Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2024

Open Access 01-12-2024 | Acute Respiratory Distress-Syndrome | Research

Effects of extracorporeal CO2 removal on gas exchange and ventilator settings: a systematic review and meta-analysis

Authors: Alexandra-Maria Stommel, Harald Herkner, Calvin Lukas Kienbacher, Brigitte Wildner, Alexander Hermann, Thomas Staudinger

Published in: Critical Care | Issue 1/2024

Login to get access

Abstract

Purpose

A systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO2R) on gas exchange and respiratory settings in critically ill adults with respiratory failure.

Methods

We conducted a comprehensive database search, including observational studies and randomized controlled trials (RCTs) from January 2000 to March 2022, targeting adult ICU patients undergoing ECCO2R. Primary outcomes were changes in gas exchange and ventilator settings 24 h after ECCO2R initiation, estimated as mean of differences, or proportions for adverse events (AEs); with subgroup analyses for disease indication and technology. Across RCTs, we assessed mortality, length of stay, ventilation days, and AEs as mean differences or odds ratios.

Results

A total of 49 studies encompassing 1672 patients were included. ECCO2R was associated with a significant decrease in PaCO2, plateau pressure, and tidal volume and an increase in pH across all patient groups, at an overall 19% adverse event rate. In ARDS and lung transplant patients, the PaO2/FiO2 ratio increased significantly while ventilator settings were variable. “Higher extraction” systems reduced PaCO2 and respiratory rate more efficiently. The three available RCTs did not demonstrate an effect on mortality, but a significantly longer ICU and hospital stay associated with ECCO2R.

Conclusions

ECCO2R effectively reduces PaCO2 and acidosis allowing for less invasive ventilation. “Higher extraction” systems may be more efficient to achieve this goal. However, as RCTs have not shown a mortality benefit but increase AEs, ECCO2R’s effects on clinical outcome remain unclear. Future studies should target patient groups that may benefit from ECCO2R.
PROSPERO Registration No: CRD 42020154110 (on January 24, 2021).

