Extra Corporeal Carbon Dioxide Removal

Gavin Denton gives a great breakdown on some of the recent papers on Extra Corporeal Carbon Dioxide Removal. He analyses the papers in some detail. A long post….but worth the time I think. Thanks Gavin.

Three part question.

In patients with chronic obstructive airway disease and hypercapneic acidosis, who are failing non-invasive ventilation, does extra corporeal carbon dioxide removal  compared to non-invasive ventilation alone, reduce the need for invasive mechanical ventilation?

 

Clinical scenario.

A patient arrives in your resuscitation room in respiratory distress and a background of chronic obstructive pulmonary disease. After administering standard medical therapy, and controlled oxygen the patient remains in respiratory acidosis. Non-invasive ventilation is instituted, but the patient continues to be acidotic and deteriorating. The patient is prepared for rapid sequence induction and ventilation, but you wonder if there is an alternative.

 

Background.

Invasive mechanical ventilation (IMV) is the use of a machine to inflate the lungs via an artificial airway placed in the trachea. The therapy provides support for breathing in the critically ill patient when the lung tissue and respiratory muscles are failing. IMV involves using an anaesthetic and muscle relaxants to place the breathing tube in the trachea, and continuous sedation to stop the patient from pulling the tube out and allowing the machine to take over the action of breathing. Respiratory failure occurs when the lungs and the neuromuscular system that controls them fail to provide sufficient oxygen to the pulmonary blood supply, and/or remove carbon dioxide from the blood. There are a multitude of causes of respiratory failure, but the supportive techniques used follow common themes. Despite IMV being a cornerstone of supporting the critically ill patient, the side effects of this therapy can lead to worsening damage to the lungs and to other essential organs by triggering inflammation. The acute respiratory distress syndrome network (Acute Respiratory Distress Syndrome Network (ARDSNET), 2000) established that in patients with acute respiratory distress syndrome, the larger the breath and the higher the pressure delivered by a ventilator, the more likely the patient would die. This study established the practice of using smaller breaths and lower pressure in patients with severe breathing failure requiring IMV. In many patients, this approach causes large rises in carbon dioxide in the blood, raising acid levels and negatively affecting the body’s ability to maintain homeostasis. Extra corporeal carbon dioxide removal is a method of passing blood through a filter which removes carbon dioxide and returns it to the body, bypassing the need for fully functioning lungs. This allows IMV to be used more gently and reduce the risk of causing further lung damage.

 

Another form of respiratory support is non-invasive ventilation (NIV). This is a method of pushing more air into the lungs through a tight-fitting face mask. It is used to make breathing easier and to increase removal of carbon dioxide. In patients with certain types of breathing failure, NIV significantly reduces the need for IMV (Ram et al, 2004). However, some patients fail to respond to this therapy and therefore need IMV, consequently, they are less likely to survive (Chandra et al, 2012). The primary problem for these patients is the inability to remove carbon dioxide. Therefore, extra corporeal carbon dioxide removal may be of benefit where patients fail to respond to NIV.

