Utilization and outcomes of extracorporeal CO₂ removal (ECCO₂R): Systematic review and meta‐analysis of arterio‐venous and veno‐venous ECCO₂R approaches

Abstract

Introduction: Extracorporeal carbon dioxide removal (ECCO 2 R) provides respiratory support to patients suffering from hypercapnic respiratory failure by utilizing an extracorporeal shunt and gas exchange membrane to remove CO 2 from either the venous (VV-ECCO 2 R) or arterial (AV-ECCO 2 R) system before return into the venous site. AV-ECCO 2 R relies on the patient's native cardiac function to generate pressures needed to deliver blood through the extracorporeal circuit.VV-ECCO 2 R utilizes a mechanical pump and can be used to treat patients with inadequate native cardiac function. We sought to evaluate the existing evidence comparing the subgroups of patients supported on VV and AV-ECCO 2 R devices. Methods: A literature search was performed to identify all relevant studies published between 2000 and 2019. Demographic information, medical indications, perioperative variables, and clinical outcomes were extracted for systematic review and meta-analysis. Results: Twenty-five studies including 826 patients were reviewed. 60% of patients (497/826) were supported on VV-ECCO 2 R. The most frequent indications were acute respiratory distress syndrome (ARDS) [69%, (95%CI: 53%-82%)] and chronic obstructive pulmonary disease (COPD) [49%, (95%CI: 37%-60%)]. ICU length of stay was significantly shorter in patients supported on VV-ECCO 2 R compared to AV-ECCO 2 R [15 (95%CI: 7-23) vs. 42 (95%CI: 17-67) days, p = 0.05].In-hospital mortality was not significantly different [27% (95%CI: 18%-38%) vs. 36% (95%CI: 24%-51%), p = 0.26]. Conclusion:Both VV and AV-ECCO 2 R provided clinically meaningful CO 2 removal with comparable mortality.

Efficacy and Safety of a Low-Flow Extracorporeal Carbon Dioxide Removal System in Acute Respiratory Failure, a Pilot Study in China

“…Cannulae for V-V ECCO 2 R can be placed in any large central vein although the jugular and femoral approaches are most commonly used. The cannulae used for ECCO 2 R have the same complications as any central venous cannula, including risk of vessel perforation leading to bleeding or damage to surrounding structures, for example, pneumothorax or arterial injury [26]. It is essential for central catheters to be used with ultrasound-guided aseptic placement to reduce the risk of complications relating to cannula.…”

Mechanical ventilation during extracorporeal membrane oxygenation support – New trends and continuing challenges

“…ECMO offers a unique opportunity to diminish the intensity of mechanical ventilation or to avoid it at all. [16][17][18][19][20][21]39 Reduction of minute ventilation and consequently using lower VT, dP, and respiratory rate (RR) may be facilitated by extracorporeal CO 2 removal with the use of V-V ECMO or dedicated low-flow circuits (ECCO 2 R), [40][41][42] first described by Kolobow in 1978. 43 Kolobow postulated near-apneic ventilation with the support of extracorporeal gas exchange.…”

The microfluidic artificial lung: Mimicking nature's blood path design to solve the biocompatibility paradox

“…Recently, low blood flow extracorporeal carbon dioxide removal (ECCO 2 R) devices have been developed for use as an adjunct to or replacement for mechanical ventilation, intended for the treatment of ARDS or COPD patients, respectively. 7,8 The use of ambulatory ECMO and ECCO 2 R has transformed the capability to bridge critically ill patients with end-stage lung disease and irreversible lung failure to lung transplantation, enabling the patient to be awake, alert, relatively mobile, and able to participate in physical therapy while awaiting transplant. Further, ECMO has largely supplanted traditional cardiopulmonary bypass for use during lung transplant surgery, allowing for a more controlled application and for the opportunity to seamlessly continue the therapy posttransplant for patients with primary graft dysfunction.…”

“…Over the last two decades, the introduction of centrifugal pumps, heparin‐coated circuits, hollow fiber membranes, and dual‐lumen cannulae has helped to improve the performance and versatility of ECMO therapy. Recently, low blood flow extracorporeal carbon dioxide removal (ECCO 2 R) devices have been developed for use as an adjunct to or replacement for mechanical ventilation, intended for the treatment of ARDS or COPD patients, respectively 7,8 . The use of ambulatory ECMO and ECCO 2 R has transformed the capability to bridge critically ill patients with end‐stage lung disease and irreversible lung failure to lung transplantation, enabling the patient to be awake, alert, relatively mobile, and able to participate in physical therapy while awaiting transplant.…”