Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress sindrome

Abstract

Background

Mechanical ventilation with a tidal volume (V _T) of 6 mL/kg/predicted body weight (PBW), to maintain plateau pressure (P _plat) lower than 30 cmH ₂O, does not completely avoid the risk of ventilator induced lung injury (VILI). The aim of this study was to evaluate safety and feasibility of a ventilation strategy consisting of very low V _T combined with extracorporeal carbon dioxide removal (ECCO ₂R).

Methods

In fifteen patients with moderate ARDS, V _T was reduced from baseline to 4 mL/kg PBW while PEEP was increased to target a plateau pressure – (P _plat) between 23 and 25 cmH ₂O. Low-flow ECCO ₂R was initiated when respiratory acidosis developed (pH < 7.25, PaCO ₂ > 60 mmHg). Ventilation parameters (V _T, respiratory rate, PEEP), respiratory compliance (C _RS), driving pressure (DeltaP = V _T/C _RS), arterial blood gases, and ECCO ₂R system operational characteristics were collected during the period of ultra-protective ventilation. Patients were weaned from ECCO ₂R when PaO ₂/FiO ₂ was higher than 200 and could tolerate conventional ventilation settings. Complications, mortality at day 28, need for prone positioning and extracorporeal membrane oxygenation, and data on weaning from both MV and ECCO ₂R were also collected.

Results

During the 2 h run in phase, V _T reduction from baseline (6.2 mL/kg PBW) to approximately 4 mL/kg PBW caused respiratory acidosis (pH < 7.25) in all fifteen patients. At steady state, ECCO ₂R with an average blood flow of 435 mL/min and sweep gas flow of 10 L/min was effective at correcting pH and PaCO ₂ to within 10 % of baseline values. PEEP values tended to increase at V _T of 4 mL/kg from 12.2 to 14.5 cmH ₂O, but this change was not statistically significant. Driving pressure was significantly reduced during the first two days compared to baseline (from 13.9 to 11.6 cmH ₂O; p < 0.05) and there were no significant differences in the values of respiratory system compliance. Rescue therapies for life threatening hypoxemia such as prone position and ECMO were necessary in four and two patients, respectively. Only two study-related adverse events were observed (intravascular hemolysis and femoral catheter kinking).

Conclusions

The low-flow ECCO ₂R system safely facilitates a low volume, low pressure ultra-protective mechanical ventilation strategy in patients with moderate ARDS.