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. 2024 Dec 27;28(1):433.
doi: 10.1186/s13054-024-05168-8.

Feasibility and safety of ultra-low volume ventilation (≤ 3 ml/kg) combined with extra corporeal carbon dioxide removal (ECCO2R) in acute respiratory failure patients

Clément Monet  1   2 , Thomas Renault  1 , Yassir Aarab  1   2 , Joris Pensier  1   2 , Albert Prades  1 , Ines Lakbar  1   2 , Clément Le Bihan  1 , Mathieu Capdevila  1   2 , Audrey De Jong  3   4 , Nicolas Molinari  5   6 , Samir Jaber  7   8
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Feasibility and safety of ultra-low volume ventilation (≤ 3 ml/kg) combined with extra corporeal carbon dioxide removal (ECCO2R) in acute respiratory failure patients

Clément Monet et al. Crit Care. .

Abstract

Background: Ultra-protective ventilation is the combination of low airway pressures and tidal volume (Vt) combined with extra corporeal carbon dioxide removal (ECCO2R). A recent large study showed no benefit of ultra-protective ventilation compared to standard ventilation in ARDS (Acute Respiratory Distress Syndrome) patients. However, the reduction in Vt failed to achieve the objective of less than or equal to 3 ml/kg predicted body weight (PBW). The main objective of our study was to assess the feasibility of the ultra-low volume ventilation (Vt ≤ 3 ml/kg PBW) facilitated by ECCO2R in acute respiratory failure patients.

Methods: Retrospective analysis of a prospective cohort of patients with either high or low blood flow veno-venous ECCO2R devices. A session was defined as a treatment of ECCO2R from the start to the removal of the device (one patient could have one more than one session). Primary endpoint was the proportion of sessions during which a Vt less or equal to 3 ml/kg PBW at 24 h after the start of ECCO2R was successfully achieved for at least 12 h. Secondary endpoints were respiratory variables, rate of adverse events and outcomes.

Results: Forty-five ECCO2R sessions were recorded among 41 patients. Ultra-low volume ventilation (tidal volume ≤ 3 ml/kg PBW, success group) was successfully achieved at 24 h in 40.0% sessions (18 out of 45 sessions, confidence interval 25.3-54.6%). At 24 h, tidal volume in the failure group was 4.1 [3.8-4.5] ml/kg PBW compared to 2.1 [1.9-2.5] in the success group (p < 0.001). After multivariate analysis, blood flow rate was significantly associated with success of ultra-low volume ventilation (adjusted OR per 100 ml/min increase 1.51 (95%CI 1.21-1.90, p = 0.0003).

Conclusion: Ultra-low volume ventilation (≤ 3 ml/kg PBW) was feasible in 18 out of 45 sessions. Higher blood flow rates were associated with the success of ultra-low volume ventilation.

Keywords: Acute respiratory distress syndrome; ECCO2R; Extracorporeal carbon dioxide removal; Intensive care; Ventilator-induced lung injury.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The institutional ethics committee reviewed the retrospective use of anonymous data for scientific purpose and waived the need to obtain informed written consent. The Institutional Review Board (IRB) of Montpellier University Hospital approved the study (2019_IRB-MTP_05-25). Consent for publication: Not applicable. Competing interests: Pr Jaber reports receiving consulting fees from Drager, Medtronic, Mindray, Fresenius, Baxter, and Fisher & Paykel. Pr De Jong reports receiving remuneration for presentations from Medtronic, Drager and Fisher & Paykel. Dr Monet reports receiving remuneration for presentations from Medtronic. The other authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Evolution over time of tidal volume, blood flow rate, driving pressure and positive end-expiratory pressure. Median, 1st and 3rd quartiles values of tidal volume (VT) (A), blood flow rate (B), driving pressure (∆P = PPLAT minus PEEP) (C) and PEEP (E) at the start of ECCO2R (H0), 4, 24, 48 h after initiation of ECCO2R in the failure group (> 3 ml/kg of predicted body weight) and in the success group (≤ 3 ml/kg of predicted body weight). Median, 1st and 3rd quartiles values of variation of driving pressure (∆P = PPLAT minus PEEP) (D), positive end-expiratory pressure (PEEP) (F) from the start of ECCO2R (H0) to 4, 24, 48 h after initiation of ECCO2R in the failure group (> 3 ml/kg of predicted body weight) and in the success group (≤ 3 ml/kg of predicted body weight). *p < 0.05 between groups, NS: not significant
Fig. 2
Fig. 2
Evolution over time of gas exchanges. Median, 1st and 3rd quartiles values of pH (A), partial pressure of arterial CO2 (PaCO2) (B), ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) (C) at the start of ECCO2R (H0), 4, 24, 48 h after initiation of ECCO2R in the failure group (> 3 ml/kg of predicted body weight) and in the success group (≤ 3 ml/kg of predicted body weight). *p < 0.05 between groups, NS: not significant
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