Extracorporeal CO2 removal: Technical and physiological fundaments and principal indications

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"apellidos" => "Ferrer" "email" => array:1 [ 0 => "rferrer@mutuaterrassa.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Mútua de Terrassa, Universidad de Barcelona, Terrassa, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eliminación extracorpórea de CO2: fundamentos fisiológicos y técnicos y principales indicaciones" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1455 "Ancho" => 2993 "Tamanyo" => 256298 ] ] "descripcion" => array:1 [ "en" => "Schematic representation of the functioning of the different CO2 removal devices." ] ] ] "textoCompleto" => "IntroductionIn recent years, different strategies and technological improvements have made it possible to reduce the size and complexity of extracorporeal membrane oxygenation (ECMO) devices–thereby allowing a gradual increase in the use and safety of these systems.<a class="elsevierStyleCrossRefs" href="#bib0165">1,2</a>In concordance with these advances, and with the aim of contributing to this simplification process, Gattinoni and Kolobow were the pioneers in describing the need to dissociate oxygenation support from exclusive ventilation extracorporeal support, with the purpose of optimizing lung protection during mechanical ventilation. This gave rise to the extracorporeal CO2 removal (ECCO2R) devices,<a class="elsevierStyleCrossRef" href="#bib0175">3</a> which extract CO2 from venous blood by passing it through a membrane similar to that used in ECMO. The main difference is that the blood flow rates used in this case are much lower, and the arterial and venous cannulas are therefore smaller.<a class="elsevierStyleCrossRef" href="#bib0180">4</a> These systems were initially conceived mainly for patients with severe acute respiratory distress syndrome (ARDS), where the protective ventilation strategies produce important hypercapnia.<a class="elsevierStyleCrossRef" href="#bib0185">5</a> More recently, however, the technique has also been used in patients with exacerbated chronic obstructive pulmonary disease (COPD).<a class="elsevierStyleCrossRef" href="#bib0190">6</a>In ARDS, the strategy of the ARDSNet of using a low tidal volume (Vt) (6–8ml/kg ideal body weight) to reduce lung distension, and a high PEEP to improve oxygenation, resulted in a very important decrease in mortality.<a class="elsevierStyleCrossRef" href="#bib0195">7</a> In addition, hyperinsufflation and alveolar opening and closure intrinsically lead to a condition known as ventilator-induced lung injury, which is minimized by using this strategy.<a class="elsevierStyleCrossRef" href="#bib0200">8</a> In a post hoc analysis of the study of the ARDSNet, both the patients receiving low Vt and those receiving high Vt were seen to benefit from a plateau pressure (Pplat) of <30cmH2O, thus evidencing that additional reductions in Vt may be needed in order to maintain Pplat <30cmH2O.<a class="elsevierStyleCrossRef" href="#bib0205">9</a> In this same line, it has been shown that the use of low Vt can prevent the development of ARDS in patients at risk.<a class="elsevierStyleCrossRef" href="#bib0210">10</a> However, despite the described benefits, adherence to the protective ventilation strategy is still not adequate or uniform, and in some cases it may prove insufficient.<a class="elsevierStyleCrossRef" href="#bib0215">11</a>Effects of hypercapniaThe effects of hypercapnia have been extensively studied in animals and have been corroborated in a number of observational clinical studies.<a class="elsevierStyleCrossRefs" href="#bib0220">12,13</a> While hypercapnic acidosis may cause vasodilatation in tissues such as the brain, at pulmonary level it causes vasoconstriction, with an increase in mean pulmonary artery pressure. This, added to the effects of positive pressure ventilation, leads to an important increase in right ventricle afterload.<a class="elsevierStyleCrossRef" href="#bib0230">14</a> The pulmonary hypertension induced by hypercapnia can contribute to the appearance of cor pulmonale in patients with ARDS, with an associated increase in mortality.<a class="elsevierStyleCrossRef" href="#bib0235">15</a> Likewise, hypercapnia and acidosis are established risk factors for the appearance of arrhythmias, which further complicate the management of these patients. In other tissues, hypercapnic acidosis can increase gastric secretion and induce a degree of systemic vasodilatation.In contrast, some studies have found that high CO2 concentrations reduce lung injury through attenuation of the effects of the free radicals and a decrease in the activity of neutrophils<a class="elsevierStyleCrossRef" href="#bib0240">16</a> and other immunological factors, and may even exert protective effects against endotoxin-induced lung damage.<a class="elsevierStyleCrossRef" href="#bib0245">17</a> However, many of these changes might be explained not only by hypercapnia but also by acidosis, and may even be independent–as occurs in the alveolar epithelial monolayers, where hypercapnia with a compensated pH affords no benefit and may even cause damage.<a class="elsevierStyleCrossRef" href="#bib0250">18</a>Different authors have proposed the use of ultra-protective mechanical ventilation (3–4ml/kg ideal body weight) combined with ECCO2R, with the ultimate aim of preventing acute ventilator-induced lung injury. In potential, this strategy would avoid the risks of hypercapnia and would reduce the needs for sedation.<a class="elsevierStyleCrossRefs" href="#bib0255">19,20</a>Technical and physiological fundaments of extracorporeal CO2 removalTechnical simplification has caused the development and potential applications of extracorporeal CO2 extraction (ECCO2R) to advance quickly, avoiding some of the initial problems associated to ECMO. In this respect, ECCO2R is theoretically simpler and has fewer logistic and personnel requirements. In fact, in the case of the low-flow devices, the complexity is similar to that of the continuous renal replacement techniques, which are now very widespread.<a class="elsevierStyleCrossRef" href="#bib0265">21</a>The elimination of CO2 currently represents an intermediate step between conventional ventilatory support and total support with ECMO. This is so because the technique is able to replace more than 50% of ventilatory demand, and therefore allows a reduction of the conventional minute ventilation requirements. The membranes allowing gas exchange are generally made of hollow biocompatible material fibers (poly-4-methyl-1-pentene)<a class="elsevierStyleCrossRef" href="#bib0270">22</a> with an exchange surface area ranging from 0.6 to 2.5m2, and in some cases they are coated with heparin or other components designed to improve biocompatibility. The fundamental technical difference with respect to ECMO is the reduced blood flow involved (300–500ml/min), which is enough for eliminating most of the CO2 produced by metabolism–all thanks to the increased solubility and linear kinetics of this gas in plasma.