Extracorporeal Carbon Dioxide Removal in the Treatment of Status Asthmaticus

Abstract

Objectives: Venovenous extracorporeal carbon dioxide removal may be lifesaving in the setting of status asthmaticus. Design: Retrospective review. Setting: Medical ICU. Patients: Twenty-six adult patients with status asthmaticus treated with venovenous extracorporeal carbon dioxide removal. Interventions: None. Measurements and Main Results: Demographic data and characteristics of current and prior asthma treatments were obtained from the electronic medical record. Mechanical ventilator settings, arterial blood gases, vital signs, and use of vasopressors were collected from the closest time prior to cannulation and 24 hours after initiation of extracorporeal carbon dioxide removal. Extracorporeal carbon dioxide removal settings, including blood flow and sweep gas flow, were collected at 24 hours after initiation of extracorporeal carbon dioxide removal. Outcome measures included rates of survival to hospital discharge, ICU and hospital lengths of stay, duration of invasive mechanical ventilation and extracorporeal carbon dioxide removal support, and complications during extracorporeal carbon dioxide removal. Following the initiation of extracorporeal carbon dioxide removal, blood gas values were significantly improved at 24 hours, as were peak airway pressures, intrinsic positive end-expiratory pressure, and use of vasopressors. Survival to hospital discharge was 100%. Twenty patients (76.9%) were successfully extubated while receiving extracorporeal carbon dioxide removal support; none required reintubation. The most common complication was cannula-associated deep venous thrombosis (six patients, 23.1%). Four patients (15.4%) experienced bleeding that required a transfusion of packed RBCs. Conclusions: In the largest series to date, use of venovenous extracorporeal carbon dioxide removal in patients with status asthmaticus can provide a lifesaving means of support until the resolution of the exacerbation, with an acceptably low rate of complications. Early extubation in select patients receiving extracorporeal carbon dioxide removal is safe and feasible and avoids the deleterious effects of positive-pressure mechanical ventilation in this patient population.

Successful Utilization of Life-saving Extra-Corporeal CO2 Removal in Catastrophic Status Asthmaticus: a Case Report

“…In these scenarios, extracorporeal membrane oxygenation (ECMO) may be utilized to provide gas exchange and adequate carbon dioxide removal with minimal to no reliance on a ventilator. 3 …”

Extracorporeal Carbon Dioxide Removal or Extracorporeal Membrane Oxygenation: Why Should We Care?

“…Bromberger et al (1) apply ECCO 2 R nomenclature to a patient cohort that was treated with standard venovenous ECMO circuitry. Mean blood flow rate 24 hours after ECMO initiation was 3.2 ± 0.6 L/min.…”

“…Mean blood flow rate 24 hours after ECMO initiation was 3.2 ± 0.6 L/min. Twenty-three patients (88.4%) received a dual-site configuration with a mean 23-Fr drainage and 20-Fr return cannula size (1). The authors state, “When standard ECLS circuitry is used with the primary intent of carbon dioxide removal, ECCO 2 R is being provided, regardless of whether or not smaller cannulae are used with lower blood flow rates (1).…”

“…Twenty-three patients (88.4%) received a dual-site configuration with a mean 23-Fr drainage and 20-Fr return cannula size (1). The authors state, “When standard ECLS circuitry is used with the primary intent of carbon dioxide removal, ECCO 2 R is being provided, regardless of whether or not smaller cannulae are used with lower blood flow rates (1). ” First, the primary intent of ECLS may be elusive and dynamic as a patient’s clinical status evolves (3–5).…”

What Is the Best Extracorporeal Carbon Dioxide Removal Blood Flow to Help Treating Patients With Severe Status Asthmaticus!

“…Bromberger et al (1), in their article published in a recent issue of Critical Care Medicine , discuss data regarding extracorporeal carbon dioxide removal (ECCO 2 R) in the treatment of status asthmaticus, suggesting that although not necessary for oxygenation support, a blood flow of at least 2 L/min is needed to prevent circuit complications when standard extracorporeal lung support circuitry is used for venovenous ECCO 2 R. We would like to comment. Indeed, some reports have shown that low flow ECCO 2 R systems with a blood flow lower than 500 mL/min were able to treat efficiently status asthmaticus without having circuit complications (2).…”