ecco r for hypoxic respiratory failure 2 r for hypoxic respiratory failure danny mcauley @dfmcauley...
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ECCO2R for hypoxic respiratory failure
Danny McAuley
@dfmcauley
Royal Victoria Hospital and Queen’s University of Belfast
ECLS basics
Critical Care Cananda Forum
October 2015
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Disclosures
• NIHR HTA study of ECCO2R for hypoxic
respiratory failure
• Supported by ALung Technologies
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ECCO2R for hypoxic respiratory failure
• Optimal ventilatory strategy
• Evidence for ECCO2R
• Planned clinical trials
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Lower tidal volume and Pplat < 30
Hospital mortality
6 ml/kg 12 ml/kg
P=0.005
0
10
20
30
40
50
Mortality(%)
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Lung protective ventilation
Early implementation
AJRCCM 2015 191:177-85
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Lung protective ventilation
2-year mortality
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Lung protective ventilation
2-year mortality
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Ventilation with low tidal volume in
patients without ARDS
JAMA 2012 308:1651-1659
NNT 11
Favours low TV Favours high TV
Incidence of ALI
NNT 23
Favours low TV Favours high TV
Mortality
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Patients undergoing elective surgery
NEJM 2013 369:428-437
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How low is low enough?
Frank et al AJRCCM 2002 165:242-249
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• 30% patients with ARDS
hyperinflation with 6ml/kg PBW
• 4ml/kg PBW and Pplat < 28cmH2O
reduced pulmonary cytokines
– Facilitated with extracorporeal
CO2 removal
How low is low enough?
Terragni et al. AJRCCM 2007, Terragni et al. Anesthesiology 2009
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How low is low enough?
Hager et al. AJRCCM 2005 172:1241–1245.
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Extracorporeal support; then and now
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Extracorporeal support techniques
Terragni 2012 Curr Opin Crit Care
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ECCO2R effects in hypoxic
respiratory failure
• Modulate hypercapnia
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Kregenow et al. CCM 2006;34:1-7
Hypercapnia in lung protective
ventilation
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ECCO2R effects in hypoxic
respiratory failure
• Modulate hypercapnia
• Early spontaneous ventilation
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• ARDS > 1 week
• Median reduction in pCO2 –
50%
• Facilitated low tidal volumes
• Reduction in sedation
• Spontaneous breathing
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ECCO2R objectives in ARDS
• Prevent hypercapnia
• Early spontaneous ventilation
• Lower volume and pressure ventilation
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Morris AJRCCM 1994
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Limiting tidal volume with arterio-venous
extracorporeal CO2 removal (ECCO2R)
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Xtravent study
Results
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Patients with PaO2/FIO2 < 150
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ECCO2R for respiratory failure and ARDS:
a systematic review
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ECCO2R for respiratory failure and ARDS:
a systematic review
• ARDS or acute respiratory failure
• 14 studies
– Clinical trial or observational study
– 7 using arterio-venous circuits and 7 using veno-venous
circuits
• ECCO2R is feasible but robust data is lacking
• Potential benefit
– Moderately severe ARDS
– Early implementation
Fitzgerald M et al. Critical Care 2014 18:222
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If a simple v-v gas exchange
device was available, would you
consider using it in respiratory
failure?
Would you consider taking part
in a clinical trial of such a
system?
UK national survey on ECCO2R for
respiratory failure
30% had used ECCO2R
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pRotective vEntilation with veno-venouS lung
assisT in respiratory failure – The REST Trial
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• UK multi-centre, open, randomised controlled trial
• Population
– Reversible cause of respiratory failure
– PF ratio <150mmHg on >5 cmH2O PEEP
– Within 48 hours of hypoxia criterion
• ECCO2R or standard care
• Outcomes
– Primary: 90-day mortality
• Sample size 1120 patients
pRotective vEntilation with veno-venouS
lung assisT in respiratory failure (REST)
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Intervention
• Single dual lumen catheter
• Very low tidal volume ventilation defined as:
– Vt of 3-4 ml/kg (PBW) and
– Plateau pressure ≤ 25cmH2O
• ECCO2R will be continued for a minimum of 2 days and
up to 14 days
• Device is weaned when there is clinical improvement
• Aim to extubate on ECCO2R although if not feasible can
wean ECCO2R
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Comparator
• Lung Protective Mechanical Ventilation as per ARMA
trial
– Vt 6-8 ml/kg (PBW) and
– Plateau pressure ≤ 30cmH2O
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Standard care
• PEEP based on the ARDSnet ARMA trial
• Oxygenation will be titrated aiming for SpO2 of 88%-
92% or PaO2 7-9kPa.
• Permissive hypercapnic respiratory acidosis aiming for a
pH ≥ 7.2
• Conservative fluid balance
• Can receive neuromuscular blockade
• Can receive prone positioning
• Standardised weaning recommended
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Comparison of planned trials
REST SUPERNOVA
Population ARF ARDS
Intervention Single device Any device
Ventilatory
strategy
Outcome 90-day 90-day
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Challenges in clinical trials
• Complex health intervention
– Process evaluation
• ECCO2R arm
– Very low tidal volume ventilation
– Likely higher PEEP
– Role of hypercapnia
– Administration of heparin
• Learning curve
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Conclusions
• ECCO2R for hypoxic respiratory failure remains
unproven
• Increasing use in the absence of evidence from
clinical trials
• Systematic review suggests benefit with early use
and if PF ratio <150 mmHg
• Need for large pragmatic clinical trials to define
the role of ECCO2R in acute hypoxic respiratory
failure