ASAIO Journal 2013
Respiratory Dialysis for Avoidance of Intubation in Acute Exacerbation of COPD Raj Kumar Mani,* Werner Schmidt,† Laura W. Lund,‡ and Felix J. F. Herth†
Noninvasive ventilatory support has become the standard of care for patients with chronic obstructive pulmonary disease (COPD) experiencing exacerbations leading to acute hypercapnic respiratory failure. Despite advances in the use of noninvasive ventilation and the associated improvement in survival, as many as 26% of these patients fail noninvasive support and have a higher subsequent risk of mortality than patients treated initially with invasive mechanical ventilation. We report the use of a novel device to avoid invasive mechanical ventilation in two patients who were experiencing acute hypercapnic respiratory failure because of an exacerbation of COPD and were deteriorating, despite support with noninvasive ventilation. This device provided partial extracorporeal carbon dioxide removal at dialysis-like settings through a single 15.5 Fr venovenous cannula inserted percutaneously through the right femoral vein. The primary results were rapid reduction in arterial carbon dioxide and correction of pH. Neither patient required intubation, despite imminent failure of noninvasive ventilation before initiation of extracorporeal support. Both patients were weaned from noninvasive and extracorporeal support within 3 days. We concluded that low-flow extracorporeal carbon dioxide removal, or respiratory dialysis, is a viable option for avoiding intubation and invasive mechanical ventilation in patients with COPD experiencing an exacerbation who are failing noninvasive ventilatory support. ASAIO Journal 2013; 59:675–678.
requiring hospitalization and ventilatory support.3 Despite the advent of noninvasive ventilation (NIV), which is now established as the standard treatment for respiratory failure in acute exacerbation of COPD, 15–26% of patients with acute exacerbations fail NIV support and require transition to invasive mechanical ventilation (MV).4–6 The mortality in patients who require invasive MV after failing NIV has been shown to be worse than those who are treated at the outset with invasive MV.7 For patients requiring invasive MV, in-hospital mortality in recent meta-analyses and observational studies has been reported to be as high as 25–39%.7–9 Furthermore, patients with COPD requiring invasive MV have a higher risk of prolonged weaning and failure to wean.10–12 The use of extracorporeal membrane oxygenation (ECMO) is not commonly considered a viable option for COPD because, in this patient population, hypoxemia is successfully managed with supplemental oxygen, and the risks associated with ECMO are not warranted.13 Gattinoni et al.14 and Kolobow et al.15,16 introduced the concept of extracorporeal CO2 removal (ECCO2R) for the treatment of hypercapnic respiratory failure in 1977; however, success was limited by the state of the technology and a lack of present day understanding of ventilator-induced lung injury and the improvement in outcome observed by introducing extracorporeal therapy earlier in the development of acute respiratory failure.17,18 Recent advances in the technology and understanding of extracorporeal gas exchange have resulted in simpler systems and less risky cannulation strategies.19,20 Clinically useful levels of CO2 removal can be achieved at much lower extracorporeal blood flow rates compared with oxygenation. Providing extracorporeal therapy at flow rates
Respiratory Dialysis for Avoidance of Intubation in Acute Exacerbation of COPD Raj Kumar Mani,* Werner Schmidt,† Laura W. Lund,‡ and Felix J. F. Herth†
Noninvasive ventilatory support has become the standard of care for patients with chronic obstructive pulmonary disease (COPD) experiencing exacerbations leading to acute hypercapnic respiratory failure. Despite advances in the use of noninvasive ventilation and the associated improvement in survival, as many as 26% of these patients fail noninvasive support and have a higher subsequent risk of mortality than patients treated initially with invasive mechanical ventilation. We report the use of a novel device to avoid invasive mechanical ventilation in two patients who were experiencing acute hypercapnic respiratory failure because of an exacerbation of COPD and were deteriorating, despite support with noninvasive ventilation. This device provided partial extracorporeal carbon dioxide removal at dialysis-like settings through a single 15.5 Fr venovenous cannula inserted percutaneously through the right femoral vein. The primary results were rapid reduction in arterial carbon dioxide and correction of pH. Neither patient required intubation, despite imminent failure of noninvasive ventilation before initiation of extracorporeal support. Both patients were weaned from noninvasive and extracorporeal support within 3 days. We concluded that low-flow extracorporeal carbon dioxide removal, or respiratory dialysis, is a viable option for avoiding intubation and invasive mechanical ventilation in patients with COPD experiencing an exacerbation who are failing noninvasive ventilatory support. ASAIO Journal 2013; 59:675–678.
requiring hospitalization and ventilatory support.3 Despite the advent of noninvasive ventilation (NIV), which is now established as the standard treatment for respiratory failure in acute exacerbation of COPD, 15–26% of patients with acute exacerbations fail NIV support and require transition to invasive mechanical ventilation (MV).4–6 The mortality in patients who require invasive MV after failing NIV has been shown to be worse than those who are treated at the outset with invasive MV.7 For patients requiring invasive MV, in-hospital mortality in recent meta-analyses and observational studies has been reported to be as high as 25–39%.7–9 Furthermore, patients with COPD requiring invasive MV have a higher risk of prolonged weaning and failure to wean.10–12 The use of extracorporeal membrane oxygenation (ECMO) is not commonly considered a viable option for COPD because, in this patient population, hypoxemia is successfully managed with supplemental oxygen, and the risks associated with ECMO are not warranted.13 Gattinoni et al.14 and Kolobow et al.15,16 introduced the concept of extracorporeal CO2 removal (ECCO2R) for the treatment of hypercapnic respiratory failure in 1977; however, success was limited by the state of the technology and a lack of present day understanding of ventilator-induced lung injury and the improvement in outcome observed by introducing extracorporeal therapy earlier in the development of acute respiratory failure.17,18 Recent advances in the technology and understanding of extracorporeal gas exchange have resulted in simpler systems and less risky cannulation strategies.19,20 Clinically useful levels of CO2 removal can be achieved at much lower extracorporeal blood flow rates compared with oxygenation. Providing extracorporeal therapy at flow rates