Author, date and countryPatient groupStudy type (level of evidence)OutcomesKey resultsStudy Weaknesses
Burki et al, 2013.• Group 1 N=7 COPD patients at risk of NIV failure.
• Group 2 N=2 failure to wean from NIV.
• Group 3 N=11 patients that had failed to wean from IMV.
• The whole patient group had COPD exacerbation as the primary diagnosis.
• This study used VV ECCO2R (Hemolung).
Case series (N=20).• The paper describes a pilot study in the use of ECCO2R in patients in various states of hypercapneic respiratory failure.
• The emphasis of the study was of feasibility and safety.
• No clear primary or secondary outcomes or objectives are stated.
• Group 1. All patients avoided IMV. 3 died within 30 days of ECCO2R cessation. One patient spent less than 30min of ECCO2R as the catheter clotted. 6 patients experienced reduction in dyspnea, increased pH and reduced pCO2. 1 patient was able to stop NIV while on ECCO2R.
• Group 2. One patient was able to stop NIV while on ECCO2R the other was able to have reduced support. Both experienced reduced dyspnea scores and improved pCO2, and pH. Both patients were alive at 30 days post ECCO2R on intermittent NIV.
• Group 1 and 2, decrease in pCO2 was statistically significant (p value .003). The increase in pH was also statistically significant (p value .002)
• ECCO2R was able improve pCO2, and pH in patients receiving NIV and suffering a COPD exacerbation who appeared to be failing NIV therapy.
• Reduced dyspnea scores following ECCO2R.
• One patient died from retroperitoneal haemorrhage as a result of the venous catheterisation procedure. One pneumothorax also occurred.
• Apart from the one death through haemorrhage, bleeding episodes were related to anticoagulation.
• The inherent biases of a case series study design.
• Exclusion criteria are not stated.
• No data on the number of patients screened, or excluded or reasons for exclusions is available.
• No information was provided regarding COPD treatment, such as steroid, nebuliser and antibiotic therapy.
• There are no pre-defined outcome measures stated in the introduction or methods section. No primary or secondary outcomes are stated prior to the results section.
• First author is a consultant and medical director for ALung, who make the Hemolung machine.
• A number of ALung employees provided editorial assistance and data inspection.
• It is not made clear in this paper, but Lund & Federspiel (2013) claim that this study was part of data collection for European Union regulatory application process (they are both Alung employees)
• The study population is too mixed, the combination of patients in receipt of NIV and IMV makes interpretation difficult. This study a best presents a proof of concept..
Del Sorbo et al, 2015.• Case patients were had an exacerbation of COPD in receipt of NIV and were deemed at risk of failure to respond toNIV. Matched controls.
• Control patients were taken from data of previous studies at the same institution and were included if they fitted the same inclusion criteria for ECCO2R.
• This study used VV ECCO2R.
Case and historical control.

Cases N=25.

Historical matched controls N=21
Population focus specifically on patients with COPD and hypercapneic respiratory failure deemed at risk of failing NIV. Very clearly stated primary endpoint of 28 day prevalence of intubation in the case group. Study also aimed to look at safety of ECCO2R.• Significant difference in pH and pCO2 between groups one hour post ECCO2R, 21% difference in pCO2 (p value .0003 for pH and .012 for pCO2),
• The effect of the above changes lead to a difference in respiratory rate of 22% between groups after one hour of ECCO2R.
• 12% intubation in the ECCO2R + NIV group vs 33% in the NIV. ARR of 21%, RR 64%. NNT 4.6.
• Hospital mortality 8% rate ECCO2R + NIV group vs 33% in the NIV group. ARR eduction of 30% and RRR of 79%. OR 0.14. NNT 3.3.
• No difference in length of hospital stay.
• 52% complications from ECCO2R, the most serious being a retroperitoneal haemotoma. All patients with ECCO2R that were intubated were related to the failure of the ECCO2R system. These were largely due to clots in the ECCO2R system and the development of respiratory acidosis.
• Reduction in the risk of need for IMV was statistically significant with a p value of .47, and a narrow confidence interval of 0.07-0.98.
• Differences in hospital morality was statistically significant p value .034, wide CI.
• Could the excluded patients where patients failed to consent be used a controls rather than the genetic match controls?
• Temporally, the control group may not be representative of cases.
• The confidence interval of the primary outcome is narrow despite the overall sample size.
• The paper acknowledges that over time, NIV failure rate may have reduced over times as demonstrated in other studies. However, both groups probably represent the COPD population being considered in this review.
• The paper supports the notion that ECCO2R may help avoid IMV and the associated morbidity and mortality.
• First author is a consultant and medical director for ALung, who make the Hemolung machine.
• ALung provided machines and circuits for the study centres.
• A number of ALung employees provided editorial assistance and data inspection.
Kluge et al, 2012.• Population focus on patients with hypercapneic respiratory failure who were considered to be failing to respond or deteriorating following application of NIV. No specification of the disease aetiology. 66% of case group had COPD.
• This study used AV pumless ECCO2R.
Case control.

Cases N= 21.

Controls N=21 (all controls had failed NIV and received IMV.

