“Awake” ECCO2R superseded intubation in a near-fatal asthma attack

Abstract

BackgroundNear-fatal asthma attacks are life threatening events that often require mechanical ventilation. Extracorporeal carbon dioxide removal (ECCO2R) is, beside extracorporeal membrane oxygenation (ECMO), a well-established rescue option whenever ventilation gets to its limits. But there seems to be very rare experience with those techniques in avoiding mechanical ventilation in severe asthma attacks.Case presentationA 67-year-old man with a near-fatal asthma attack deteriorated under non-invasive ventilation conditions. Beside pharmacological treatment, the intensivists decided to use an extracorporeal carbon dioxide removal system (ECCO2R) to avoid sedation and intubation. Within only a few hours, there was a breakthrough and the patient’s status improved continuously. One and a half days later, weaning from ECCO2R was already completed.ConclusionsThe discussion deals with several advantages of extracorporeal lung support in acute asthma, the potential of avoiding intubation and sedation, as well as the benefits of a conscious and spontaneously breathing patient. Extracorporeal membrane oxygenation (ECMO) in general and ECCO2R in particular is a highly effective method for the treatment of an acute near-fatal asthma attack. Pathophysiological aspects favor the “awake” approach, without sedation, intubation, and mechanical ventilation. Therefore, experienced clinicians might consider “awake” ECCO2R in similar cases.

Extracorporeal carbon dioxide removal for acute hypercapnic respiratory failure

“…ECCO 2 R as an adjunct to IMV for refractory asthma was first reported in 1981 [50]. Subsequently, several case series have been reported (Table 3) [51–55]. In the international Extracorporeal Life Support Organization (ELSO) registry, the use of ECMO for asthma has been reported in 24 adult patients between 1986 and 2006.…”

Extracorporeal gas exchange: when to start and how to end?

“…The veno-venous extracorporeal support, through different settings, recognizes two primary rationales:Rescue intervention for tissue hypoxia, primarily due to respiratory failure (high-flow veno-venous ECMO) [5]Reduction of mechanical ventilation and related damages in ARDS [6–8], status asthmaticus [9, 10], and COPD exacerbation (low-flow ECCO 2 R or minimally invasive ECCO 2 R) [11, 12]. To this, another possible use of minimally invasive ECCO 2 R may be considered for COPD patients in order to improve the quality of life by programmed CO2 dialysis [13]…”

Extracorporeal Carbon Dioxide Removal for the Exacerbation of Chronic Hypercapnic Respiratory Diseases

“…These data show that in patients treated with ECMO for status asthmaticus, hypercapnia, rather than hypoxemia, was the central exchange derangement, suggesting that a less invasive technique like ECCO 2 R will be suitable, with fewer complications. Although most of the clinical applications of ECCO 2 R for the treatment of obstructive lung diseases have been reported in patients with COPD, several cases describe ECCO 2 R in patients with near-fatal asthma [50][51][52][53][54] ( Table 4). The first cases reported were by using a pumpless extracorporeal life assist (pECLA) device.…”

“…Sakai et al [53] Extracorporeal Taking into account the deleterious effects of mechanical ventilation and sedation, and the advantages of keeping the patient awake, recently, an awake approach using a double lumen cannula has been described [51]. NIV was used as ventilatory support.…”