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CO2 removal: Is a new simplified device could extended
the indications?
Laurent Papazian, Samir Jaber
To cite this version:
Laurent Papazian, Samir Jaber. CO2 removal: Is a new simplified device could extended the
indi-cations?. Anaesthesia Critical Care & Pain Medicine, Elsevier Masson, 2015, 34 (3), pp.131 - 132.
�10.1016/j.accpm.2015.03.001�. �hal-01760110�
CO
2
removal:
Is
a
new
simplified
device
could
extended
the
indications?
Inthepresentissueofthejournal,Godetetal.[1]reportedinan invivoanimalstudyincluding15pigs,thesafetyandfeasibilityuse ofadevicebasedonaPrismaflex1
platforminremovingCO2from
theblood,thus decreasingPaCO2andacidosis hypercapnia.The
technique wasbased on a standard renal replacement therapy (RRT)platform(Prismaflex1
)thatcanbeeasilyimplementedon existing devices. This strategy used a novel stand alone gas exchangerkitincorporatingahollowfiberchamberwithoutany RRThemofilter.Although,theauthorsevaluatedtheeffectsona shorttermperiod(lessthan2hours)andreportedtheefficiencyby decreasingbloodCO2,theeffectsonalongtermperiodshouldbe
evaluatedinbothanimalandhumanfuturestudiesespeciallyin non-healthylungs.
Invasivemechanicalventilationislifesavingforpatientswith acuterespiratorydistresssyndrome(ARDS).However,weknow forabout30yearsthatpositivepressuremechanicalventilationis abletocreatelunginjuriesandtoworsenpreviouslunginjuries (ventilator-inducedlunginjury;VILI).TominimizetheseVILI,itis generallyrecommendedlimitingtidalvolume(VT)to6mL/kgof predictedbodyweightandplateaupressurelessthan30cmH2O.
However, evidence is accumulating that it may not be fully protectiveagainstVILIandthelesspositivepressureventilationis given,thelessVILIarecreated.ThepricetopaythislimitedVTisa reduction of minute ventilation even if respiratory rate is increased,leadingarespiratoryhypercapniasocalled‘‘permissive hypercapnia’’. The first extracorporeal CO2 removal (ECCO2R)
devicesweredesigned40yearsago.Thetechniqueneverentered into clinical practice, probably because high blood flows were necessary,extracorporealcircuits werenot biocompatible,large catheterswereusedandfullanticoagulationwasrequired.
ECCO2Riscapableofeliminatingatleast50%ofthecalculated
CO2production,withrapidnormalizationofrespiratoryacidosis.
Thishasledtotheattemptofthistechniqueinpatientspresenting withacutehypercapnicrespiratoryfailure(COPDpatients,bridge totransplantlungpatients)[2].ECCO2Rsystemsarenowproposed
toreduceinvasiveness ofmechanicalventilationand, therefore, VILIinARDSpatients[3–7].
Theoldersystemsweredrivenbythearterio-venouspressure gradient; thus, cannulation of an arterial vessel (usually the femoral artery) was necessary for driving the system. Recent pump-drivenveno-venoussystems havebeendesignedandare able to improve respiratory acidosis without requiring arterial cannulation.There arealsosomeattempts toadaptcontinuous renal replacementdevices tobe able toclear CO2 by specially
designedfilters.Clinicalexperiencesuggeststhathighflowrates areneededtocorrectsevererespiratoryacidosis(pH<7.2).Inthis
regard,thephysiologicalrelationshipsbetweencannulasize,blood flow,sweepgasflowandgastransfercapacity,respectively,still remainlargelyunknown.Forthisreason,morephysiologicaldata on these issues are needed before the promising technique of miniaturizedveno-venous ECCO2Rcanbetested inrandomized
controlledtrials(RCTs)aimingtoevaluatethepossiblebeneficial clinicalimpact.Recently,aporcinestudy[7]indicatedthat pump-driven veno-venous ECCO2R required a blood flow of 750 to
1000mL/mintonormalizepHvaluesandreducePaCO2insevere
life-threatening respiratory acidosis under constant ventilatory support. Therefore,usinglow-diametercathetersandlow blood flowrates, pump-drivenveno-venous ECCO2Rmaybeprimarily
feasible inpatients withmild tomoderate respiratoryacidosis. This may be aimed at reducing aggressiveness of invasive ventilation in patients with ARDS. Recently Grasso et al. [6]
showedthattheuseofECCO2Rpermittedtoreducerespiratory
rate from 30 to 14 breaths/min while removing 39% of CO2
production.Interestinglysomecytokines(interleukin-6andtumor necrosis factor-
a
) concentrations were significantly lower in plasma and in bronchoalveolar lavage, suggesting that ECCO2Risalsocapabletolimitbiotrauma.
Sinceintensivecarespecialistsarefamiliarwithhemodialysis catheters, it is necessary to test whether these catheters also qualify for ECCO2R. The maximal blood flow through these
catheters is usually restricted to approximately 400mL/min. Furthermore, catheters specificallydesigned for ECCO2R aimto
avoidrecirculation(PCO2ofthevenousblood,whichisdirected
towardstheoxygenator,islowerthanarterialPCO2).Recirculation
wasobviouswhenhemodialysiscatheterswereused,evenwith low bloodflow[7].Recirculationhasnotbeenevaluatedinthe Godetetal.study[1].