<a class="elsevierStyleCrossRef" href="#bib0265">21</a> The main advantage of using a lower blood flow is that we can use smaller-caliber cannulas, with improved anticoagulation control.This efficient elimination of CO2 can allow us to safely reduce the mechanical ventilation needs and lower hypercapnia–avoiding its effects upon the central nervous system, the right side of the heart, and other previously described effects.The cannulas we can use range between 13 and 17Fr in caliber, and are usually placed at the patient bedside using the Seldinger technique. On the other hand, thanks to the cumulative technical experienced gained with ECMO, the blood pumps have also experienced important developments, and we can now use electromagnetic pumps in which heat and mechanical trauma are minimized. Mention also should be made of the availability of “pump-free” devices that use the arteriovenous gradient of the patient to make the blood flow across the CO2 extracting membrane.A brief description is provided below of the devices that are currently available (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Arteriovenous devicesNovalung iLA® (Novalung, Germany) and Affinity® NT (Medtronic, Minneapolis, MN, USA): The elimination of CO2 and partial oxygenation is achieved through the percutaneous or preferably surgical placement of a cannula occupying no more than 70% of the vascular lumen (usually the femoral artery), with another cannula placed in a large-caliber vein. In order to function correctly, the gradient must be ≥60mmHg, and a certain degree of patient hemodynamic stability is therefore required.Venovenous devicesNovalung iLA Activve® (Novalung, Germany): This system uses the same iLA® membrane described above, but incorporated within a console with a diagonal pump capable of operating over a broad range of flows (0.5–4.5l/min)–thus making it possible to administer the entire spectrum of extracorporeal ventilatory support from low-flow ECCO2R to venovenous ECMO.DecapSmart® (Hemodec, Salerno, Italy): This is a device fitted with a roller pump that uses an oxygenation membrane and a hemofilter in series. The hemofilter ultrafiltrate is returned to the circulation before the membrane, producing a plasma recirculation effect with the purpose of securing additional elimination of the CO2 dissolved in it. Likewise, the system allows the use of anticoagulation in a way similar to the renal replacement devices.ProLUNG® (Estor SpA, Pero, Italy): This device is similar to that described above, but does not use a hemofilter in the circuit. Instead, it has a non-porous biocompatible poly-4-methyl-1-pentene membrane with a surface area of 1.8m2, making recirculation unnecessary. It also comes with a monitor that regulates the administered air flow and measures the elimination of CO2 in digital form (ProLUNG Meter®).Hemolung® (Alung Technologies, Pittsburgh, USA): In contrast to the previous membranes, this system makes use of a cartridge which houses the pump and the membrane. The central core rotates to radially accelerate the blood toward the periphery where the membrane is located. Although the latter has a surface of 0.67m2, its efficacy in eliminating CO2 is similar to that of the devices described above.Pump-Assisted Lung Protection or PALP® (Maquet, Rastatt, Germany): This is a compact system including the console, pump and membrane in a single small piece of equipment (CardioHelp®)–thus making it very portable. In addition, it allows us to replace the conventional membrane with a membrane designed for complete ECMO, for transfer purposes.The elimination of CO2 using the different systems is mainly determined by the mean blood flow, and to a lesser extent by the air flow and membrane surface area and contact time. Therefore, correct catheter placement is crucial in order to optimize the treatment, avoid membrane coagulation problems, and maximize treatment efficiency.Evidence for useDifferent experimental studies have shown ECCO2R to be feasible, effective and safe.<a class="elsevierStyleCrossRefs" href="#bib0275">23,24</a> Based on the results of such studies, the use of ECCO2R techniques in ventilation support has been suggested in clinical situations where they may be useful, such as acute respiratory distress syndrome and the exacerbation of chronic obstructive pulmonary disease.In acute respiratory distress syndromeThe bases for the use of ECCO2R in acute respiratory distress syndrome (ARDS) have largely been extrapolated from studies with ECMO. The studies evaluating the use of ECCO2R in ARDS are heterogeneous and involve different devices, designs and primary outcomes. The different studies evaluate the use of ECCO2R as an adjuvant to protective ventilation, and even in what has been called “ultraprotective” ventilation.Terragni et al. carried out a small study of 32 patients with less than 72h of ARDS. They selected those patients who despite protective ventilation presented a Pplat between 28 and 30cmH2O, lowering the Vt to 4ml/kg and connecting them to ECCO2R. In the mentioned group it proved possible to reach a Pplat of 25cmH2O with higher PEEP, and a decrease in proinflammatory cytokines was demonstrated in the bronchoalveolar lavage,<a class="elsevierStyleCrossRef" href="#bib0255">19</a> thereby evidencing a biological effect indicating lesser ventilator-induced damage. Adopting a similar approach, the randomized Xtravent study<a class="elsevierStyleCrossRef" href="#bib0260">20</a> compared protective ventilation (6ml/kg ideal body weight) versus ultraprotective ventilation (3ml/kg ideal body weight)+ECCO2R. In a post hoc analysis of the subgroup of patients with PaO2/FiO2 <150mmHg, treatment with ultraprotective ventilation+ECCO2R was found to significantly reduce the days without mechanical ventilation. Complications in the form of bleeding or local problems with the vascular cannulas were recorded in 7.5% of the patients treated with ECCO2R. In this case the arteriovenous technique was used.ECCO2R integrated in a dialysis circuit demonstrated a decrease in the use of vasopressors and improvement of acidosis in patients with renal and respiratory failure mostly due to viral pneumonia.<a class="elsevierStyleCrossRef" href="#bib0285">25</a>Lastly, a recent systematic review<a class="elsevierStyleCrossRef" href="#bib0290">26</a> including 14 studies (two randomized controlled trials and 12 observational studies) found no global differences in mortality, stay in the UCI or days without mechanical ventilation, except in the subgroup corresponding to the more seriously ill patients. In relation to safety, a progressive decrease in the number of complications was observed. In the case of the arteriovenous techniques, the most frequent complication was ischemia of the extremity in which the cannula was placed–the problem being serious in 6 cases (5 compartmental syndromes and one amputation). In the venovenous techniques, the most frequent complication was coagulation of the membrane/circuit of the device. In both cases the patients assigned to ECCO2R had greater transfusion needs.A number of studies are currently underway to determine the clinical usefulness of the ECCO2R devices combined with ultraprotective ventilation (such as the SUPERNOVA trial, endorsed by the European Society of Intensive Care Medicine). However, the evidence available to date is inconclusive, and the use of this treatment modality in ARDS must be individualized, based on physiological and clinical criteria.In exacerbated chronic obstructive pulmonary diseaseExacerbations of chronic obstructive pulmonary disease (COPD) are the leading cause of hospital admission in these patients, and can manifest on different occasions in a short period of time (winter season). Although most such episodes can be treated on a medical basis, in some cases both noninvasive ventilatory support (NIMV) and invasive ventilatory support may prove necessary, depending on the severity of the condition and the predominant symptoms. Thus, in a fraction of these patients, despite the absence of major changes in oxygenation or in the symptoms, the exacerbation of COPD may sometimes lead to CO2 retention–with the inevitable consequences this has at central nervous system level. Furthermore, each exacerbation constitutes a risk factor for further exacerbations, with an increase in mortality.