Control of respiratory drive by extracorporeal CO2 removal in acute exacerbation of COPD breathing on non-invasive NAVA

Abstract

Background Veno-venous extracorporeal CO 2 removal (vv-ECCO 2 R) and non-invasive neurally adjusted ventilator assist (NIV-NAVA) are two promising techniques which may prevent complications related to prolonged invasive mechanical ventilation in patients with acute exacerbation of COPD. Methods A physiological study of the electrical activity of the diaphragm (Edi) response was conducted with varying degrees of extracorporeal CO 2 removal to control the respiratory drive in patients with severe acute exacerbation of COPD breathing on NIV-NAVA. Results Twenty COPD patients (SAPS II 37 ± 5.6, age 57 ± 9 years) treated with vv-ECCO 2 R and supported by NIV-NAVA were studied during stepwise weaning of vv-ECCO 2 R. Based on dyspnea, tolerance, and blood gases, weaning from vv-ECCO 2 R was successful in 12 and failed in eight patients. Respiratory drive (measured via the Edi) increased to 19 ± 10 μV vs. 56 ± 20 μV in the successful and unsuccessful weaning groups, respectively, resulting in all patients keeping their CO 2 and pH values stable. Edi was the best predictor for vv-ECCO 2 R weaning failure (ROC analysis AUC 0.95), whereas respiratory rate, rapid shallow breathing index, and tidal volume had lower predictive values. Eventually, 19 patients were discharged home, while one patient died. Mortality at 90 days and 180 days was 15 and 25%, respectively. Conclusions This study demonstrates for the first time the usefulness of the Edi signal to monitor and guide patients with severe acute exacerbation of COPD on vv-ECCO 2 R and NIV-NAVA. The Edi during vv-ECCO 2 R weaning was found to be the best predictor of tolerance to removing vv-ECCO 2 R. Electronic supplementary material The online version of this article (10.1186/s13054-019-2404-y) contains supplementary material, which is available to authorized users.

ECCO2R and NIV-NAVA for stepwise early weaning in extremely severe COPD patients: a promising solution with details to be defined

“…Second, five major bleeding events occurred during ECCO 2 R in Karagiannidis's report [1], which prolonged ICU length of stay but had no impact on mortality. Therefore, although rapid extubation with ECCO 2 R would be preferred, such a strategy has to be weighed against the potentially severe complications of ECCO 2 R [4].…”

“…We read with great interest of the report by Karagiannidis and colleagues [1] about the usefulness of the electrical activity of the diaphragm (Edi) signal to monitor and guide patients with severe acute exacerbation of chronic obstructive pulmonary disease (COPD) on venovenous extracorporeal CO 2 removal (ECCO 2 R) and neurally adjusted ventilatory assist non-invasive ventilation (NIV-NAVA). They found the Edi during ECCO 2 R weaning was the best predictor of tolerance to removing ECCO 2 R. Interestingly, based on their study, a stepwise weaning protocol for extremely severe COPD is worth being proposed.…”

“…First, in Karagiannidis's study [1], the investigators applied an average ECCO 2 R blood flow (BF) of 2.1 L/min in the initial phase, which is higher than what is typically applied in COPD exacerbations. This may suggest that they actually used a mini-ECMO for both oxygenation support and CO 2 removal in getting an early stabilization and weaning from IMV, rather than the classic ECCO 2 R with low BF of 1 L/min or less reported in other studies [2].…”

“…The dual-lumen cannula access facilitated early rehabilitation [5]. However, Karagiannidis and colleagues [1] did not use a dual-lumen cannula for ECCO 2 R to get an early ambulation. Therefore, dual-lumen cannula may be a factor which may help in avoiding delayed recovery and weaning failure.…”

“…ECCO2R and NIV-NAVA for stepwise early weaning in extremely severe COPD patients: a promising solution with details to be defined Heyan Wang 1…”