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

Mathilde Azzi, Jerome Aboab, Sophie Alviset, Daria Ushmorova, Luis Ferreira, Vincent Ioos, Nathalie Memain, Tazime Issoufaly, Mathilde Lermuzeaux, Laurent Laine, Rita Serbouti, Daniel Silva, Mathilde Azzi, Jerome Aboab, Sophie Alviset, Daria Ushmorova, Luis Ferreira, Vincent Ioos, Nathalie Memain, Tazime Issoufaly, Mathilde Lermuzeaux, Laurent Laine, Rita Serbouti, Daniel Silva

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.

Conflict of interest statement

Competing interests: Rita Serbouti, from Fresenius Medical Care France, Medical affairs, helped train staff in Extracorporeal CO2 Removal Device and contributed to proofreading this paper. No financial support from the industry was received.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
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
Figure 2
ECCO2R group outcomes. ECCO2R, extracorporeal CO2 removal; ICU, intensive care unit.
Figure 3
Figure 3
IMV group outcomes. IMV, invasive mechanical ventilation; N/A, non-available; VAP, ventilator-associated pneumonia. *With catecholamine administration required.
Figure 4
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
Figure 5
Anti-Xa in ECCO2 patients with major bleeding events.
Figure 6
Figure 6
Anti-Xa in ECCO2R patients with circuit thrombosis event.

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