Extracorporeal CO2 removal safe, effective for acute exacerbation of COPD

Extracorporeal CO₂ removal (ECCO₂R) devices significantly improve pH and carbon dioxide arterial pressure (PaCO₂) in patients with acute exacerbation of chronic obstructive pulmonary disease (ae-COPD) who had previously failed noninvasive ventilation (NIV), according to a recent study.

Moreover, the use of ECCO₂R devices reduces the need for subsequent intubation and confers low rates of complication.

“We observed a much better clinical response compared with previous studies, leading to avoiding intubation in 85 percent of cases despite including severe patients with COPD, some of them receiving long-term oxygen therapy or NIV at home,” the researchers said.

“Good results and low complication rate are likely to revive the discussion about the role of ECCO₂R in the therapeutic arsenal of COPD acute decompensation,” they added.

The study included 26 patients who had undergone ECCO₂R and 25 controls. Aside from body mass index, which was significantly higher in those with device use (p=0.035), both groups were statistically comparable at baseline, even in terms of comorbidities, causes of exacerbation, and arterial blood gas parameters. [BMJ Open Respir Res 2021;8:e001089]

The primary outcome measure was ECCO₂R failure by day 90, as defined by death or invasive mechanical ventilation (IMV). Five patients (19 percent) reached such endpoint: four patients needed intubation (15 percent), three of whom subsequently died. One patient died before intubation due to multiple organ failure.

Most cases of IMV occurred after ECCO₂R device weaning and were driven by recurrent hypercapnia; only one patient needed intubation while still on ECCO₂R. The average duration between device weaning and IMV was 3.2 days.

Such low rates of failure could be attributed to the effectiveness of ECCO₂R intervention. The mean blood pH value increased significantly from 7.24 6 hours before device use to 7.41 at the time of decannulation (p<0.001). At the same time, average PaCO₂ significantly dropped from 86 mm Hg 6 hours before ECCO₂R use to 53 mm Hg at decannulation (p<0.001).

Similarly, the ECCO₂R device led to shorter stays in the intensive care unit (18 vs 30 days) and in the hospital (29 vs 49 days) relative to IMV, though the differences failed to reach statistical significance. Ninety-day mortality was likewise nominally lower in the ECCO₂R group (15 percent vs 28 percent).

In terms of safety, only seven major bleeding events occurred in six patients (23 percent) in the ECCO₂R group. Such bleeding events led to device discontinuation in three patients. In addition, five patients (20 percent) developed six minor bleeding episodes. No cases of cerebral or digestive bleeding were reported.

“Prospective randomized studies are required. Technical progress may facilitate the management of this emerging technique in the near future,” the researchers said.