Terms feasibility, effectiveness and safety used as opposed to a specific pre-defined outcome.• Need for intubation 10% in ECCO2R group.
• No significant difference in ITU or hospital length of stay (p value .53 and .32).
• No statistically significant difference in 28 day or six month mortality (24% versus 19% and 33% versus 33%).
• 33% of patients experienced complications related to ECCO2R, these centred on bleeding, and possibly related more to arterial cannulation rather than venous cannula.
• Both groups had at least one patient with extremely long length of stay and will distort results with such small numbers of patients.
• The extreme length of stay of some patients in both groups may have confounded this. Conversely, does this population represent a group of patients who would be denied critical care interventions due to the end stage nature of their disease?
• The decision to intubate a patient who is failing NIV can be very subjective. Therefore, using a control group who all received IMV is a significant confounder in this study
• A high number of cases on this study were on a lung transplant waiting list. This suggest a group of patients with end stage disease, yet received aggressive treatment.
• This population may not represent the majority of COPD patients who develop hypercapneic acidosis.
• Multiple authors have ties to Novalung, the manufacturer of iLA.
Barosik et al, 2011.• Use of the Novalung for self ventilating patients.
• Two patients, one with connective tissue disease, and the other with COPD.
• AV ECCO2R via Novalung was used in this case report.
Case report. N=2The cases are presented as evidence of proof of principle in the use of ECCO2R in hypercapneic respiratory failure.• Novolung was discontinued after four days and the patient later went on to receive lung transplantation.
• No adverse events were reported for the COPD case.
• The authors suggest that Novalung is simple and requires less skilled staff compared to ECMO. Some conclusions are based on the non-COPD case.
• The authors claim that Novolung may be medium to lung term extracorporeal option for hypercapneic respiratory failure.
• Very limited information, it is impossible to known what standard medical therapy either patient received.
• pH and pCO2 are provided, but there is no data regarding respiratory rate, work of breathing or dispensary scales.
• The time line focuses on the initiation of ECCO2R and the effects on pH and pCO2, but does not provide the reader with information on the clinical context of standard medical therapy.
• It is not stated wether NIV was used or not. However, NIV has been the standard of care for COPD respiratory acidosis for some years prior to this.
• There is no discussion regarding anticoagulation, sweep gas flows. Standard medical therapy was not discussed.
Bonin et al, 2013.• Single case report of a patient with an exacerbation of COPD and hypercapneic respiratory failure at risk of failure of NIV.
• This study used VV ECCO2R (Hemolung).
Case report. N=1.The cases are presented as evidence of proof of principle in the use of ECCO2R in hypercapneic respiratory failure.• The patient survived the episode of respiratory failure and went on to receive a lung transplant 31 days after cessation of ECCO2R.
• This patient suffered an episode of bleeding as a result of over anticoagulation.
• Provides a proof of principle to an emerging technology.
• There is no statement as why this particular case was selected from the Burki et al (2013) case series. Selection bias?
• It is unclear from this report what the experience of the institution with ECMO.
• This case represent the use of the most recent generation of ECCO2R technology using medium bore vena-venous a catheter.
• There is minimal attempt to use the literature to support papers findings and conclusion. However, key points were base of use and assumption of lower risk of adverse event compared with IMV.
• One author is an employee of the Hemolung manufacturer, the remaining authors declare no conflicts of interest.
• The original Burki et al 2013 study held significant conflicts of interests.
Cardens et al, 2009.• The case was a patient in her forties with COPD and asthma. The patient received IMV due to hypercapneic respiratory failure.
• Presentation and symptoms are not mentioned. An ECMO machine was adapted to provide CO2 removal using a VV approach.
Case report. N=1.The cases are presented as evidence of proof of principle in the use of ECCO2R in hypercapneic respiratory failure.• The patient was extubated two days after cessation of ECCO2R. The patient was discharged from hospital on day 13.
• One episode of desaturation was reported which was attributed to large pH shift following ECCO2R initiation and omission of changes to IMV parameters. No bleeding, coagulopathy or other complications were noted.
• It is not clear in the abstract that this case involved the use of IMV as part of the management of a COPD exacerbation or why NIV was not used. It was only evident halfway through this paper that the patient received intubation and IMV and not NIV.
• At the time of publication, this was the earliest care report referring to COPD that the search criteria identified. The paper on closer analysis does not fit the defined PICO question, but due to the title and abstract construction, this was not evident in the inclusion criteria. This was due to the omission of information in the title or abstract that the case did not receive NIV.
• Little supporting evidence is considered external to this case report regarding the conclusions reached.
• This was the first use of ECCO2R for the institution involved in this case report. Given the type of ECMO machine used, this was likely an institution with full ECMO capability and a high level of experience, despite this novel application.
Cole et al, 2014• The patient had an exacerbation of COPD and was failing to respond to NIV.
• This study used VV ECCO2R (Hemolung).
Case report.Proof of principle benefit based on risks of IMV for NIV failure.• The patient survived to discharge from hospital and had not been re-admitted within a thirty day period.
• The intervention was well tolerated, and allowed the patient to discontinue NIV without any deleterious effect.
• There is no discussion regarding any adverse events during the therapy.
• The presentation and background to this case is clearly explained. It is also made clear that the institution that provided the care was a commissioned ECMO centre.
• This represent use of the most recent generation of ECCO2R technology using medium bore vena-venous catheters. However, this also involves an expert centre in the use of ECMO.
• The author presents a strong theoretical case for the potential benefit for ECCO2R, but does not attempt to assert this case as proof of efficacy. The need for a randomised controlled trial is asserted.
• Conclusions are very circumspect and emphasise the theoretical benefits and do not attempt to assert a proof of efficacy.
• One author has received travel expenses from Alung (manufacturer of Hemolung) but had received no direct payments. One author is also on the medical advisory board of Hemolung.
Mani et al, 2011.• Two patients with an exacerbation of COPD and hypercapneic respiratory failure at risk of failure of NIV.
• This study used VV ECCO2R (Hemolung).
Case report. N=2.The cases are presented as evidence of proof of principle in the use of ECCO2R in hypercapneic respiratory failure.• Both patients survived to hospital discharge, one was re-admitted at thirty days. In both cases, intubation was avoided.
