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. 2018 May 10;22(1):122.
doi: 10.1186/s13054-018-2038-5.

Feasibility and safety of low-flow extracorporeal CO2 removal managed with a renal replacement platform to enhance lung-protective ventilation of patients with mild-to-moderate ARDS

Matthieu Schmidt  1   2 , Samir Jaber  3 , Elie Zogheib  4 , Thomas Godet  5   6 , Gilles Capellier  7   8 , Alain Combes  9   10
Affiliations

Feasibility and safety of low-flow extracorporeal CO2 removal managed with a renal replacement platform to enhance lung-protective ventilation of patients with mild-to-moderate ARDS

Matthieu Schmidt et al. Crit Care. .

Abstract

Background: Extracorporeal carbon-dioxide removal (ECCO2R) might allow ultraprotective mechanical ventilation with lower tidal volume (VT) (< 6 ml/kg predicted body weight), plateau pressure (Pplat) (< 30 cmH2O), and driving pressure to limit ventilator-induced lung injury. This study was undertaken to assess the feasibility and safety of ECCO2R managed with a renal replacement therapy (RRT) platform to enable very low tidal volume ventilation of patients with mild-to-moderate acute respiratory distress syndrome (ARDS).

Methods: Twenty patients with mild (n = 8) or moderate (n = 12) ARDS were included. VT was gradually lowered from 6 to 5, 4.5, and 4 ml/kg, and PEEP adjusted to reach 23 ≤ Pplat ≤ 25 cmH2O. Standalone ECCO2R (no hemofilter associated with the RRT platform) was initiated when arterial PaCO2 increased by > 20% from its initial value. Ventilation parameters (VT, respiratory rate, PEEP), respiratory system compliance, Pplat and driving pressure, arterial blood gases, and ECCO2R-system operational characteristics were collected during at least 24 h of very low tidal volume ventilation. Complications, day-28 mortality, need for adjuvant therapies, and data on weaning off ECCO2R and mechanical ventilation were also recorded.

Results: While VT was reduced from 6 to 4 ml/kg and Pplat kept < 25 cmH2O, PEEP was significantly increased from 13.4 ± 3.6 cmH2O at baseline to 15.0 ± 3.4 cmH2O, and the driving pressure was significantly reduced from 13.0 ± 4.8 to 7.9 ± 3.2 cmH2O (both p < 0.05). The PaO2/FiO2 ratio and respiratory-system compliance were not modified after VT reduction. Mild respiratory acidosis occurred, with mean PaCO2 increasing from 43 ± 8 to 53 ± 9 mmHg and mean pH decreasing from 7.39 ± 0.1 to 7.32 ± 0.10 from baseline to 4 ml/kg VT, while the respiratory rate was not altered. Mean extracorporeal blood flow, sweep-gas flow, and CO2 removal were 421 ± 40 ml/min, 10 ± 0.3 L/min, and 51 ± 26 ml/min, respectively. Mean treatment duration was 31 ± 22 h. Day-28 mortality was 15%.

Conclusions: A low-flow ECCO2R device managed with an RRT platform easily and safely enabled very low tidal volume ventilation with moderate increase in PaCO2 in patients with mild-to-moderate ARDS.

Trial registration: ClinicalTrials.gov, NCT02606240. Registered on 17 November 2015.

Keywords: Acute respiratory distress syndrome; Extracorporeal carbon-dioxide removal; Protective ventilation.

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Conflict of interest statement

Ethics approval and consent to participate

The study was approved by the Comité de Protection des Personnes Ile-de-France 6, Paris, France (no. 15.1026). The clinical trial protocol was registered with www.clinicaltrials.gov (ClinicalTrials.gov identifier: NCT02606240, 17 November 2015). Informed consent was obtained from all patients or their surrogates.

Competing interests

MS has received lecture fees from Maquet. SJ has received lecture fees from Drager, Fisher-Paykel, and Xenios. EZ has received consultant fees from Gambro. TG has received lecture fees and travel reimbursements for meetings from Gambro-Baxter and General Electrics. GC has received lecture fees from Alung and Baxter. AC has received lecture fees from Baxter and Maquet. AC is the primary investigator of the EOLIA trial (ClinicalTrials.gov identifier: NCT01470703), partly supported by Maquet.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Evolution of driving pressure, PEEP, and respiratory rate when tidal volume reduced on ECCO2R. Horizontal lines, median; lower and upper box limits, 25th–75th percentiles; T-bars, 10th–90th percentiles. *p < 0.05 vs 6 ml/kg tidal volume step. PBW predicted body weight, PEEP positive end-expiratory pressure
See this image and copyright information in PMC

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