*4.1.2 ECCO2R to avoid IMV*

Brederlau et al. [37] described their experience in three patients that failed NIV for severe aeCOPD. They applied a pumpless AV ECCO2R device with the goal of avoiding endotracheal intubation. Shortly after beginning ECCO2R, PaCO2 fell significantly (from 91, 109, and 142 mmHg to 52, 59, and 83 mmHg, respectively), while pH rose (from 7.2, 7.19, and 7.06 to 7.41, 7.43, and 7.34, respectively). Simultaneously, the respiratory rate dropped from 38, 45, and 37 breaths/min to 15, 25, and 18 breaths/min, respectively. The ECCO2R flow ranged between 1.1 and 1.6 L/min, with the sweep gas flow varying from 3 to 10 L/min.

Kluge et al. [5] in the same year evaluated the safety and efficacy of using AV pumpless extracorporeal lung assist (PECLA) in 21 COPD patients who did not respond to NIV compared to 21 matched controls. The use of PECLA was associated with a decrease in PaCO2 levels and improved pH after 24 h and obviated the need for intubation and IMV in 90% of the experimental arm. Although the experimental group demonstrated a shorter length of stay, a retrospective analysis with the control group showed no significant difference in mortality at 28 days (19% with ECCO2R vs. 24% without ECCO2R) or 6 months (both groups 33%).

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

replacement therapy, and in fact, some systems are trying to combine the two in one [18, 19] (NCT02590575). One of the advantages of VV-ECCO2R compared to the AV approach is the less invasiveness by the omission of the arterial cannulation and facilitates early mobilization of patients. It is also possible to set up an ECCO2R system through cannulation of two central veins, one for drainage and the other for

*ECCO2R common configurations. (A) Minimally invasive veno-venous ECCO2R system with a single venous vascular access through a double lumen cannula that can be inserted in the internal jugular or femoral vein (B) Pumpless arteriovenous ECCO2R system with the placement of the membrane in the circuit connecting the* 

One ECCO2R configuration is through percutaneous cannulation of the femoral artery to the contralateral femoral vein and creating an arteriovenous (AV) bypass, equipped with an artificial gas exchanger membrane across the AV shunt which acts as a "sweep gas" to remove CO2 that has diffused out of the patient's blood (**Figure 1B**). In this configuration, pumpless systems require an arteriovenous pres-

hemodynamically unstable patients [16, 20]. Further, cannulation of a major artery can result in distal ischemia [21], although measuring the artery diameter with ultrasound and selecting a cannula that occupies no more than 70% of the lumen

Chronic obstructive pulmonary disease (COPD) is a significant worldwide health burden. Currently, it is the fourth leading cause of death worldwide, is the only leading cause of death that is rising, and will likely become the third cause of

, which is unsuitable for

reinfusion (femoral-femoral configuration).

*femoral artery with the contralateral vein.*

sure gradient ≥60 mmHg and a cardiac index >3 L/min/m<sup>2</sup>

**3.2 AV-ECCO2R**

**Figure 1.**

reduce this risk [22].

**4. Indications and evidence**

**4.1 Chronic obstructive pulmonary disease**

**94**


**97**

**Study** **ECCO**

**2**

Abrams

5

et al. [3]

**R to wean from mechanical ventilation**

VV configuration via a 20-

1700

1–7

PMP; 0.98 (Maquet

8 days

Mean (SD) time to ambulation after ECCO

initiation was 29.4 ± 12.6 h

Four patients were discharged home, and one

underwent planned lung transplantation

Only two minor bleeding complications

Patient extubated 48 h after decannulation.

No complications reported

 R 2

PALP CardioHelp)

to 24-Fr single dual-lumen

jugular

catheter using lower flow on

ECMO system

VV configuration with

800

10

PMP; 1.8 (Quadrox-d,

3.6 days

Maquet)

pediatric dual-lumen jugular

cannula

Cardenas

1

et al. [42]

Roncon

et al. [43]

**ECCO**

**2**

Burki [38]

20

VV configuration via a

430

Not reported

PLP with a base of

2–192 h

20 hypercapnic COPD patients received

R in three distinct groups: group 1 2

(*n* = 7) NIV patients with

high risk of IMV; group 2 (*n* = 2) could not be

weaned from NIV; and group 3 (*n* = 11) on

IMV and failed to wean

IMV avoided in all patient in group 1

Both patients in group 2 weaned from NIV

In group 3, three patients weaned, and IMV

was reduced in two patients

One patient died due to a retroperitoneal

hemorrhage (during cannulation)

*\*PMP: poly-4-methyl-1-pentene.*

*\*\*PLP: polypropylene.*

**Table 2.**

*Relevant clinical studies of ECCO*

*2*

*R in COPD.*

ECCO

siloxane layer; 0.59

(ALung Hemolung

RAS)

15.5-Fr single dual-lumen

catheter (femoral or jugular)

**R with mixed indications**

**No of patients** **Configuration**

**Blood flow** 

**Sweep flow** 

**Membrane (material);** 

**surface in m2**

**(L/min)**

**(mL/min)**

**ECCO**

**2**

**R characteristics**

**Time on ECCO**

**Major results**

**R2**

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

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


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

> *\*\*PLP: polypropylene.*

**Table 2.** *Relevant clinical studies of ECCO*

*2*

*R in COPD.*

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

**96**

**Study** **ECCO**

**2**

Kluge et al.

