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Table 4 Relevant clinical studies of ECCO2R in ARDS patients

From: The role of hypercapnia in acute respiratory failure

Study

ECCO2R technique

Description and results

Terragni et al. [56]

Modified continuous VV hemofiltration system with membrane lung via a 14-Fr single dual lumen catheter (femoral) with an extracorporeal blood flow of 191–422 mL/min

Prospective study.

Ten ARDS patients with 28 ≤ Pplat ≤ 30 after 72 h of ARDSNet ventilation were placed on ECCO2R and had a progressive reduction in VT.

VT was reduced from 6.3 ± 0.2 to 4.2 ± 0.3 mL/kg PBW and Pplat decreased from 29.1 ± 1.2 to 25.0 ± 1.2 cmH2O (P < 0.001).

Consequent respiratory acidosis was managed by ECCO2R.

Improvement of morphological markers of lung protection and reduction in pulmonary cytokines (P < 0.01) after 72 h of ventilation with VT < 6 mL/kg PBW.

No patient-related complications.

Membrane clotting in three patients.

Bein et al. [58]

Femoral AV pumpless extracorporeal lung assist (PECLA) via a 15-Fr arterial cannula and 17-Fr venous cannula with a mean extracorporeal blood flow of 1.3 L/min

Randomized controlled trial.

Moderate/severe ARDS after 24-h stabilization period with higher PEEP.

Randomized to ECCO2R group with ~ 3 mL/kg PBW ventilation or control group with ~ 6 mL/kg PBW ventilation.

There were no significant differences in VFDs at day 28 (10 vs. 9 days, P = 0.78) or day 60 (33 vs. 29, P = 0.47).

Post hoc analysis showed that patients with P/F ≤ 150 at randomization in ECCO2R group had a significantly shorter duration of ventilation (VFDs at day 60, 41 vs. 28, P = 0.033).

Significantly higher red blood cell transfusion in the PECLA group up to day 10 (3.7 vs. 1.5 units, P < 0.05).

Fanelli et al. [59]

VV configuration via a 15.5-Fr single dual lumen catheter (femoral or jugular) with a mean extracorporeal blood flow of 435 mL/min

Prospective study.

Moderate/severe ARDS.

VT was reduced from baseline to 4 mL/kg PBW.

Low-flow ECCO2R was initiated when pH < 7.25 and PaCO2 > 60 mmHg.

ECCO2R was effective in correcting pH and PaCO2.

Life-threatening hypoxemia such as prone position and ECMO were necessary in four and two patients, respectively.

Schmidt et al. [69]

VV configuration managed with renal replacement platform via a 15.5-Fr single dual lumen catheter (femoral or jugular) with a mean extracorporeal blood flow of 421 mL/min

Prospective multicenter study.

Twenty-two patients with mild/moderate ARDS

VT gradually reduced following 2-h run-in time from 6 to 5, 4.5, and 4 mL/kg every 30 min and PEEP adjusted to reach 23 ≤ Pplat ≤ 25 cmH2O.

No patients required ECMO.

No worsening oxygenation.

Low-flow ECCO2R managed by RRT platform easily and safely enabled ultraprotective ventilation.

Performance of RRT ECCO2R in severe ARDS patients not known.

Combes et al. (NCT 02282657) [70]

VV configuration 15.5 to 19 Fr single dual lumen catheter (femoral or jugular) with three different devices.

Prospective multicenter study.

Ninety-five patients with moderate ARDS. VT progressively decreased to 4 mL/kg PBW.

PEEP adjusted to reach 23 ≤ Pplat ≤ 25 cmH2O.

Objective to maintain PaCO2 ± 20% of baseline values obtained at VT 6 mL/kg IBW with pH > 7.30.

ECCO2R was able to reduce Pplat from 26 ± 5 cmH2O to 23 ± 3 cmH2O (P < 0.01) in 73% of patients.

ECCO2R was able to increase PEEP from 12 ± 4 cmH2O to 14 ± 4 cmH2O (P < 0.01).

ECCO2R allowed ∆P reduction from 13 ± 5 to 9 ± 4 cmH2O (P < 0.01).

There were no significant changes in pH, PaCO2, and PaO2/FiO2 with VT reduction to 4 mL/kg/IBW

ECCO2R device length: 5 (3–8 days).

Derecruitment/hypoxia (n = 2) that need to increase VT, hemolysis (n = 3). Hemorrhage at the cannula insertion point (n = 4), pneumothorax (n = 1).