Graphical abstract

Appendix
Available only for authorised users
Literature
1.
Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion. 2020;35(6):492–508.PubMedCrossRef
2.
Gattinoni L, Kolobow T, Tomlinson T, Iapichino G, Samaja M, White D, et al. Low-frequency positive pressure ventilation with extracorporeal carbon dioxide removal (LFPPV-ECCO2R): an experimental study. Anesth Analg. 1978;57(4):470–7.PubMedCrossRef
3.
Gattinoni L, Pesenti A, Mascheroni D, Marcolin R, Fumagalli R, Rossi F, et al. Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA. 1986;256(7):881–6.PubMedCrossRef
4.
Bein T, Weber F, Philipp A, Prasser C, Pfeifer M, Schmid FX, et al. A new pumpless extracorporeal interventional lung assist in critical hypoxemia/hypercapnia. Crit Care Med. 2006;34(5):1372–7.PubMedCrossRef
5.
Fitzgerald M, Millar J, Blackwood B, Davies A, Brett SJ, McAuley DF, et al. Extracorporeal carbon dioxide removal for patients with acute respiratory failure secondary to the acute respiratory distress syndrome: a systematic review. Crit Care. 2014;18(3):222.PubMedPubMedCentralCrossRef
6.
Combes A, Fanelli V, Pham T, Ranieri VM, European Society of Intensive Care Medicine Trials G, the Strategy of Ultra-Protective lung ventilation with Extracorporeal CORfN-OmtsAi. Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med. 2019;45(5):592–600.
7.
Sklar MC, Beloncle F, Katsios CM, Brochard L, Friedrich JO. Extracorporeal carbon dioxide removal in patients with chronic obstructive pulmonary disease: a systematic review. Intensive Care Med. 2015;41(10):1752–62.PubMedCrossRef
8.
Schellongowski P, Riss K, Staudinger T, Ullrich R, Krenn CG, Sitzwohl C, et al. Extracorporeal CO2 removal as bridge to lung transplantation in life-threatening hypercapnia. Transpl Int. 2015;28(3):297–304.PubMedCrossRef
9.
Benazzo A, Schwarz S, Frommlet F, Schweiger T, Jaksch P, Schellongowski P, et al. Twenty-year experience with extracorporeal life support as bridge to lung transplantation. J Thorac Cardiovasc Surg. 2019;157(6):2515-25e10.PubMedCrossRef
10.
Camporota L, Barrett N. Current applications for the use of extracorporeal carbon dioxide removal in critically Ill patients. Biomed Res Int. 2016;2016:9781695.PubMedPubMedCentralCrossRef
11.
Morales-Quinteros L, Del Sorbo L, Artigas A. Extracorporeal carbon dioxide removal for acute hypercapnic respiratory failure. Ann Intensive Care. 2019;9(1):79.PubMedPubMedCentralCrossRef
12.
Park M, Costa EL, Maciel AT, Silva DP, Friedrich N, Barbosa EV, et al. Determinants of oxygen and carbon dioxide transfer during extracorporeal membrane oxygenation in an experimental model of multiple organ dysfunction syndrome. PLoS ONE. 2013;8(1): e54954.PubMedPubMedCentralCrossRef
13.
Karagiannidis C, Strassmann S, Brodie D, Ritter P, Larsson A, Borchardt R, et al. Impact of membrane lung surface area and blood flow on extracorporeal CO2 removal during severe respiratory acidosis. Intensive Care Med Exp. 2017;5(1):34.PubMedPubMedCentralCrossRef
14.
Hermann A, Riss K, Schellongowski P, Bojic A, Wohlfarth P, Robak O, et al. A novel pump-driven veno-venous gas exchange system during extracorporeal CO2-removal. Intensive Care Med. 2015;41(10):1773–80.PubMedCrossRef
15.
Combes A, Tonetti T, Fanelli V, Pham T, Pesenti A, Mancebo J, et al. Efficacy and safety of lower versus higher CO2 extraction devices to allow ultraprotective ventilation: secondary analysis of the SUPERNOVA study. Thorax. 2019;74(12):1179–81.PubMedCrossRef
16.
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372: n71.PubMedPubMedCentralCrossRef
17.
Higgins JPT, Cochrane Collaboration. Cochrane handbook for systematic reviews of interventions. Second edition. ed. Hoboken, NJ: Wiley-Blackwell; 2020.
18.
Winiszewski H, Aptel F, Belon F, Belin N, Chaignat C, Patry C, et al. Daily use of extracorporeal CO(2) removal in a critical care unit: indications and results. J Intensive Care. 2018;6:36.PubMedPubMedCentralCrossRef
19.
Augy JL, Aissaoui N, Richard C, Maury E, Fartoukh M, Mekontso-Dessap A, et al. A 2-year multicenter, observational, prospective, cohort study on extracorporeal CO(2) removal in a large metropolis area. J Intensive Care. 2019;7:45.PubMedPubMedCentralCrossRef
20.
Bein T, Weber-Carstens S, Goldmann A, Muller T, Staudinger T, Brederlau J, et al. Lower tidal volume strategy ( approximately 3 ml/kg) combined with extracorporeal CO2 removal versus “conventional” protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med. 2013;39(5):847–56.PubMedPubMedCentralCrossRef
