Extracorporeal CO2 Removal: An alternative to intubation in AECOPD when NIV fails?

In patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) who have experienced failure with noninvasive ventilation (NIV), the use of extracorporeal CO₂ removal (ECCO₂R) shows promise with respect to the avoidance of intubation, particularly in the absence of significant hypoxemia. An observational, single-center, retrospective study (ClinicalTrials.gov identifier: NCT04882410) was conducted at the Centre Hospitalier de Saint-Denis, in Saint-Denis, France. Results of the analysis were published in the journal BMJ Open Respiratory Research.

The researchers sought to evaluate the efficacy and safety of ECCO₂R devices as an alternative to intubation in individuals with AECOPD through a retrospective review of data from patients’ electronic health records. All study participants were hospital patients with consecutive AECOPD who had failed NIV. Exclusion criteria included severe hypoxemia and contraindications to anticoagulant therapy. The researchers retrospectively assessed 26 patients treated with a newly implemented ECCO₂R device between 2015 and 2020. The primary study endpoint was to record ECCO₂R failure (ie, IMV or death by day 90). Secondary endpoints included effectiveness, safety, and observational data.

The outcomes of the ECCO₂R-treated patients were also compared with those of a control group of 25 patients who had been treated in the hospital’s ICU between 2010 and 2015, prior to implementation of the ECCO₂R device, and had received IMV; these IMV/control group patients met the same inclusion and exclusion criteria to the patients in the ECCO₂R group and had similar comorbidities and demographic characteristics except for body mass index, which was significantly higher among those in the ECCO₂R arm (30 kg/m² vs 25 kg/m²).

Overall, 72% of the study participants were men; the average patient age was 69 ± 11 years. Among the patients treated with ECCO₂R, 42% received long-term oxygen therapy and 27% received NIV prior to being hospitalized. Arterial blood gas tests (acid-base balance [pH], partial pressure of carbon dioxide in arterial blood [PaCO₂], partial pressure of oxygen in arterial blood [PaO₂], and calculated concentration of bicarbonate in arterial blood [HCO₃]), which were performed 6 hours prior to the intervention, did not differ between the ECCO₂R group and the control group.

In both the ECCO₂R and IMV/control groups, pH and PaCO₂ values improved significantly. The pH level was significantly lower 6 hours prior to ECCO₂R implementation compared with the time of decannulation (7.24 ± 0.05 vs 7.41 ± 0.06, respectively; P <.001). Similarly, the PaCO₂ value 6 hours prior to ECCO₂R was significantly higher than at the time of decannulation (86 ± 21 mm Hg vs 53 ± 10 mm Hg, respectively; P <.001). In the IMV/control group, the mean arterial blood pH value 6 hours prior to intubation was 7.23 ± 0.13, increasing to 7.39 ± 0.06 prior to extubation (P <.001). Additionally, the mean PaCO₂ value at 6 hours prior to IMV was 82 ±24 mm Hg, decreasing to 52 ± 13 mm Hg prior to extubation (P <.001).

The mean time on ECCO₂R was 5.4 days, compared with 27 days on IMV in the control group. In the ECCO₂R group, 4 patients required IMV, of whom 3 received IMV after being weaned from ECCO₂R. The ICU length of stay in the ECCO₂R arm was 18 ±14 days, compared with 30 ± 43 days in the IMV/control arm. Further, the length of hospital stay was 29 ± 22 days in the ECCO₂R group, compared with 49 ± 53 days in the IMV/control group. The 90-day mortality rates in the ECCO₂R arm vs the IMV control arm were 15% and 28%, respectively. There were 7 major bleeding events reported in 23% (6 of 26) of patients in the ECCO₂R group, with only 3 of these episodes leading to premature discontinuation of ECCO₂R.

The investigators concluded that the favorable results and low rates of complications reported in this study will likely revive the discussion about the role played by ECCO₂R in the therapeutic arsenal of COPD acute decompensation.

Disclosure: None of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies. 

Reference

Azzi M, Aboab J, Alviset S, et al. Extracorporeal CO₂ removal in acute exacerbation of COPD unresponsive to non-invasive ventilation. BMJ Open Respir Res. 2021;8(1):e001089. doi:10.1136/bmjresp-2021-001089