<a class="elsevierStyleCrossRef" href="#bib0295">27</a> The mortality rate among patients with exacerbations of COPD is about 4.8% in individuals subjected NIMV, according to Lindenauer et al.,<a class="elsevierStyleCrossRef" href="#bib0300">28</a> and 29.3% in those in which NIMV fails and conversion to invasive ventilation is required.<a class="elsevierStyleCrossRef" href="#bib0305">29</a> Despite the advances in the application and refinement of the protocols regarding the use of NIMV, an important proportion of patients (19–40%) continue to fail and require intubation.<a class="elsevierStyleCrossRef" href="#bib0310">30</a>The first clinical study on the efficacy and safety of ECCO2R in patients with hypercapnic respiratory failure was published in 2012.<a class="elsevierStyleCrossRef" href="#bib0315">31</a> This was a retrospective, multicenter study in which 21 patients with exacerbated hypercapnia received treatment with arteriovenous ECCO2R before NIMV failure, defined as the need for intubation. This group of patients was then compared with a retrospective cohort of individuals requiring invasive ventilation. Ninety percent of the patients in the intervention group did not require invasive ventilation. However, no differences in mortality were demonstrated. As regards the complications, two cases of major bleeding and 7 cases of minor bleeding were reported in the course of treatment, as well as one femoral pseudoaneurysm and one case of heparin-induced thrombocytopenia.Burki et al.<a class="elsevierStyleCrossRef" href="#bib0190">6</a> conducted a pilot study involving venovenous ECCO2R and, as in the previous study, used the technique in a group of patients with hypercapnia and with an important risk of requiring intubation. Furthermore, in another arm of the study they included patients who had suffered two failed NIMV weaning attempts and who rejected intubation, while a third group was subjected to invasive ventilation, with the evaluation of ECCO2R in those individuals who could not be weaned from ventilation. Intubations and invasive ventilation were avoided in both the first and the second group. In the third group the authors recorded a decrease in dyspnea and in the degree of ventilatory support, allowing satisfactory weaning of three of 11 patients.More recently, Del Sorbo et al.<a class="elsevierStyleCrossRef" href="#bib0320">32</a> conducted a similar clinical (paired cohort) study in which the intervention group was subjected to NIMV plus venovenous ECCO2R. The risk of intubation was seen to increase three-fold in the patients with NIMV alone compared to those patients in which NIMV was combined with ECCO2R. The observed difference was not significant, however. The most frequent complication associated to ECCO2R was coagulation of the circuit, as has been reported by other authors.Other indicationsThere is clinical experience with the use of ECCO2R in patients with bronchopleural fistula, primary graft dysfunction in lung transplantation, intracranial hypertension and hypercapnia, as well as in other clinical situations in which the physiopathology suggests to a potential beneficial effect of ECCO2R. However, such uses are merely anecdotal, with a lack of sufficient cumulative clinical experience.ConclusionsThe technical advances in recent years have allowed ECCO2R to become simple and feasible, and it now represents a further option for the support of patients with serious respiratory diseases and high mortality. As a treatment option, ECCO2R is positioned between conventional ventilatory support and total respiratory support (ECMO). We therefore feel that its place in clinical practice could be the population of patients with ARDS presenting PaO2/FiO2 >80 and <150mmHg, in which treatment and conventional ventilation support have been maximally optimized, and in which it is considered advisable to minimize pulmonary distension and/or attenuate the effects of hypercapnia and acidosis–since ECCO2R has been found to be effective in this setting. Likewise, in patients with exacerbated COPD without indications of intubation or in which NIMV is contraindicated, ECCO2R represents a new management option that should be considered on an individualized basis, in coherence with the risk/benefit ratio.Due to their lower complications rate, we consider the venovenous techniques to be the best option. However, ECCO2R is neither a definitive solution nor a perfect device, and its effects upon other clinical indicators remain to be determined.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres600895" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec615084" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres600896" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec615085" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Effects of hypercapnia" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Technical and physiological fundaments of extracorporeal CO removal" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Arteriovenous devices" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Venovenous devices" ] ] ] 7 => array:3 [ "identificador" => "sec0030" "titulo" => "Evidence for use" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "In acute respiratory distress syndrome" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "In exacerbated chronic obstructive pulmonary disease" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Other indications" ] ] ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-29" "fechaAceptado" => "2015-06-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec615084" "palabras" => array:5 [ 0 => "Artificial respiration" 1 => "Carbon dioxide" 2 => "Extracorporeal circulation" 3 => "Adult respiratory distress syndrome" 4 => "Chronic obstructive pulmonary disease" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec615085" "palabras" => array:5 [ 0 => "Respiración artificial" 1 => "Dióxido de carbono" 2 => "Circulación extracorpórea" 3 => "Síndrome de distrés respiratorio" 4 => "Enfermedad pulmonar obstructiva crónica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "In recent years, technological improvements have reduced the complexity of extracorporeal membrane oxygenation devices. This has enabled the development of specific devices for the extracorporeal removal of CO2. These devices have a simpler configuration than extracorporeal membrane oxygenation devices and uses lower blood flows which could reduce the potential complications. Experimental studies have demonstrated the feasibility, efficacy and safety of extracorporeal removal of CO2 and some of its effects in humans.This technique was initially conceived as an adjunct therapy in patients with severe acute respiratory distress syndrome, as a tool to optimize protective ventilation. More recently, the use of this technique has allowed the emergence of a relatively new concept called “TRA-protective ventilation” whose effects are still to be determined. In addition, the extracorporeal removal of CO2 has been used in patients with exacerbated hypercapnic respiratory failure with promising results.In this review we will describe the physiological and technical fundamentals of this therapy and its variants as well as an overview of the available clinical evidence, focused on its current potential." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Recientemente las mejoras tecnológicas han permitido reducir la complejidad de los dispositivos de oxigenación por membrana extracorpórea, dando paso al desarrollo de dispositivos específicos para la eliminación extracorpórea de CO2. Estos dispositivos tienen un montaje más simple y utilizan flujos sanguíneos más bajos, lo que potencialmente disminuye las complicaciones vasculares y hemodinámicas. Estudios experimentales han demostrado la factibilidad, eficacia y seguridad de la eliminación extracorpórea de CO2 y algunos de sus efectos en humanos.Esta técnica, que fue concebida como un tratamiento complementario en los pacientes con SDRA grave, permite la optimización de la ventilación protectora e incluso ha abierto el camino a nuevos conceptos, como lo que se ha denominado ventilación «ultraprotectora»”, cuyos beneficios aún están por determinarse. Además, la eliminación extracorpórea de CO2 se está implementando en pacientes con insuficiencia respiratoria hipercápnica agudizada con resultados prometedores.En esta revisión describiremos los fundamentos fisiológicos y técnicos de esta terapia y sus distintas variantes, así como la evidencia clínica disponible hasta la fecha, enfocados en su potencial en el paciente con insuficiencia respiratoria." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Romay E, Ferrer R. Eliminación extracorpórea de CO2: fundamentos fisiológicos y técnicos y principales indicaciones. Med Intensiva. 2016;40:33–38." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1455 "Ancho" => 2993 "Tamanyo" => 256298 ] ] "descripcion" => array:1 [ "en" => "Schematic representation of the functioning of the different CO2 removal devices." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "A-V: arteriovenous; PMP: poly-4-methyl-1-pentene; PLP: polypropylene; V-A: venoarterial (extracorporeal membrane oxygenation); V-V: venovenous." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Device \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of therapy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pump \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Membrane (material); surface in m2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blood flow (l/min) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Purge volume (ml) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maquet PALP® CardioHelp® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">V-V/V-A/A-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Magnetic roller \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PMP (option of coating with Bioline®); 0.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2–2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">247 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alung Hemolung® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low flow V-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Centrifugal with integrated membrane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Porous PLP with siloxane and heparin; 0.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.35–0.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">259 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Estor ProLUNG® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low flow V-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peristaltic roller \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PMP with phosphorylcholine coating; 1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">220 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemodec DecapSmart® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low flow V-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peristaltic roller \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Porous PLP; 1.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">140–160 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Novalung iLA Activve® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low, medium and high flow V-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagonal rotor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PMP; 0.32 (MiniLung® petite) PMP; 1.3 (iLA®) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5–4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">240 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Novalung iLA Novalung® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PMP; 1.3 (iLA®) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">240 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab983103.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Technical characteristics of the different extracorporeal CO2 removal devices." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0165" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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Extracorporeal CO2 removal: Technical and physiological fundaments and principal indications

Eliminación extracorpórea de CO2: fundamentos fisiológicos y técnicos y principales indicaciones

E. Romaya, R. Ferrera,b,

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rferrer@mutuaterrassa.es

Corresponding author.

a Servicio de Medicina Intensiva, Hospital Universitario Mútua de Terrassa, Universidad de Barcelona, Terrassa, Barcelona, Spain

b Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years&#44; different strategies and technological improvements have made it possible to reduce the size and complexity of extracorporeal membrane oxygenation &#40;ECMO&#41; devices&#8211;thereby allowing a gradual increase in the use and safety of these systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In concordance with these advances&#44; and with the aim of contributing to this simplification process&#44; Gattinoni and Kolobow were the pioneers in describing the need to dissociate oxygenation support from exclusive ventilation extracorporeal support&#44; with the purpose of optimizing lung protection during mechanical ventilation&#46; This gave rise to the extracorporeal CO<span class="elsevierStyleInf">2</span> removal &#40;ECCO2R&#41; devices&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">3</span></a> which extract CO<span class="elsevierStyleInf">2</span> from venous blood by passing it through a membrane similar to that used in ECMO&#46; The main difference is that the blood flow rates used in this case are much lower&#44; and the arterial and venous cannulas are therefore smaller&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a> These systems were initially conceived mainly for patients with severe acute respiratory distress syndrome &#40;ARDS&#41;&#44; where the protective ventilation strategies produce important hypercapnia&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> More recently&#44; however&#44; the technique has also been used in patients with exacerbated chronic obstructive pulmonary disease &#40;COPD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In ARDS&#44; the strategy of the ARDSNet of using a low tidal volume &#40;Vt&#41; &#40;6&#8211;8<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal body weight&#41; to reduce lung distension&#44; and a high PEEP to improve oxygenation&#44; resulted in a very important decrease in mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a> In addition&#44; hyperinsufflation and alveolar opening and closure intrinsically lead to a condition known as ventilator-induced lung injury&#44; which is minimized by using this strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a> In a <span class="elsevierStyleItalic">post hoc</span> analysis of the study of the ARDSNet&#44; both the patients receiving low Vt and those receiving high Vt were seen to benefit from a plateau pressure &#40;Pplat&#41; of &#60;30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; thus evidencing that additional reductions in Vt may be needed in order to maintain Pplat &#60;30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> In this same line&#44; it has been shown that the use of low Vt can prevent the development of ARDS in patients at