• Both patients developed thrombocytopenia, treatment was not required and reversed following cessation of ECCO2R.
• An argument is put forward that due to the mortality associated with NIV failure in this context, avoiding intubation with ECCO2R offers theoretical advantages.
• It is not clear why these particular patients were chosen from the case series by Burki et al (2013). This may represent positive reporting bias as four other patients in the NIV plus ECCO2R group in the original study died within the follow up period.
• It is unclear from these two reports what the experience of these two institutions was. Were these centres with previous experience of ECCO2R or ECMO?
• There is minimal attempt to use the literature to support papers findings and conclusion. However, key points were base of use and assumption of lower risk of adverse event compared with IMV.
• One author is an employee of the Hemolung manufacturer, the remaining authors declare no conflicts of interest.
• The original Burki et al 2013 study held significant conflicts of interests.
Braune and Kluge, 2013.A review of ECCO2R and its application to patients with COPD.Narrative review.A question as such is not posed, but a focused statement regarding the potential indications, safety and effectiveness in regards to COPD is made.• A reduction in risk of complications from ECCO2R compared to ECMO are asserted. However, the authors also argue that risks or ECCO2R must be weighed against the benefits.
• Further studies are needed to identify subsets of patients where patients may benefit from ECCO2R. Proof of concept has been established, but randomised controlled trials are needed.
• Use of ECCO2R in avoidance of IMV in COPD patients is the most radical innovation, this ideal scenario being the combination of NIV and ECCO2R where NIV alone is failing.
• ECCO2R technology has seen marked improvements and innovations in the last few year.
• The aim of ECCO2R is to reduce or avoid the complications associated with IMV.
• High level hierarchy studies do not exist in regard to ECCO2R, especially in the context of COPD. Due to this, the majority of evidence considered is low level, a combination of case series, controls, case reports and expert opinion.
• The key papers that have been published to date were considered. Many papers were considered in the context of ARDS and the evolution of ECMO and ECCO2R. As the COPD literature is limited in regard to ECCO2R, there is a degree of extrapolation from wider literature.
• A systematic data base search was not carried out, nor was there in any use of inclusion/exclusion criteria applied. This makes it difficult to discern if there was selection bias in the papers used in the review.
• There is little attempt to critique any of the referenced literature, no critical appraisal tools were applied despite using the statistics from these studies.
• There is little use of statistics to support assertions, as there are only two studies identified in the reference list and these are case control or case series, which have also been reviewed here.
• The findings are borne out through expert opinion and proof of principle rather than statistical difference and confidence interval.
• Many of the quoted studies and case reports involve centres with experience of ECMO and although the COPD patients themselves can probably be generalised, the experience and expertise of the centres can not.
• A reduction in risk of complications from ECCO2R compared to ECMO are asserted. However, the authors also argue that risks or ECCO2R must be weighed against the benefits.
• Kluge has ties to Novolung based on conflicts of interest statement in Kluge et al (2013).
Lund and Frederspiel, 2013.A review of ECCO2R and its application to patients with COPD.Narrative review.A question as such is not posed, but a focused statement regarding the potential indications, safety and effectiveness in regards to COPD is made.• There is substantial increase in mortality and morbidity associated with NIV failure resulting in the use of IMV.
• Up to 50% of CO2 can be removed with ECCO2R and sweep gas flow can be titrated to respiratory rate.
• There is insufficient evidence to initiate ECCO2R where NIV is not failing.
• Risks or ECCO2R over ECMO are reduced, but must be acknowledged.
• Current evidence prevents conclusions regarding mortality or length of stay.
• Reduced need for IMV is argued.
• Randomised controlled trials are also needed on the use of ECCO2R in the weaning of COPD patients from IMV and NIV failure.
• The ideal studies for a review following a hierarchy of evidence such as randomised controlled trials, systematic reviews do not exist. Therefore, the available evidence is review (Lund being an author of several ECCO2R studies).
• There is no attempt to systematically search the evidence base or provide inclusion and exclusion criteria. This may cause a strong selection bias in the literature reviewed.
• This paper looks at a number of case reports and a case series and also makes some extrapolations from ECCO2R applied to ARDS patients. Some effort is also made that addresses the issue of NIV failure and the associated mortality in this group.
• A large proportion of the review literature focused on NIV and the associated risks of failure, and on historical aspects of ECMO and ECCO2R. All the relevant papers regarding ECCO2R and NIV to that date were considered.
• Some effort is made to critique Klunge et al (2012), but there is little further critique of any other papers that were discussed. No critical appraisal tools were applied to the referenced literature.
• There is little use of statistics to support assertions, as there are only two studies identified in the reference list and these are case control or case series, which have also been reviewed here.
• The findings are borne out through expert opinion and proof of principle rather than statistical difference and confidence interval.
• Both authors are both employees of Alung, a VV ECCO2R system manufacturer. Lund appears in three other papers.
Terragni et al, 2012.Technical aspects of ECCO2R and application in ARDS, COPD and as a bridge to transplantation.Narrative review.A review of the technical aspects of ECCO2R and its clinical application.• Combining ECCO2R with ultra protective ventilation may be a promising therapeutic option in the future.
• ECCO2R is new potential strategy in the management of COPD exacerbation.
• Randomised controlled trials are needed.
• High level hierarchy studies do not exist in regard to ECCO2R, especially in the context of COPD. Due to this, the majority of evidence considered is low level, a combination of case series, controls, case reports and expert opinion. The paper considers ECCO2R literature in general, although does have a focused section on COPD.
• The key papers that have been published to date were considered. Many papers were considered in the context of ARDS and the evolution of ECMO and ECCO2R. The COPD/ECCO2R references did not include papers identified in this papers systematic search.
• A systematic data base search was not carried out, nor was there in any use of inclusion/exclusion criteria applied. This makes it difficult to discern if there was selection bias in the papers used in the review.
• Many of the quoted studies and case reports involve centres with experience of ECMO and although the COPD patients themselves can probably be generalised, the experience and expertise of the centres can not.