Using a pumplessextracorporeallungassist, Beinet al.’s[4]
randomized79ARDSpatientswereenrolledtoreceivealowVT ventilation(3mL/kg)combinedwithextracorporealCO2
elimina-tion,ortoaARDS-Netstrategy(6mL/kg)withoutthe extracorpo-realdevice.Ventilator-freedays(VFD)within60 dayswerenot different between the two groups. However, in the more hypoxemicpatients(PaO2/FIO2<150mmHg)VFD-60washigher
intheECCO2Rgroupsuggestingthatnexttrialsshouldfocusonthis
moderatetosevereARDSgroup[4].
TheconceptofECCO2Revolved inresponsetoearlytrials of
ECMOwherethehighincidenceofadverseeventsandmechanical complicationsrelegatedthetherapytoonlythesickestofpatients as a last ditch effort [4,8,9]. Furthermore, the high cost and complexityoftheextracorporealmembraneoxygenation(ECMO) systems limited their use to a small number of high volume
specializedmedicalfacilities.Asthetechnologyandunderstanding ofextracorporealgasexchangehasimproved,furtherreductionsin theincidenceofadverseeventsandmechanicalfailureshavebeen achievedby:
advances in hollow fiber membrane technology, in terms of reductions in the fiber diameter and wall thickness, and prevention of plasma leakage to reduce the need for gas exchangerreplacements;
moresophisticated arrangements of hollow fibermembranes whichreduceprimingvolume,reduceresistancetobothblood and sweep gasflowthrough thedevice,andimprovethegas exchangeefficiencyallowingforreducedfibersurfaceareaand/ orcircuitflowrate;
the use of centrifugal pumps or non-occlusive pressure controlled roller pumps, which reduces damage tothe blood (hemolysis)andtheincidenceofcircuitrupture;
biocompatiblecoatings on thefibers and circuit components (suchasheparin),whichreducetheriskofclotformationaswell asthenecessarylevelsofsystemicanticoagulation;
theuseofsingledual-lumencathetersandpercutaneousvenous cannulation, which reduces the incidence of cannulation-associated adverse events as well as the level of patient discomfort;
simplificationsinthesystemdesigntoreduceriskofmechanical failureandoperatorerror;
useofactivemixingofbloodadjacenttothefiberstoincreasegas exchangeefficiency,whichallowsforreducedfibersurfacearea and/orreducedbloodflow;
useofarterial-to-venouscannulationtoeliminatetheneedfora pump.
Finally, the study of Godet et al. [1] showed that a simple techniquebasedonastandardRRTplatform(Prismaflex1
)could beeasilyimplementedonexistingdevices.Inthefuture,sucha devicecouldbeusedassociatedwiththelungprotectiveor ultra-lung protective ventilation in more ICU patients in extended indications.
Disclosureofinterest
ConflictofinterestofSamirJABER:DrJaberreportsreceiving consultingfeesfromDra¨ger,Hamilton,MaquetandFisherPaykel ConflictofinterestofLaurentPAPAZIAN:LaurentPAPAZIANdo not have any conflicts of interest to declare regarding this manuscript.
References
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[2]RozeH,RepusseauB,OuattaraA.Extracorporealmembraneoxygenationinadults forsevereacuterespiratoryfailure.AnnFrAnesthReanim2014;33:492–4.
[3]AbramsDC,BrennerK,BurkartKM,AgerstrandCL,ThomashowBM,Bacchetta M,etal.Pilotstudyofextracorporealcarbondioxideremovalto facilitate extubationandambulationinexacerbationsofchronicobstructivepulmonary disease.AnnAmThoracSoc2013;10:307–14.
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[5]BurkiNK,ManiRK,HerthFJ,SchmidtW,TeschlerH,BoninF,etal.Anovel extracorporealCO2removalsystem:resultsofapilotstudyofhypercapnic respiratoryfailureinpatientswithCOPD.Chest2013;143:678–86.
[6]GrassoS,StripoliT,MazzoneP,PezzutoM,LacitignolaL,CentonzeP,etal.Low respiratoryrateplusminimallyinvasiveextracorporealCO2removaldecreases systemic and pulmonary inflammatory mediators in experimental. Acute RespirDistressSyndrome.CritCareMed2014;42:e451–60.
[7]KaragiannidisC,KampeKA,SipmannFS,LarssonA,HedenstiernaG,Windisch W,etal.Veno-venousextracorporealCO2removalforthetreatmentofsevere respiratoryacidosis:pathophysiologicalandtechnicalconsiderations.CritCare 2014;18:R124.
[8]AzoulayE,CiterioG,BakkerJ,BassettiM,BenoitD,CecconiM,etal.Yearin reviewinIntensiveCareMedicine2013:II.Sedation,invasiveandnoninvasive ventilation,airways,ARDS,ECMO,familysatisfaction,end-of-lifecare,organ donation, informed consent, safety, hematological issues in critically ill patients.IntensiveCareMed2014;40:305–19.
[9]Roncon-AlbuquerqueJrR,CaronaG,NevesA,MirandaF,Castelo-BrancoS, OliveiraT,etal.VenovenousextracorporealCO2removalforearlyextubationin COPDexacerbationsrequiringinvasivemechanicalventilation.IntensiveCare Med2014;40:1969–70.
LaurentPapaziana,*,b aIntensivecareunit‘‘acuterespiratoryfailureandsevereinfections’’,
Assistancepublique–hoˆpitauxdeMarseille, CHUNord,13015Marseille,France
bFaculte´ deme´decine,Aix-Marseilleuniversity,
URMITEUMRCNRS7278,13005Marseille,France SamirJaberc cIntensiveCareUnitandTransplantation,CriticalCareandAnesthesia
Department(DARB),Saint-EloiHospital,UniversityofMontpellier, INSERMU1046,CNRSUMR9214,34295Montpelliercedex5,France
*Correspondingauthor E-mailaddress:laurent.papazian@ap-hm.fr(L.Papazian)