risk&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">10</span></a> However&#44; despite the described benefits&#44; adherence to the protective ventilation strategy is still not adequate or uniform&#44; and in some cases it may prove insufficient&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Effects of hypercapnia</span><p id="par0020" class="elsevierStylePara elsevierViewall">The effects of hypercapnia have been extensively studied in animals and have been corroborated in a number of observational clinical studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">12&#44;13</span></a> While hypercapnic acidosis may cause vasodilatation in tissues such as the brain&#44; at pulmonary level it causes vasoconstriction&#44; with an increase in mean pulmonary artery pressure&#46; This&#44; added to the effects of positive pressure ventilation&#44; leads to an important increase in right ventricle afterload&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">14</span></a> The pulmonary hypertension induced by hypercapnia can contribute to the appearance of <span class="elsevierStyleItalic">cor pulmonale</span> in patients with ARDS&#44; with an associated increase in mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a> Likewise&#44; hypercapnia and acidosis are established risk factors for the appearance of arrhythmias&#44; which further complicate the management of these patients&#46; In other tissues&#44; hypercapnic acidosis can increase gastric secretion and induce a degree of systemic vasodilatation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In contrast&#44; some studies have found that high CO<span class="elsevierStyleInf">2</span> concentrations reduce lung injury through attenuation of the effects of the free radicals and a decrease in the activity of neutrophils<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a> and other immunological factors&#44; and may even exert protective effects against endotoxin-induced lung damage&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> However&#44; many of these changes might be explained not only by hypercapnia but also by acidosis&#44; and may even be independent&#8211;as occurs in the alveolar epithelial monolayers&#44; where hypercapnia with a compensated pH affords no benefit and may even cause damage&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">18</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Different authors have proposed the use of ultra-protective mechanical ventilation &#40;3&#8211;4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal body weight&#41; combined with ECCO2R&#44; with the ultimate aim of preventing acute ventilator-induced lung injury&#46; In potential&#44; this strategy would avoid the risks of hypercapnia and would reduce the needs for sedation&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">19&#44;20</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Technical and physiological fundaments of extracorporeal CO<span class="elsevierStyleInf">2</span> removal</span><p id="par0035" class="elsevierStylePara elsevierViewall">Technical simplification has caused the development and potential applications of extracorporeal CO<span class="elsevierStyleInf">2</span> extraction &#40;ECCO2R&#41; to advance quickly&#44; avoiding some of the initial problems associated to ECMO&#46; In this respect&#44; ECCO2R is theoretically simpler and has fewer logistic and personnel requirements&#46; In fact&#44; in the case of the low-flow devices&#44; the complexity is similar to that of the continuous renal replacement techniques&#44; which are now very widespread&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The elimination of CO<span class="elsevierStyleInf">2</span> currently represents an intermediate step between conventional ventilatory support and total support with ECMO&#46; This is so because the technique is able to replace more than 50&#37; of ventilatory demand&#44; and therefore allows a reduction of the conventional minute ventilation requirements&#46; The membranes allowing gas exchange are generally made of hollow biocompatible material fibers &#40;poly-4-methyl-1-pentene&#41;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">22</span></a> with an exchange surface area ranging from 0&#46;6 to 2&#46;5<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; and in some cases they are coated with heparin or other components designed to improve biocompatibility&#46; The fundamental technical difference with respect to ECMO is the reduced blood flow involved &#40;300&#8211;500<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#44; which is enough for eliminating most of the CO<span class="elsevierStyleInf">2</span> produced by metabolism&#8211;all thanks to the increased solubility and linear kinetics of this gas in plasma&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a> The main advantage of using a lower blood flow is that we can use smaller-caliber cannulas&#44; with improved anticoagulation control&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This efficient elimination of CO<span class="elsevierStyleInf">2</span> can allow us to safely reduce the mechanical ventilation needs and lower hypercapnia&#8211;avoiding its effects upon the central nervous system&#44; the right side of the heart&#44; and other previously described effects&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The cannulas we can use range between 13 and 17<span class="elsevierStyleHsp" style=""></span>Fr in caliber&#44; and are usually placed at the patient bedside using the Seldinger technique&#46; On the other hand&#44; thanks to the cumulative technical experienced gained with ECMO&#44; the blood pumps have also experienced important developments&#44; and we can now use electromagnetic pumps in which heat and mechanical trauma are minimized&#46; Mention also should be made of the availability of &#8220;pump-free&#8221; devices that use the arteriovenous gradient of the patient to make the blood flow across the CO<span class="elsevierStyleInf">2</span> extracting membrane&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A brief description is provided below of the devices that are currently available &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Arteriovenous devices</span><p id="par0060" class="elsevierStylePara elsevierViewall">Novalung iLA<span class="elsevierStyleSup">&#174;</span> &#40;Novalung&#44; Germany&#41; and Affinity<span class="elsevierStyleSup">&#174;</span> NT &#40;Medtronic&#44; Minneapolis&#44; MN&#44; USA&#41;&#58; The elimination of CO<span class="elsevierStyleInf">2</span> and partial oxygenation is achieved through the percutaneous or preferably surgical placement of a cannula occupying no more than 70&#37; of the vascular lumen &#40;usually the femoral artery&#41;&#44; with another cannula placed in a large-caliber vein&#46; In order to function correctly&#44; the gradient must be &#8805;60<span class="elsevierStyleHsp" style=""></span>mmHg&#44; and a certain degree of patient hemodynamic stability is therefore required&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Venovenous devices</span><p id="par0065" class="elsevierStylePara elsevierViewall">Novalung iLA Activve<span class="elsevierStyleSup">&#174;</span> &#40;Novalung&#44; Germany&#41;&#58; This system uses the same iLA<span class="elsevierStyleSup">&#174;</span> membrane described above&#44; but incorporated within a console with a diagonal pump capable of operating over a broad range of flows &#40;0&#46;5&#8211;4&#46;5<span class="elsevierStyleHsp" style=""></span>l&#47;min&#41;&#8211;thus making it possible to administer the entire spectrum of extracorporeal ventilatory support from low-flow ECCO2R to venovenous