Comments.

The evidence base for the use of extra corporeal carbon dioxide removal in the context of COPD exacerbation and a failed response to NIV is very small and very recent. This is emphasised in the identified narrative reviews which cite a handful of the same papers. They extrapolate extensively from the literature surrounding extra corporeal carbon dioxide removal in the context of ARDS. In the case of ARDS, Fitzgerald et al (2014) a systematic review only elicited two RCTs, with the bulk of the literature lying within the lower hierarchy of evidence in the form of case series and case-controls. This low level evidence may be an appropriate beginning in the developing literature, given the very recent nature of the application of extra corporeal carbon dioxide removal to patients with COPD and acute exacerbations. In view of the cost of new technology and its implementation, proof of principle is a minimum requirement before expensive, large scale and multi centre RCTs can be contemplated.

The obvious conflicts of interest in the available evidence include: funding, employment, editorial assistance and provision of equipment from industry. Although these issues are clearly disclosed, there has been a history of conflicts of interest and their impact on research and clinical practice over the last fifteen years. Drugs such as COX2 inhibitors (a selective non-steroidal anti-inflammatory drug class) and hydroxyethyl starch (a fluid used in shock resuscitation) have been withdrawn from the UK market, following the incomplete publication of data or outright research fraud. This emphasises that even large multi-centre RCTs can become biased and compromised when commercial interests are heavily invested in a research process.

