Extracorporeal CO2 removal in acute exacerbation of COPD unresponsive to non-invasive ventilation

Abstract

Background: The gold-standard treatment for acute exacerbation of chronic obstructive pulmonary disease (ae-COPD) is non-invasive ventilation (NIV). However, NIV failures may be observed, and invasive mechanical ventilation (IMV) is required. Extracorporeal CO₂ removal (ECCO₂R) devices can be an alternative to intubation. The aim of the study was to assess ECCO₂R effectiveness and safety.

Methods: Patients with consecutive ae-COPD who experienced NIV failure were retrospectively assessed over two periods of time: before and after ECCO₂R device implementation in our ICU in 2015 (Xenios AG).

Results: Both groups (ECCO₂R: n=26, control group: n=25) were comparable at baseline, except for BMI, which was significantly higher in the ECCO₂R group (30 kg/m² vs 25 kg/m²). pH and PaCO₂ significantly improved in both groups. The mean time on ECCO₂R was 5.4 days versus 27 days for IMV in the control group. Four patients required IMV in the ECCO₂R group, of whom three received IMV after ECCO₂R weaning. Seven major bleeding events were observed with ECCO₂R, but only three led to premature discontinuation of ECCO₂R. Eight cases of ventilator-associated pneumonia were observed in the control group. Mean time spent in the ICU and mean hospital stay in the ECCO₂R and control groups were, respectively, 18 vs 30 days, 29 vs 49 days, and the 90-day mortality rates were 15% vs 28%.

Conclusions: ECCO₂R was associated with significant improvement of pH and PaCO₂ in patients with ae-COPD failing NIV therapy. It also led to avoiding intubation in 85% of cases, with low complication rates.

Trial registration number: ClinicalTrials.gov, NCT04882410. Date of registration 12 May 2021, retrospectively registered.https://www.clinicaltrials.gov/ct2/show/NCT04882410.

Keywords: COPD exacerbations.

Figure 1

Flow chart. Ae-COPD, acute exacerbation of chronic obstructive pulmonary disease; DNR, do not resuscitate order; ECCO₂R, extracorporeal CO₂ removal; NIV, non-invasive ventilation.

Figure 2

ECCO₂R group outcomes. ECCO₂R, extracorporeal CO₂ removal; ICU, intensive care unit.

Figure 3

IMV group outcomes. IMV, invasive mechanical ventilation; N/A, non-available; VAP, ventilator-associated pneumonia. *With catecholamine administration required.

Figure 4

Evolution of pH and carbon dioxide arterial pressure (PaCO₂) from 6 hours before cannulation or intubation until before weaning. ECCO₂R, extracorporeal CO₂ removal; IMV, invasive mechanical ventilation.

Figure 5

Anti-Xa in ECCO₂ patients with major bleeding events.

Figure 6

Anti-Xa in ECCO₂R patients with circuit thrombosis event.