ExtraCorporeal CO removal Devices - Critical Care Canada · ExtraCorporeal CO 2 removal Devices...
Transcript of ExtraCorporeal CO removal Devices - Critical Care Canada · ExtraCorporeal CO 2 removal Devices...
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ExtraCorporeal CO2
removal Devices
Alain Combes
Service de Réanimation
iCAN, Institute of Cardiometabolism and Nutrition
Hôpital Pitié-Salpêtrière, AP-HP, Paris
Université Pierre et Marie Curie, Paris 6 www.reamedpitie.com
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Conflict of interest
Principal Investigator: HEROICS trial HVHF after complicated heart surgery NCT01077349 Sponsored by GAMBRO
Principal Investigator: EOLIA trial VV ECMO in ARDS NCT01470703 Sponsored MAQUET, Getinge Group
Received honoraria from MAQUET, Getinge Group Gambro
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The rationale…
For ARDS patients…
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The goods and the bads of MV in
patients with ARDS…
MV harms the respiratory system
Ventilator-Induced Lung Injury
• Pressure
• Volume
Inactivity of the diaphragm
MV promotes VAP
MV requires patients sedation/paralysis
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Dreyfuss D & Saumon G. AJRCCM 1998; 157: 294-323
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The Acute Respiratory Distress Syndrome Network, ARMA
N Engl J Med 2000; 342:1301-1308
6 ml/Kg PBW
12 ml/Kg PBW
10%
20%
30%
Mortality
40%
30%
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Hager AJRCCM 2005
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Am J Respir Crit Care Med 2007;175:160-166.
Hyperrinflation Overdistension
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Hyperrinflation Overdistension
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Hager AJRCCM 2005
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Needham DM et al., BMJ 2012;344:e2124.
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The evolving paradigm…
ARDSnet strategy might not protect against tidal hyperinflation When Pplat remains >28-30 cm H2O
Further decrease of Vt From 6 to 5, 4 or 3 ml/kg IBW To decrease Pplat <25 cm H2O, To decrease ∆P To further reduce VILI With sufficient PEEP to prevent lung derecruitment
Induced Hypercapnia controlled by extracorporeal CO2 removal “CO2 dialysis” Low-flow devices
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Move the patient out of the bed…
Courtesy of
Dr Brodie
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The History of CO2
removal in ARDS …
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The History
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Luciano Gattinoni, JAMA 1986;256:881-886
43 patients, uncontrolled study
Low-flow veno-venous CO2 removal device
ECCO2-R
To avoid lung injury from conventional MV, the lungs
were kept "at rest"
3-5 breaths/min
“Low” peak airway pressure, 35-45 cm H2O
Survival: 21/43 (48.8%) patients
Lung function improved in 31(72.8%) patients
Blood loss: 1800±850mL/day…
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Randomized clinical trial of pressure-controlled inverse ratio
ventilation and extracorporeal CO2 removal for adult
respiratory distress syndrome
Randomized controlled clinical trial
40 patients with severe ARDS
Extracorporeal CO2 removal:
ECCO2R
Low-flow veno-venous device
Survival at 30 days not significantly different:
42% in the 19 mechanical ventilation
33% in the 21 ECCO2R patients (p = 0.8)
All deaths occurred within 30 days of randomization
Study stopped for futility
>30% patients with severe hemorrhage
Morris, AH, AJRCCM, 94
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Techniques of the
2000’s…
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Hemodec DECAP
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Novalung, ILA,
Pumpless AV shunt
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Novalung, ILA pumpless AV shunt
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25% Incidence of complications and side effects
Limb ischemia due to arterial canulation +++
Need for IV norepinephrine
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The Xtravent trial
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Techniques of the
2010’s…
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NOVALUNG
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Hemolung, Alung Technologies
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PALP, MAQUET®
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PrismaLung, Amplya…
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More to come…
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A new paradigm…
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Mild ARDS Severe ARDS Moderate ARDS
Incre
asin
g I
nte
nsit
y o
f In
terv
en
tio
n
300 200 250 0 100 150 50
PaO2/FiO2
Low Tidal Volume Ventilation
Higher PEEP
Low-Moderate PEEP
Prone Positioning
NIV
HFVO
Inhaled NO
ECMO
Neuromuscular Blockade
The ARDS Definition Taskforce. JAMA 2012;307:2526-2533.
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Mild ARDS Severe ARDS Moderate ARDS
Incre
asin
g I
nte
nsit
y o
f In
terv
en
tio
n
300 200 250 0 100 150 50
PaO2/FiO2
Low Tidal Volume Ventilation
Higher PEEP
Low-Moderate PEEP
Prone Positioning
NIV
HFVO
Inhaled NO
ECMO
Neuromuscular Blockade
The ARDS Definition Taskforce. JAMA 2012;307:2526-2533.
Lower Tidal Volume/Pplat + ECCO2R ?
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Conclusion
ExtraCorporeal CO2 Removal
“Respiratory dialysis”
Not for refractory hypoxemia: VV-ECMO
Potential for use for moderate to severe ARDS
To allow further reduction of Vt/Pplat
To limit VILI, without major respiratory acidosis
For COPD patients
Prevent intubation when NIV fails
Should be (re)tested in large clinical trials…
Recent major technological improvement in devices
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A Strategy of UltraProtective lung ventilation
With Extracorporeal CO2 Removal for
New-Onset moderate to seVere ARDS
The SUPERNOVA trial