With regard to extra corporeal carbon dioxide removal and its effectiveness in the removal of CO2, there is little doubt. The NIV and ARDS literature show consistently that the technique is effective. Using this removal of CO2 as the surrogate endpoint does not necessarily translate into a meaningful patient centred outcome (e.g. survival) and its use must be treated with caution. There is a strong theoretical basis that reducing or avoiding the need for IMV in patients who have failed NIV may translate to an improvement in morbidity and mortality in this population. This argument combined with the effectiveness of CO2 removal with ECCO2R, is an important bench to bed side translation of research and a pertinent research question. At present, the theoretical advantage of ECCO2R seems to be the primary argument for its use, implying cause and effect. Within the limits of the available level of evidence, there is support for the notion that extra corporeal carbon dioxide removal can reduce the need for IMV in this population. Taken at face value, Del Sorbo et al (2015) found a significant treatment effect. However, it is important not to automatically assume cause and effect. Chandra et al (2012) noted increased mortality in patients who required IMV when NIV failed to stabilise COPD patients. Conversely, patients who received IMV from the outset had an improved outcome compared to patients who failed NIV later and then received IMV. There may be other factors at play with regard to morbidity and mortality in this group of patients which are not immediately apparent. It is possible that reducing IMV in this group of patients may not provide the hoped-for mortality benefit, and other confounders may be present.

VV-ECCO2R is likely to supersede the initial pump-less AV system which was designed to be a less invasive alternative to ECMO. The equivalent CO2 removal capacity of VV-ECCO2R, without the risks of large bore arterial cannulation, make AV-ECCO2R of little additional value. This is particularly pertinent when balancing the risks of ECCO2R with IMV, and could potentially switch the benefits to harm. The additional benefit of VV-ECCO2R its increased utility outside of specialist ECMO centres. If future research is to establish a firm mortality benefit, it will not be possible to transport unstable patients who are not responding to NIV around the country to regional ECMO centres. It seems that if there is to be a future for ECCO2R, it will be in its integration into the typical therapies currently available in the average intensive care unit.

There is insufficient evidence to make assumptions about the impact of ECCO2R upon mortality or morbidity. Whilst proof of principle has been established, this does not mean to say that the reduction of NIV failure should continue to be accepted as a surrogate for reduced mortality. The risks of major bleeding and even death from haemorrhage should not be downplayed. Exchanging the risk of mortality from IMV with that of major bleeding and infection should not be considered advantageous. Using a comparable therapeutic method that is expensive, invasive and not widely available is not in the best interests of the patient. There is insufficient data to draw conclusions as to whether ECCO2R is a safer alternative to IMV.

There are signals in the current body of evidence that ECCO2R may reduce the need for IMV in patients with COPD with an exacerbation which does not respond to NIV. It is unclear whether there is a mortality benefit or if there is a reduction in morbidity. The current evidence base suffers from significant conflicts of interests which may incur a high bias in the results of these studies.

 

Bottom line.

  1. An RCT is required which is adequately powered to detect statistically significant differences in the need for invasive ventilation, mortality and morbidity between groups. A multi-centre (possibly international) trial would be needed to recruit a sufficient number of subjects.
  2. It is important that future trials compare like for like technology. VV-ECCO2R should be used to compare with IMV to remove the potential confounding increase in complications that may be associated with AV-ECCO2R.
  3. It is difficult to justify the risks of AV-ECCO2R versus a VV approach. VV-ECCO2R should be the mode of choice, particularly in the context of use outside of the domain of an ECMO centre.
  4. Patients who receive extracorporeal support should have data submitted to the Extracorporeal Life Support Organisation (ELSO, accessed July 2016). ELSO compiles an international registry of patients who receive extracorporeal life support. This is an organisation that is independent of industry and may be able to provide large volume cohort or case series data in the future.
  5. Any future research should aim for the greatest independence possible from commercial companies involved in the manufacture of ECCO2R This may require the use of government grants in order to maintain independence from corporate interests.
  6. There is insufficient evidence to recommend the routine use of ECCO2R in any population. In centres where a system of training and clinical governance is in place, ECCO2R is a potential option in individual cases.

References.