ECMO&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">DecapSmart<span class="elsevierStyleSup">&#174;</span> &#40;Hemodec&#44; Salerno&#44; Italy&#41;&#58; This is a device fitted with a roller pump that uses an oxygenation membrane and a hemofilter in series&#46; The hemofilter ultrafiltrate is returned to the circulation before the membrane&#44; producing a plasma recirculation effect with the purpose of securing additional elimination of the CO<span class="elsevierStyleInf">2</span> dissolved in it&#46; Likewise&#44; the system allows the use of anticoagulation in a way similar to the renal replacement devices&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">ProLUNG<span class="elsevierStyleSup">&#174;</span> &#40;Estor SpA&#44; Pero&#44; Italy&#41;&#58; This device is similar to that described above&#44; but does not use a hemofilter in the circuit&#46; Instead&#44; it has a non-porous biocompatible poly-4-methyl-1-pentene membrane with a surface area of 1&#46;8<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; making recirculation unnecessary&#46; It also comes with a monitor that regulates the administered air flow and measures the elimination of CO<span class="elsevierStyleInf">2</span> in digital form &#40;ProLUNG Meter<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Hemolung<span class="elsevierStyleSup">&#174;</span> &#40;Alung Technologies&#44; Pittsburgh&#44; USA&#41;&#58; In contrast to the previous membranes&#44; this system makes use of a cartridge which houses the pump and the membrane&#46; The central core rotates to radially accelerate the blood toward the periphery where the membrane is located&#46; Although the latter has a surface of 0&#46;67<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; its efficacy in eliminating CO<span class="elsevierStyleInf">2</span> is similar to that of the devices described above&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Pump-Assisted Lung Protection or PALP<span class="elsevierStyleSup">&#174;</span> &#40;Maquet&#44; Rastatt&#44; Germany&#41;&#58; This is a compact system including the console&#44; pump and membrane in a single small piece of equipment &#40;CardioHelp<span class="elsevierStyleSup">&#174;</span>&#41;&#8211;thus making it very portable&#46; In addition&#44; it allows us to replace the conventional membrane with a membrane designed for complete ECMO&#44; for transfer purposes&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The elimination of CO<span class="elsevierStyleInf">2</span> using the different systems is mainly determined by the mean blood flow&#44; and to a lesser extent by the air flow and membrane surface area and contact time&#46; Therefore&#44; correct catheter placement is crucial in order to optimize the treatment&#44; avoid membrane coagulation problems&#44; and maximize treatment efficiency&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Evidence for use</span><p id="par0095" class="elsevierStylePara elsevierViewall">Different experimental studies have shown ECCO2R to be feasible&#44; effective and safe&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">23&#44;24</span></a> Based on the results of such studies&#44; the use of ECCO2R techniques in ventilation support has been suggested in clinical situations where they may be useful&#44; such as acute respiratory distress syndrome and the exacerbation of chronic obstructive pulmonary disease&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">In acute respiratory distress syndrome</span><p id="par0100" class="elsevierStylePara elsevierViewall">The bases for the use of ECCO2R in acute respiratory distress syndrome &#40;ARDS&#41; have largely been extrapolated from studies with ECMO&#46; The studies evaluating the use of ECCO2R in ARDS are heterogeneous and involve different devices&#44; designs and primary outcomes&#46; The different studies evaluate the use of ECCO2R as an adjuvant to protective ventilation&#44; and even in what has been called &#8220;ultraprotective&#8221; ventilation&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Terragni et al&#46; carried out a small study of 32 patients with less than 72<span class="elsevierStyleHsp" style=""></span>h of ARDS&#46; They selected those patients who despite protective ventilation presented a Pplat between 28 and 30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; lowering the Vt to 4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg and connecting them to ECCO2R&#46; In the mentioned group it proved possible to reach a Pplat of 25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O with higher PEEP&#44; and a decrease in proinflammatory cytokines was demonstrated in the bronchoalveolar lavage&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a> thereby evidencing a biological effect indicating lesser ventilator-induced damage&#46; Adopting a similar approach&#44; the randomized Xtravent study<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a> compared protective ventilation &#40;6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal body weight&#41; <span class="elsevierStyleItalic">versus</span> ultraprotective ventilation &#40;3<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal body weight&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ECCO2R&#46; In a <span class="elsevierStyleItalic">post hoc</span> analysis of the subgroup of patients with PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#60;150<span class="elsevierStyleHsp" style=""></span>mmHg&#44; treatment with ultraprotective ventilation<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ECCO2R was found to significantly reduce the days without mechanical ventilation&#46; Complications in the form of bleeding or local problems with the vascular cannulas were recorded in 7&#46;5&#37; of the patients treated with ECCO2R&#46; In this case the arteriovenous technique was used&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">ECCO2R integrated in a dialysis circuit demonstrated a decrease in the use of vasopressors and improvement of acidosis in patients with renal and respiratory failure mostly due to viral pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">25</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Lastly&#44; a recent systematic review<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> including 14 studies &#40;two randomized controlled trials and 12 observational studies&#41; found no global differences in mortality&#44; stay in the UCI or days without mechanical ventilation&#44; except in the subgroup corresponding to the more seriously ill patients&#46; In relation to safety&#44; a progressive decrease in the number of complications was observed&#46; In the case of the arteriovenous techniques&#44; the most frequent complication was ischemia of the extremity in which the cannula was placed&#8211;the problem being serious in 6 cases &#40;5 compartmental syndromes and one amputation&#41;&#46; In the venovenous techniques&#44; the most frequent complication was coagulation of the membrane&#47;circuit of the device&#46; In both cases the patients assigned to ECCO2R had greater transfusion needs&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A number of studies are currently underway to determine the clinical usefulness of the ECCO2R devices combined with ultraprotective ventilation &#40;such as the SUPERNOVA trial&#44; endorsed by the European Society of Intensive Care Medicine&#41;&#46; However&#44; the evidence available to date is inconclusive&#44; and the use of this treatment modality in ARDS must be individualized&#44; based on physiological and clinical criteria&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">In exacerbated chronic