21.
Zimmermann M, Bein T, Arlt M, Philipp A, Rupprecht L, Mueller T, et al. Pumpless extracorporeal interventional lung assist in patients with acute respiratory distress syndrome: a prospective pilot study. Crit Care. 2009;13(1):R10.PubMedPubMedCentralCrossRef
22.
Weber-Carstens S, Bercker S, Hommel M, Deja M, MacGuill M, Dreykluft C, et al. Hypercapnia in late-phase ALI/ARDS: providing spontaneous breathing using pumpless extracorporeal lung assist. Intensive Care Med. 2009;35(6):1100–5.PubMedCrossRef
23.
Nierhaus A, Frings DP, Braune S, Baumann HJ, Schneider C, Wittenburg B, et al. Interventional lung assist enables lung protective mechanical ventilation in acute respiratory distress syndrome. Minerva Anestesiol. 2011;77(8):797–801.PubMed
24.
Cho WH, Lee K, Huh JW, Lim CM, Koh Y, Hong SB. Physiologic effect and safety of the pumpless extracorporeal interventional lung assist system in patients with acute respiratory failure–a pilot study. Artif Organs. 2012;36(4):434–8.PubMedCrossRef
25.
Allardet-Servent J, Castanier M, Signouret T, Soundaravelou R, Lepidi A, Seghboyan JM. Safety and efficacy of combined extracorporeal CO2 removal and renal replacement therapy in patients with acute respiratory distress syndrome and acute kidney injury: the pulmonary and renal support in acute respiratory distress syndrome study. Crit Care Med. 2015;43(12):2570–81.PubMedPubMedCentralCrossRef
26.
Fanelli V, Ranieri MV, Mancebo J, Moerer O, Quintel M, Morley S, et al. Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress sindrome. Crit Care. 2016;20:36.PubMedPubMedCentralCrossRef
27.
Peperstraete H, Eloot S, Depuydt P, De Somer F, Roosens C, Hoste E. Low flow extracorporeal CO(2) removal in ARDS patients: a prospective short-term crossover pilot study. BMC Anesthesiol. 2017;17(1):155.PubMedPubMedCentralCrossRef
28.
Hilty MP, Riva T, Cottini SR, Kleinert EM, Maggiorini A, Maggiorini M. Low flow veno-venous extracorporeal CO2 removal for acute hypercapnic respiratory failure. Minerva Anestesiol. 2017;83(8):812–23.PubMedCrossRef
29.
Schmidt M, Jaber S, Zogheib E, Godet T, Capellier G, Combes A. Feasibility and safety of low-flow extracorporeal CO(2) removal managed with a renal replacement platform to enhance lung-protective ventilation of patients with mild-to-moderate ARDS. Crit Care. 2018;22(1):122.PubMedPubMedCentralCrossRef
30.
Consales G, Zamidei L, Turani F, Atzeni D, Isoni P, Boscolo G, et al. Combined renal-pulmonary extracorporeal support with low blood flow techniques: a retrospective observational study (CICERO study). Blood Purif. 2022;51(4):299–308.PubMedCrossRef
31.
McNamee JJ, Gillies MA, Barrett NA, Perkins GD, Tunnicliffe W, Young D, et al. Effect of lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal vs standard care ventilation on 90-day mortality in patients with acute hypoxemic respiratory failure: the REST randomized clinical trial. JAMA. 2021;326(11):1013–23.PubMedPubMedCentralCrossRef
32.
Wohlfarth P, Schellongowski P, Staudinger T, Rabitsch W, Hermann A, Buchtele N, et al. A bi-centric experience of extracorporeal carbon dioxide removal (ECCO(2) R) for acute hypercapnic respiratory failure following allogeneic hematopoietic stem cell transplantation. Artif Organs. 2021;45(8):903–10.PubMedPubMedCentralCrossRef
33.
Inal V, Efe S. Extracorporeal carbon dioxide removal (ECCO2R) in COPD and ARDS patients with severe hypercapnic respiratory failure. A retrospective case-control study. Turk J Med Sci. 2021;51(4):2127–35.PubMedPubMedCentralCrossRef
34.
Del Sorbo L, Pisani L, Filippini C, Fanelli V, Fasano L, Terragni P, et al. Extracorporeal CO2 removal in hypercapnic patients at risk of noninvasive ventilation failure: a matched cohort study with historical control. Crit Care Med. 2015;43(1):120–7.PubMedCrossRef
35.
Braune S, Sieweke A, Brettner F, Staudinger T, Joannidis M, Verbrugge S, et al. The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case-control study. Intensive Care Med. 2016;42(9):1437–44.PubMedCrossRef
36.
Barrett NA, Hart N, Daly KJR, Marotti M, Kostakou E, Carlin C, et al. A randomised controlled trial of non-invasive ventilation compared with extracorporeal carbon dioxide removal for acute hypercapnic exacerbations of chronic obstructive pulmonary disease. Ann Intensive Care. 2022;12(1):36.PubMedPubMedCentralCrossRef
37.
