL/kg PBW while PEEP was increased to target a plateau pressure--(Pplat) between 23 and 25 cmH2O. Low-flow ECCO2R was initiated when respiratory acidosis developed (pH < 7.25, PaCO2 > 60 mmHg). Ventilation parameters (VT, respiratory rate, PEEP), respiratory compliance (CRS), driving pressure (DeltaP = VT/CRS), arterial blood gases, and ECCO2R system operational characteristics were collected during the period of ultra-protective ventilation. Patients were weaned from ECCO2R when PaO2/FiO2 was higher than 200 and could tolerate conventional ventilation settings. Complications, mortality at day 28, need for prone positioning and extracorporeal membrane oxygenation, and data on weaning from both MV and ECCO2R were also collected. RESULTS: During the 2 h run in phase, VT reduction from baseline (6.2 mL/kg PBW) to approximately 4 mL/kg PBW caused respiratory acidosis (pH < 7.25) in all fifteen patients. At steady state, ECCO2R with an average blood flow of 435 mL/min and sweep gas flow of 10 L/min was effective at correcting pH and PaCO2 to within 10 % of baseline values. PEEP values tended to increase at VT of 4 mL/kg from 12.2 to 14.5 cmH2O, but this change was not statistically significant. Driving pressure was significantly reduced during the first two days compared to baseline (from 13.9 to 11.6 cmH2O; p < 0.05) and there were no significant differences in the values of respiratory system compliance. Rescue therapies for life threatening hypoxemia such as prone position and ECMO were necessary in four and two patients, respectively. Only two study-related adverse events were observed (intravascular hemolysis and femoral catheter kinking). CONCLUSIONS: The low-flow ECCO2R system safely facilitates a low volume, low pressure ultra-protective mechanical ventilation strategy in patients with moderate ARDS. SN - 1466-609X UR - https://www.unboundmedicine.com/medline/citation/26861596/Feasibility_and_safety_of_low_flow_extracorporeal_carbon_dioxide_removal_to_facilitate_ultra_protective_ventilation_in_patients_with_moderate_acute_respiratory_distress_sindrome_ L2 - https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1211-y DB - PRIME DP - Unbound Medicine ER -