Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in Acute Respiratory Distress Syndrome
Ultra-protective ventilation (VT3-4 mL/kg and PPLAT ≤ 25 cm H2O) was proposed to reduce the risk of ventilator-induced lung injury (VILI) in Acute Respiratory Distress Syndrome (ARDS), but it entailed the risk of respiratory acidosis [1, 2]. Extracorporeal carbon dioxide removal (ECCO2R) – while minimising this acidosis by clearing carbon dioxide (CO2) – may be associated with ultra-protective ventilation in ARDS .
The aim of the SUERNOVA trial was to evaluate the feasibility and the safety of ECCO2R in terms of patients who successfully achieved a VT of 4 mL/kg PBW with PaCO2 not increasing more than 20% from the baseline with a value of arterial pH > 7.30. Secondary endpoints were the assessment of physiological variables during ultra-protective strategy and the frequency of adverse events.
STUDY STRENGTHS & LIMITATIONS
The SUPERNOVA study included 95 patients with moderate ARDS; 33 patients were treated with Hemolung, 34 patients with ILA ACTIVE and 28 patients with Cardiohelp®. As results, 78% of patients achieved the ultra-protective ventilation settings by 8 hours while 82% of patients by 24 hours.
Compared to baseline, PaCO2 and PaO2/FiO2 ratio remained stable, while pH significantly increased at 8 hours and 24 hours. Only two serious adverse events were considered attributable to ECCO2R.
This study showed that ECCO2R can be used to minimise the respiratory acidosis due to ultra-protective ventilation in moderate ARDS. However, randomised controlled trials are required to assess benefits and harms of this procedure.
TAKE HOME MESSAGE
ECCO2R may facilitate the use of ultra-protective ventilation in moderate ARDS by minimising the risk of respiratory acidosis, However, further trials are required to evaluate the benefits and risks of this procedure.
This article review was prepared and submitted by Professor Maria Vargas, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples (Italy), on behalf of the ESICM Journal Review Club.
1) Terragni PP, Del Sorbo L, Mascia L, Urbino R, Martin EL, Birocco A, Faggiano C, Quintel M, Gattinoni L, Ranieri VM (2009), Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal, Anesthesiology 111:826–835.
2) Fanelli V, Ranieri MV, Mancebo J, Moerer O, Quintel M, Morley S, Moran I, Parrilla F, Costamagna A, Gaudiosi M, Combes A (2016), Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress syndrome, Crit Care 20:36–43.
3) Deniau B, Ricard JD, Messika J, Dreyfuss D, Gaudry S (2016), Use of extracorporeal carbon dioxide removal (ECCO2R) in 239 intensive care units: results from a French national survey, Intensive Care Med 42:624–625.