21

[5]

Del Sorbo

25

Modified continuous VV

255

8

PLP\*\*; 1.35 (Hemodec

1–2 days

DecapSmart®)

hemofiltration system with

membrane

lung via 14-Fr single duallumen cannula (femoral)

et al. [4]

Braune

25

VV configuration via a 22

1300

Not reported

PMP; 1.3 (Novalung

8.5 days

iLA Activve)

or 24-Fr single dual-lumen

cannula (femoral or jugular)

et al. [39]

**R to avoid mechanical ventilation**

Femoral AV with 13- to 15-Fr

1100

Not reported

PMP\*; 1.3 (iLA®)

9 days

19 (90%) PECLA patients did not require

intubation

Two major and seven minor bleeding

complications during PECLA

No significant difference in 28-day (24

vs. 19%, *p* = 0.85), 6-month mortality (33

vs. 33%), or hospital length of stay (23 vs.

42 days, *p* = 0.06)

Significantly fewer tracheostomies in PECLA

group (10 vs. 67%, *p* = 0.004)

Significantly higher risk of intubation in NIVonly group (HR 0.27; 95% CI 0.07–0.98) 13 patients experienced adverse events: 3 had

bleeding, 1 had vein perforation, and 9 had

device malfunction

Intubation was avoided in 14 out of all 25

ECCO

Seven ECCO

2

R patients (56%)

R patients were intubated 2

because of progressive hypoxemia and four

due to ventilatory failure despite ECCO

NIV

R patients (36%) suffered from 2

major bleeding complications

90-day mortality rates were 28 vs. 28%

Nine ECCO

 R and 2

arterial cannula and 13- to

17-Fr venous cannula

**No of** 

**ECCO**

**2**

**R characteristics**

**Time on** 

**Major results**

**ECCO**

**R2**

**patients**

**Configuration**

**Blood flow** 

**Sweep flow** 

**Membrane (material);** 

**surface in m2**

**(L/min)**

**(mL/min)**

In the study by Burki et al. [38], 20 hypercapnic patients with COPD were treated with ECCO2R using a 15.5-Fr dual-lumen cannula allowing a mean blood flow of 430 mL/min. Of the 20 patients recruited into the trial, 7 were at risk of MV despite NIV, 2 were difficult to wean from NIV, and 11 had failed liberation from MV. None of the patients failing NIV required endotracheal intubation, and both patients with difficult weaning from NIV were weaned. However, only 3 of the 11 IMV patients were liberated successfully. Moreover, significant complications arose in a number of patients: bleeding requiring blood transfusion was reported in three patients, deep vein thrombosis was diagnosed in one patient after removal of the ECCO2R catheter, one patient experienced pneumothorax due to catheter insertion, and one died from hemorrhage when the iliac vein was perforated during ECCO2R catheter placement.

Del Sorbo et al. [4] examined 25 patients with NIV + ECCO2R versus NIV alone (historical controls n = 21) for prevention of intubation in aeCOPD. They reported that ECCO2R with a 14-Fr dual-lumen catheter and blood flow rates of 177–333 mL/ min not only improved respiratory acidosis but also reduced the need for intubation by 75% (12 vs. 33%; p = 0.047) and significantly reduced the in-hospital mortality (8 vs. 35%; p = 0.035). However, this came with a cost of 52% prevalence of ECCO2R-related side effects and led the authors to suggest the end point of future studies should be long-term mortality.

In the ECLAIR study, Braune et al. [39] showed that IMV was avoided in 56% of cases treated with ECCO2R but was associated with a higher incidence of complications. However, several significant differences must be taken into account. In the latter study, there was an inclusion of patients with relative contraindications to NIV, and there was an unexpectedly high incidence of hypoxemic patients [40].

Finally, Morelli et al. [41] and colleagues confirmed the efficacy of ECCO2R (with a flow rate of 250–450 mL/min through a 13-Fr dual-lumen cannula) in reducing the PaCO2 in a series of 30 patients with acute hypercapnic respiratory failure due to aeCOPD, who refused endotracheal intubation after failing NIV. The duration of ECCO2R was 2–16 days, and it was possible to prevent endotracheal intubation in 27 patients.