obstructive pulmonary disease</span><p id="par0125" class="elsevierStylePara elsevierViewall">Exacerbations of chronic obstructive pulmonary disease &#40;COPD&#41; are the leading cause of hospital admission in these patients&#44; and can manifest on different occasions in a short period of time &#40;winter season&#41;&#46; Although most such episodes can be treated on a medical basis&#44; in some cases both noninvasive ventilatory support &#40;NIMV&#41; and invasive ventilatory support may prove necessary&#44; depending on the severity of the condition and the predominant symptoms&#46; Thus&#44; in a fraction of these patients&#44; despite the absence of major changes in oxygenation or in the symptoms&#44; the exacerbation of COPD may sometimes lead to CO<span class="elsevierStyleInf">2</span> retention&#8211;with the inevitable consequences this has at central nervous system level&#46; Furthermore&#44; each exacerbation constitutes a risk factor for further exacerbations&#44; with an increase in mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">27</span></a> The mortality rate among patients with exacerbations of COPD is about 4&#46;8&#37; in individuals subjected NIMV&#44; according to Lindenauer et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">28</span></a> and 29&#46;3&#37; in those in which NIMV fails and conversion to invasive ventilation is required&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a> Despite the advances in the application and refinement of the protocols regarding the use of NIMV&#44; an important proportion of patients &#40;19&#8211;40&#37;&#41; continue to fail and require intubation&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">30</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The first clinical study on the efficacy and safety of ECCO2R in patients with hypercapnic respiratory failure was published in 2012&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">31</span></a> This was a retrospective&#44; multicenter study in which 21 patients with exacerbated hypercapnia received treatment with arteriovenous ECCO2R before NIMV failure&#44; defined as the need for intubation&#46; This group of patients was then compared with a retrospective cohort of individuals requiring invasive ventilation&#46; Ninety percent of the patients in the intervention group did not require invasive ventilation&#46; However&#44; no differences in mortality were demonstrated&#46; As regards the complications&#44; two cases of major bleeding and 7 cases of minor bleeding were reported in the course of treatment&#44; as well as one femoral pseudoaneurysm and one case of heparin-induced thrombocytopenia&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Burki et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a> conducted a pilot study involving venovenous ECCO2R and&#44; as in the previous study&#44; used the technique in a group of patients with hypercapnia and with an important risk of requiring intubation&#46; Furthermore&#44; in another arm of the study they included patients who had suffered two failed NIMV weaning attempts and who rejected intubation&#44; while a third group was subjected to invasive ventilation&#44; with the evaluation of ECCO2R in those individuals who could not be weaned from ventilation&#46; Intubations and invasive ventilation were avoided in both the first and the second group&#46; In the third group the authors recorded a decrease in dyspnea and in the degree of ventilatory support&#44; allowing satisfactory weaning of three of 11 patients&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">More recently&#44; Del Sorbo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">32</span></a> conducted a similar clinical &#40;paired cohort&#41; study in which the intervention group was subjected to NIMV plus venovenous ECCO2R&#46; The risk of intubation was seen to increase three-fold in the patients with NIMV alone compared to those patients in which NIMV was combined with ECCO2R&#46; The observed difference was not significant&#44; however&#46; The most frequent complication associated to ECCO2R was coagulation of the circuit&#44; as has been reported by other authors&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Other indications</span><p id="par0145" class="elsevierStylePara elsevierViewall">There is clinical experience with the use of ECCO2R in patients with bronchopleural fistula&#44; primary graft dysfunction in lung transplantation&#44; intracranial hypertension and hypercapnia&#44; as well as in other clinical situations in which the physiopathology suggests to a potential beneficial effect of ECCO2R&#46; However&#44; such uses are merely anecdotal&#44; with a lack of sufficient cumulative clinical experience&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">The technical advances in recent years have allowed ECCO2R to become simple and feasible&#44; and it now represents a further option for the support of patients with serious respiratory diseases and high mortality&#46; As a treatment option&#44; ECCO2R is positioned between conventional ventilatory support and total respiratory support &#40;ECMO&#41;&#46; We therefore feel that its place in clinical practice could be the population of patients with ARDS presenting PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#62;80 and &#60;150<span class="elsevierStyleHsp" style=""></span>mmHg&#44; in which treatment and conventional ventilation support have been maximally optimized&#44; and in which it is considered advisable to minimize pulmonary distension and&#47;or attenuate the effects of hypercapnia and acidosis&#8211;since ECCO2R has been found to be effective in this setting&#46; Likewise&#44; in patients with exacerbated COPD without indications of intubation or in which NIMV is contraindicated&#44; ECCO2R represents a new management option that should be considered on an individualized basis&#44; in coherence with the risk&#47;benefit ratio&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Due to their lower complications rate&#44; we consider the venovenous techniques to be the best option&#46; However&#44; ECCO2R is neither a definitive solution nor a perfect device&#44; and its effects upon other clinical indicators remain to be determined&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Effects of hypercapnia"
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        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Technical and physiological fundaments of extracorporeal CO removal"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Arteriovenous devices"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Venovenous devices"
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        7 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Evidence for use"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "In acute respiratory distress syndrome"
            ]
            1 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "In exacerbated chronic obstructive pulmonary disease"
            ]
            2 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Other indications"
            ]
          ]
        ]
        8 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conclusions"
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        9 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicts of interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2015-05-29"
    "fechaAceptado" => "2015-06-02"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec615084"
          "palabras" => array:5 [
            0 => "Artificial respiration"
            1 => "Carbon dioxide"
            2 => "Extracorporeal circulation"
