*4.1.3 ECCO2R to facilitate weaning from IMV*

Cardenas et al. [42] made the first attempt to use modern ECLS components for VV ECCO2R in a patient with aeCOPD. They demonstrated a successful reduction in PaCO2, minute ventilation, and ventilator pressures.

Burki et al. [38] showed that in a subgroup of 11 patients receiving IMV, ECCO2R allowed the weaning from mechanical ventilator in only 3 patients.

Abrams and colleagues [3] reported five older patients (age 73 ± 8.7 years) with aeCOPD who failed NIV, requiring IMV. After an average of 16.5 ± 5.9 h of IMV, ECCO2R was initiated. By using a dual-lumen cannula (20–23 Fr) with blood flow rates of 1–1.7 L/min and with a sweep gas flow from 1 to 7 L/min, they were able to extubate all five patients within 24 h of treatment (median duration of MV post ECCO2R = 4 h, range 1.5–21.5 h). Once extubated, patients were rehabilitated while on ECCO2R, with a mean time to ambulation of 29.4 ± 12.6 h after ECCO2R. Moreover, all patients survived to hospital discharge.

Using a pediatric VV ECMO system (with blood flow rates of 0.9 L/min through a 19 Fr dual-lumen cannula placed in the right jugular vein) in two patients with aeCOPD, Roncon-Albuquerque Jr. et al. reported early extubation after 72 h and patient mobilization out of bed at day 6 [43].

**99**

*Extracorporeal Carbon Dioxide Removal for the Exacerbation of Chronic Hypercapnic…*

Sklar et al. [44] reviewed 10 studies of ECCO2R for aeCOPD and a total of 87 patients, to examine cumulative safety and efficacy. They reported that ECCO2R was able to prevent intubation in 65 (93%) of 70 patients and assist in successful extubation of 9 (53%) of 17 patients. There were a total of 11 major complications and 30 minor complications. Half of all patients experienced complications related to ECCO2R, and half of those complications were related to bleeding (21/41). No study showed any evidence of increased mortality or increased length of intensive

In a recent publication, Taccone et al. [45] performed a systematic review of ECCO2R in adult critically ill patients. Three of the six studies included in the review evaluated patients with COPD that developed hypercapnic respiratory failure [4, 5, 39]. In all the three studies, the reduction of PaCO2 was reported within a few hours following the initiation of ECCO2R. Median values decreased from 73 to 88 mmHg to 34–66 mmHg. Regarding the duration of mechanical ventilation, only one described no significant difference between ECCO2R and the controlled group [4]. The need for endotracheal intubation was significantly reduced from 53/67 (79%) to 16/71 (22% p < 0.001). However, neither ICU nor hospital length of stay

Based on the existing data, we believe that the ideal trial for ECCO2R should be a randomized controlled trial designed such ECCO2R should be implemented within 12 h of intubation after failing to show improvement (i.e., pH < 7.25 for persistent acidosis) with conventional therapy. Given the risks associated with the technique, it should be instituted once patients fail conventional treatment and require IMV. Patients should be randomized to ECCO2R plus IMV or standard IMV. Given the high rate of mortality associated with invasive mechanical ventilation, the study should be powered to demonstrate a mortality benefit, and secondary endpoints include ventilator-free days,

More data will be forthcoming on the application of ECCO2R in the management of patients with COPD exacerbations from a number of ongoing or planned clinical

Asthma is an inflammatory disorder of the airways characterized by airway hyperactivity with bronchospasm, mucosal swelling, and mucus production.

The standard treatment of severe acute asthma consists of measures to reverse airflow obstruction. β2 agonists and steroids are the mainstays of treatment causing bronchodilation and anti-inflammatory effects, respectively [10]. Other available adjunct therapies including anticholinergics, magnesium sulfate, methylxanthines,

Despite advances in asthma therapy, asthma mortality has remained stable in recent years. One reason is status asthmaticus, which can be unresponsive to initial treatment and may lead to hypercapnic respiratory failure despite maximal therapy. Status asthmaticus, also known as severe acute asthma or near-fatal asthma, is a condition of progressively worsening bronchospasm and respiratory dysfunction due to asthma, which is unresponsive to standard conventional therapy and may progress to respiratory failure and the need for mechanical ventilation. The current indication of mechanical ventilation in a patient presenting with status asthmaticus is a clinical one and does not require a blood gas assessment. These include certain specific situations including alteration of consciousness, respiratory fatigue, or

transfusion requirements, and rates of ventilator-associated events.

ketamine, and heliox have been utilized with varying results [46].

*DOI: http://dx.doi.org/10.5772/intechopen.84936*

care unit (ICU) or hospital stay with ECCO2R.

was statistically significantly reduced.

trials (**Table 3**).

**4.2 Severe acute asthma**

impending cardiopulmonary arrest.

*4.1.4 Reviews of ECCO2R in COPD*

*Extracorporeal Carbon Dioxide Removal for the Exacerbation of Chronic Hypercapnic… DOI: http://dx.doi.org/10.5772/intechopen.84936*