Abrams, D.C., Brenner, K., Burkart, K.M., et al. (2013) Pilot study of extracorporeal carbon dioxide removal to facilitate extubation and ambulation in exacerbations of chronic obstructive pulmonary disease. Annals of the American Thoracic Society, 10 (4): 307–314

ARDS Definition Task Force (2012) Acute respiratory distress syndrome [online]. JAMA, 307 (23). http://jama.jamanetwork.com/article.aspx?articleID=1160659&utm_source=Silverchair%20Infor [Accessed 16 July 2015] .

Bartosik, W., Egan, J.J. and Wood, A.E. (2011) The Novalung interventional lung assist as bridge to lung transplantation for self-ventilating patients – initial experience. Interactive cardiovascular and thoracic surgery, 13 (2): 198–200

Bonin, F., Sommerwerck, U., Lund, L.W., et al. (2013) Avoidance of intubation during acute exacerbation of chronic obstructive pulmonary disease for a lung transplant candidate using extracorporeal carbon dioxide removal with the Hemolung. The Journal of Thoracic and Cardiovascular Surgery, 145 (5): e43–e44

Braune, S.A. and Kluge, S. (2013) Extracorporeal lung support in patients with chronic obstructive pulmonary disease. Minerva anestesiologica, 79 (8): 934–943

Burki, N.K., Mani, R.K., Herth, F.J.F., et al. (2013) A novel extracorporeal CO(2) removal system: results of a pilot study of hypercapnic respiratory failure in patients with COPD. Chest, 143 (3): 678–686

Cardenas, V.J., Jr, Lynch, J.E., Ates, R., et al. (2009) Venovenous Carbon Dioxide Removal in Chronic Obstructive Pulmonary Disease. ASAIO Journal, 55 (4): 420–422

Chandra, D., Stamm, J.A., Taylor, B., et al. (2012) Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998-2008. American Journal of Respiratory and Critical Care Medicine, 185 (2): 152–159

Cole, S., Barrett, N.A., Glover, G., et al. (2014) Extracorporeal carbon dioxide removal as an alternative to endotracheal intubation for non-invasive ventilation failure in acute exacerbation of COPD. Journal of the  …, 15 (4)

Del Sorbo, L., Pisani, L., Filippini, C., et al. (2015) Extracorporeal Co2 Removal in Hypercapnic Patients At Risk of Noninvasive Ventilation Failure. Critical Care Medicine, 43 (1): 120–127

Kluge, S., Braune, S.A., Engel, M., et al. (2012) Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilation. Intensive Care Medicine, 38 (10): 1632–1639

Lund, L.W. and Federspiel, W.J. (2013) Removing extra CO2 in COPD patients. Current respiratory care reports, 2: 131–138

Mani, R.K., Schmidt, W., Lund, L.W., et al. (2013) Respiratory Dialysis for Avoidance of Intubation in Acute Exacerbation of COPD. ASAIO Journal, 59 (6): 675–678.

Ram, F.S.F., Picot, J., Lightowler, J., et al. (2004) Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane database of systematic reviews, (3): CD004104

Terragni, P., Maiolo, G. and Ranieri, V.M. (2012) Role and potentials of low-flow CO(2) removal system in mechanical ventilation. Current Opinion in Critical Care, 18 (1): 93–98

Terragni, P.P., Maiolo, G., Tenaglia, T., et al. (2011) Extracorporeal CO2 removal and O2 transfer: A review of the concept, improvements and future development. Trends in Anaesthesia and Critical Care, 1 (3): 123–127

Gavin Denton @dentongavin – Current role: Critical care practitioner, critical care, West Midlands. Roles include; assessment and management of the critically ill patient, insertion of invasive lines, advanced airway management (under supervision), transfer of the critically ill patient, resuscitation (from airway, to team leader to post resus care). Trenching and support of junior doctors of the above.
Graduated from the University of Birmingham with BN(hons). BSc from Birmingham City University. About to complete MSc in health sciences from the University of Warwick.
Working background: 15 years working within various aspects of critical care. 7 years in critical care, 6 years in critical care outreach, 2 years as a critical care practitioner. Adult life support instructor. Independent non-medical prescriber.
Future aims: faculty of critical care medicine affiliation. FEEL course, POCUS training.
Clinical interests: USS, airway management.

 

Originally posted 2016-01-28 22:21:45. Republished by Blog Post Promoter

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