Bein T, Prasser C, Philipp A, Muller T, Weber F, Schlitt HJ, et al. Pumpless extracorporeal lung assist using arterio-venous shunt in severe ARDS. Experience with 30 cases. Anaesthesist. 2004;53(9):813–9.PubMed
38.
Fischer S, Simon AR, Welte T, Hoeper MM, Meyer A, Tessmann R, et al. Bridge to lung transplantation with the novel pumpless interventional lung assist device NovaLung. J Thorac Cardiovasc Surg. 2006;131(3):719–23.PubMedCrossRef
39.
Floerchinger B, Philipp A, Foltan M, Rupprecht L, Klose A, Camboni D, et al. Switch from venoarterial extracorporeal membrane oxygenation to arteriovenous pumpless extracorporeal lung assist. Ann Thorac Surg. 2010;89(1):125–31.PubMedCrossRef
40.
Muller T, Lubnow M, Philipp A, Bein T, Jeron A, Luchner A, et al. Extracorporeal pumpless interventional lung assist in clinical practice: determinants of efficacy. Eur Respir J. 2009;33(3):551–8.PubMedCrossRef
41.
Kluge S, Braune SA, Engel M, Nierhaus A, Frings D, Ebelt H, et al. Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilation. Intensive Care Med. 2012;38(10):1632–9.PubMedCrossRef
42.
Forster C, Schriewer J, John S, Eckardt KU, Willam C. Low-flow CO(2) removal integrated into a renal-replacement circuit can reduce acidosis and decrease vasopressor requirements. Crit Care. 2013;17(4):R154.PubMedPubMedCentralCrossRef
43.
Hermann A, Staudinger T, Bojic A, Riss K, Wohlfarth P, Robak O, et al. First experience with a new miniaturized pump-driven venovenous extracorporeal CO2 removal system (iLA Activve): a retrospective data analysis. ASAIO J. 2014;60(3):342–7.PubMedCrossRef
44.
Grasselli G, Castagna L, Bottino N, Scaravilli V, Corcione N, Guzzardella A, et al. Practical clinical application of an extracorporeal carbon dioxide removal system in acute respiratory distress syndrome and acute on chronic respiratory failure. ASAIO J. 2020;66(6):691–7.PubMedCrossRef
45.
Liebold A, Philipp A, Kaiser M, Merk J, Schmid FX, Birnbaum DE. Pumpless extracorporeal lung assist using an arterio-venous shunt. Appl Limit Minerva Anestesiol. 2002;68(5):387–91.
46.
Muellenbach RM, Kredel M, Wunder C, Kustermann J, Wurmb T, Schwemmer U, et al. Arteriovenous extracorporeal lung assist as integral part of a multimodal treatment concept: a retrospective analysis of 22 patients with ARDS refractory to standard care. Eur J Anaesthesiol. 2008;25(11):897–904.PubMedCrossRef
47.
Arlt M, Philipp A, Zimmermann M, Voelkel S, Amann M, Bein T, et al. Emergency use of extracorporeal membrane oxygenation in cardiopulmonary failure. Artif Organs. 2009;33(9):696–703.PubMedCrossRef
48.
Ried M, Bein T, Philipp A, Muller T, Graf B, Schmid C, et al. Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience. Crit Care. 2013;17(3):R110.PubMedPubMedCentralCrossRef
49.
Burki NK, Mani RK, Herth FJF, Schmidt W, Teschler H, Bonin F, et al. A novel extracorporeal CO(2) removal system: results of a pilot study of hypercapnic respiratory failure in patients with COPD. Chest. 2013;143(3):678–86.PubMedCrossRef
50.
Quintard JM, Barbot O, Thevenot F, de Matteis O, Benayoun L, Leibinger F. Partial extracorporeal carbon dioxide removal using a standard continuous renal replacement therapy device: a preliminary study. ASAIO J. 2014;60(5):564–9.PubMedCrossRef
51.
Munoz-Bendix C, Beseoglu K, Kram R. Extracorporeal decarboxylation in patients with severe traumatic brain injury and ARDS enables effective control of intracranial pressure. Crit Care. 2015;19:381.PubMedPubMedCentralCrossRef
52.
Tiruvoipati R, Buscher H, Winearls J, Breeding J, Ghosh D, Chaterjee S, et al. Early experience of a new extracorporeal carbon dioxide removal device for acute hypercapnic respiratory failure. Crit Care Resusc. 2016;18(4):261–9.PubMed
53.
Seiler F, Trudzinski FC, Hennemann K, Niermeyer T, Schmoll C, Kamp A, et al. The homburg lung: efficacy and safety of a minimal-invasive pump-driven device for veno-venous extracorporeal carbon dioxide removal. ASAIO J. 2017;63(5):659–65.PubMedCrossRef
54.
Cummins C, Bentley A, McAuley DF, McNamee JJ, Patrick H, Barrett NA. A United Kingdom Register study of in-hospital outcomes of patients receiving extracorporeal carbon dioxide removal. J Intensive Care Soc. 2018;19(2):114–21.PubMedCrossRef
55.
Moerer O, Harnisch LO, Barwing J, Heise D, Heuer JF, Quintel M. Minimal-flow ECCO(2)R in patients needing CRRT does not facilitate lung-protective ventilation. J Artif Organs. 2019;22(1):68–76.PubMedCrossRef
56.