            3 => "Adult respiratory distress syndrome"
            4 => "Chronic obstructive pulmonary disease"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec615085"
          "palabras" => array:5 [
            0 => "Respiraci&#243;n artificial"
            1 => "Di&#243;xido de carbono"
            2 => "Circulaci&#243;n extracorp&#243;rea"
            3 => "S&#237;ndrome de distr&#233;s respiratorio"
            4 => "Enfermedad pulmonar obstructiva cr&#243;nica"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent years&#44; technological improvements have reduced the complexity of extracorporeal membrane oxygenation devices&#46; This has enabled the development of specific devices for the extracorporeal removal of CO<span class="elsevierStyleInf">2</span>&#46; These devices have a simpler configuration than extracorporeal membrane oxygenation devices and uses lower blood flows which could reduce the potential complications&#46; Experimental studies have demonstrated the feasibility&#44; efficacy and safety of extracorporeal removal of CO<span class="elsevierStyleInf">2</span> and some of its effects in humans&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This technique was initially conceived as an adjunct therapy in patients with severe acute respiratory distress syndrome&#44; as a tool to optimize protective ventilation&#46; More recently&#44; the use of this technique has allowed the emergence of a relatively new concept called &#8220;TRA-protective ventilation&#8221; whose effects are still to be determined&#46; In addition&#44; the extracorporeal removal of CO<span class="elsevierStyleInf">2</span> has been used in patients with exacerbated hypercapnic respiratory failure with promising results&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this review we will describe the physiological and technical fundamentals of this therapy and its variants as well as an overview of the available clinical evidence&#44; focused on its current potential&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Recientemente las mejoras tecnol&#243;gicas han permitido reducir la complejidad de los dispositivos de oxigenaci&#243;n por membrana extracorp&#243;rea&#44; dando paso al desarrollo de dispositivos espec&#237;ficos para la eliminaci&#243;n extracorp&#243;rea de CO<span class="elsevierStyleInf">2</span>&#46; Estos dispositivos tienen un montaje m&#225;s simple y utilizan flujos sangu&#237;neos m&#225;s bajos&#44; lo que potencialmente disminuye las complicaciones vasculares y hemodin&#225;micas&#46; Estudios experimentales han demostrado la factibilidad&#44; eficacia y seguridad de la eliminaci&#243;n extracorp&#243;rea de CO<span class="elsevierStyleInf">2</span> y algunos de sus efectos en humanos&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Esta t&#233;cnica&#44; que fue concebida como un tratamiento complementario en los pacientes con SDRA grave&#44; permite la optimizaci&#243;n de la ventilaci&#243;n protectora e incluso ha abierto el camino a nuevos conceptos&#44; como lo que se ha denominado ventilaci&#243;n &#171;ultraprotectora&#187;&#8221;&#44; cuyos beneficios a&#250;n est&#225;n por determinarse&#46; Adem&#225;s&#44; la eliminaci&#243;n extracorp&#243;rea de CO<span class="elsevierStyleInf">2</span> se est&#225; implementando en pacientes con insuficiencia respiratoria hiperc&#225;pnica agudizada con resultados prometedores&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En esta revisi&#243;n describiremos los fundamentos fisiol&#243;gicos y t&#233;cnicos de esta terapia y sus distintas variantes&#44; as&#237; como la evidencia cl&#237;nica disponible hasta la fecha&#44; enfocados en su potencial en el paciente con insuficiencia respiratoria&#46;</p></span>"
      ]
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Romay E&#44; Ferrer R&#46; Eliminaci&#243;n extracorp&#243;rea de CO<span class="elsevierStyleInf">2</span>&#58; fundamentos fisiol&#243;gicos y t&#233;cnicos y principales indicaciones&#46; Med Intensiva&#46; 2016&#59;40&#58;33&#8211;38&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Schematic representation of the functioning of the different CO<span class="elsevierStyleInf">2</span> removal devices&#46;</p>"
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        "etiqueta" => "Table 1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A-V&#58; arteriovenous&#59; PMP&#58; poly-4-methyl-1-pentene&#59; PLP&#58; polypropylene&#59; V-A&#58; venoarterial &#40;extracorporeal membrane oxygenation&#41;&#59; V-V&#58; venovenous&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Device&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pump&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Membrane &#40;material&#41;&#59; surface in m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blood flow &#40;l&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Purge volume &#40;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maquet PALP<span class="elsevierStyleSup">&#174;</span> CardioHelp<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V-V&#47;V-A&#47;A-V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Magnetic roller&nbsp;\t\t\t\t\t\t\n
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]

Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2015.12.002

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Year/Month	Html	Pdf	Total

2024 November	27	11	38
2024 October	203	84	287
2024 September	187	53	240
2024 August	259	69	328
2024 July	261	54	315
2024 June	247	89	336
2024 May	257	58	315
2024 April	253	66	319
2024 March	280	73	353
2024 February	342	80	422
2024 January	328	72	400
2023 December	265	71	336
2023 November	248	90	338
2023 October	271	69	340
2023 September	208	56	264
2023 August	166	45	211
2023 July	133	60	193
2023 June	148	43	191
2023 May	224	62	286
2023 April	151	55	206
2023 March	286	99	385
2023 February	234	69	303
2023 January	187	43	230
2022 December	234	67	301
2022 November	276	120	396
2022 October	304	95	399
2022 September	226	97	323
2022 August	192	68	260
2022 July	230	62	292
2022 June	257	59	316
2022 May	306	92	398
2022 April	323	99	422
2022 March	291	108	399
2022 February	323	84	407
2022 January	352	104	456
2021 December	247	90	337
2021 November	240	72	312
2021 October	249	132	381
2021 September	231	74	305
2021 August	179	82	261
2021 July	185	88	273
2021 June	206	102	308
2021 May	290	109	399
2021 April	759	224	983
2021 March	433	113	546
2021 February	315	83	398
2021 January	349	81	430
2020 December	368	80	448
2020 November	281	99	380
2020 October	212	64	276
2020 September	308	69	377
2020 August	211	69	280
2020 July	233	80	313
2020 June	313	56	369
2020 May	313	78	391
2020 April	373	114	487
2020 March	181	80	261
2020 February	380	123	503
2020 January	141	59	200
2019 December	123	50	173
2019 November	192	82	274
2019 October	243	73	316
2019 September	202	74	276
2019 August	149	55	204
2019 July	132	46	178
2019 June	133	47	180
2019 May	180	78	258
2019 April	172	52	224
2019 March	120	56	176
2019 February	99	68	167
2019 January	84	35	119
2018 December	209	67	276
2018 November	275	65	340
2018 October	184	35	219
2018 September	90	8	98
2018 August	50	9	59
2018 July	58	8	66
2018 June	70	13	83
2018 May	58	10	68
2018 April	94	14	108
2018 March	171	12	183
2018 February	46	12	58
2018 January	60	8	68
2017 December	52	8	60
2017 November	58	23	81
2017 October	46	15	61
2017 September	45	14	59
2017 August	44	15	59
2017 July	51	16	67
2017 June	68	28	96
2017 May	61	27	88
2017 April	51	19	70
2017 March	38	7	45
2017 February	96	10	106
2017 January	18	13	31
2016 December	62	17	79
2016 November	115	18	133
2016 October	110	30	140
2016 September	142	24	166
2016 August	72	20	92
2016 July	48	32	80
2016 June	1	0	1

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