Diehl JL, Piquilloud L, Vimpere D, Aissaoui N, Guerot E, Augy JL, et al. Physiological effects of adding ECCO(2)R to invasive mechanical ventilation for COPD exacerbations. Ann Intensive Care. 2020;10(1):126.PubMedPubMedCentralCrossRef
57.
Petran J, Muelly T, Dembinski R, Steuer N, Arens J, Marx G, et al. Validation of RESP and PRESERVE score for ARDS patients with pumpless extracorporeal lung assist (pECLA). BMC Anesthesiol. 2020;20(1):102.PubMedPubMedCentralCrossRef
58.
Ding X, Chen H, Zhao H, Zhang H, He H, Cheng W, et al. ECCO(2)R in 12 COVID-19 ARDS patients with extremely low compliance and refractory hypercapnia. Front Med (Lausanne). 2021;8:654658.PubMedCrossRef
59.
Moss CE, Galtrey EJ, Camporota L, Meadows C, Gillon S, Ioannou N, et al. A retrospective observational case series of low-flow venovenous extracorporeal carbon dioxide removal use in patients with respiratory failure. ASAIO J. 2016;62(4):458–62.PubMedCrossRef
60.
Nentwich J, Wichmann D, Kluge S, Lindau S, Mutlak H, John S. Low-flow CO(2) removal in combination with renal replacement therapy effectively reduces ventilation requirements in hypercapnic patients: a pilot study. Ann Intensive Care. 2019;9(1):3.PubMedPubMedCentralCrossRef
61.
Pestana D, Gomis A, de Pablo R, Tenorio MT. Extracorporeal carbon dioxide removal may prevent the need for extracorporeal membrane oxygenation in severe respiratory failure: a cohort study. Eur J Anaesthesiol. 2020;37(10):950–2.PubMedCrossRef
62.
Ricci D, Boffini M, Del Sorbo L, El Qarra S, Comoglio C, Ribezzo M, et al. The use of CO2 removal devices in patients awaiting lung transplantation: an initial experience. Transplant Proc. 2010;42(4):1255–8.PubMedCrossRef
63.
Akkanti B, Jagpal S, Darwish R, Saavedra Romero R, Scott LK, Dinh K, et al. Physiologic improvement in respiratory acidosis using extracorporeal CO(2) removal with hemolung respiratory assist system in the management of severe respiratory failure from coronavirus disease 2019. Crit Care Explor. 2021;3(3):e0372.PubMedPubMedCentralCrossRef
64.
65.
Terragni PP, Del Sorbo L, Mascia L, Urbino R, Martin EL, Birocco A, et al. Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Anesthesiology. 2009;111(4):826–35.PubMedCrossRef
66.
Combes A, Peek GJ, Hajage D, Hardy P, Abrams D, Schmidt M, et al. ECMO for severe ARDS: systematic review and individual patient data meta-analysis. Intensive Care Med. 2020;46(11):2048–57.PubMedPubMedCentralCrossRef
67.
Munshi L, Walkey A, Goligher E, Pham T, Uleryk EM, Fan E. Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Lancet Respir Med. 2019;7(2):163–72.PubMedCrossRef
68.
Mikkelsen ME, Woo YJ, Sager JS, Fuchs BD, Christie JD. Outcomes using extracorporeal life support for adult respiratory failure due to status asthmaticus. ASAIO J. 2009;55(1):47–52.PubMedPubMedCentralCrossRef
69.
Yeo HJ, Kim D, Jeon D, Kim YS, Rycus P, Cho WH. Extracorporeal membrane oxygenation for life-threatening asthma refractory to mechanical ventilation: analysis of the Extracorporeal Life Support Organization registry. Crit Care. 2017;21(1):297.PubMedPubMedCentralCrossRef
70.
Bromberger BJ, Agerstrand C, Abrams D, Serra A, Apsel D, Tipograf Y, et al. Extracorporeal carbon dioxide removal in the treatment of status asthmaticus. Crit Care Med. 2020;48(12):e1226–31.PubMedCrossRef
Metadata
Title
Effects of extracorporeal CO2 removal on gas exchange and ventilator settings: a systematic review and meta-analysis
Authors
Alexandra-Maria Stommel
Harald Herkner
Calvin Lukas Kienbacher
Brigitte Wildner
Alexander Hermann
Thomas Staudinger
Publication date
01-12-2024
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2024
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-024-04927-x

Other articles of this Issue 1/2024

Critical Care 1/2024 Go to the issue

Correspondence

How often do we need to update PEEP setting during prone positioning in ARDS?

Research

Monocyte state 1 (MS1) cells in critically ill patients with sepsis or non-infectious conditions: association with disease course and host response

Correspondence

Life-threatening complications and intensive care unit management in patients treated with blinatumomab for B-cell acute lymphoblastic leukemia

Review

Triggering receptor expressed on myeloid cells-1 in sepsis, and current insights into clinical studies

Research

Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials

Research

Long-term outcome in new onset refractory status epilepticus: a retrospective study