Acute Exacerbation of Chronic Obstructive Pulmonary Disease Treated by Extracorporeal Carbon Dioxide Removal
Introduction
Chronic obstructive pulmonary disease (COPD) is a major health concern worldwide. Acute exacerbations of COPD (AECOPD) often pose significant challenges in treatment. Mechanical ventilation is commonly used, but it comes with its own set of problems like side effects and treatment failures. In this context, extracorporeal carbon dioxide removal (ECCO2R) emerges as a potentially promising alternative. ECCO2R involves draining blood to artificial membrane lungs for oxygenation and carbon dioxide removal without the need for traditional mechanical ventilation. While it has been widely used outside China, there was a lack of official reports on its use within the country until recently.
Case Presentations
Case 1: 69-year-old male patient
This patient had a 20-year history of COPD. He was hospitalized in March 2017 and had undergone two endotracheal intubations and invasive positive pressure ventilation (IPPV). His arterial blood gas analysis (with a fraction of inspired oxygen [FiO2] of 0.4) showed a pH of 7.25, arterial partial pressure of carbon dioxide (PaCO2) of 92 mmHg, arterial partial pressure of oxygen (PaO2) of 90 mmHg, HCO3⁻ of 45.8 mmol/L, and base excess (BE) of 15.4 mmol/L. After 8 days of non-invasive positive-pressure ventilation (NPPV) failure, he was on IPPV for 4 days and the endotracheal tube was removed. However, 12 hours after the end of IPPV, his PaCO2 increased to 130 mmHg, so IPPV was restarted. To meet the patient’s need to remove the endotracheal tube, ECCO2R was performed.
A 22F double-lumen venous catheter (Nova-twin, Germany) was placed in the right internal jugular vein with an insertion depth of 17 cm. It was connected to extracorporeal membrane oxygenation (ECMO) (Maquet, Rotaflow, Germany). The pump blood flow was adjusted to 1.0 – 1.5 L/min, and the gas flow was 4 L/min. Heparin (400 – 600 U/h) was given for anticoagulation. The activated partial prothrombin time was maintained at 60 s, and the activated clotting time was about 160 s. After 1 hour of treatment, the peripheral arterial PaCO2 decreased to 45.8 mmHg, and the pH rose to 7.42. The patient’s ventilation parameters were reduced (pressure support 10 cmH2O, FiO2 0.4, and positive end-expiratory pressure [PEEP] 5 cmH2O), sedation and analgesia were stopped, and the endotracheal tube was removed the next day. NPPV was given intermittently, airway clearance was used to assist sputum drainage, and the patient started exercise with assistance. The gas flow was gradually reduced (from 4 L/min to 500 mL/min), and NPPV was gradually restored to the usual support level (IPAP 18 – 20 cmH2O, EPAP 14 cmH2O, FiO2 0.4) during ECCO2R treatment. Five weeks later, ECCO2R was removed with no obvious complications.
Case 2: 81-year-old male patient
This patient had a 20-year history of COPD without regular treatment. He was hospitalized in April 2017. Fifteen days before admission, he had severe dyspnea, accompanied by obvious cough and expectoration, and bilateral pneumothorax for 5 days. There was extensive subcutaneous emphysema from the neck to the chest, abdomen, waist, and bilateral upper limbs. A thoracic drainage tube was placed in the right thoracic fourth intercostal space. Arterial blood gas analysis (FiO2 0.35) showed a pH of 7.43, PaCO2 of 46 mmHg, PaO2 of 73 mmHg, HCO3⁻ of 31.2 mmol/L, and BE of 5.6 mmol/L. After admission, his dyspnea and subcutaneous emphysema worsened. Arterial blood gas analysis (FiO2 0.5) showed a pH of 7.26, PaCO2 of 66 mmHg, and PaO2 of 120 mmHg. Then, ECCO2R was given (with the same process and anticoagulation requirements as the 69-year-old patient). Meanwhile, NPPV (IPAP 6 cmH2O, EPAP 4 cmH2O, FiO2 0.4) was also provided. However, due to weak cough and hypoxemia, endotracheal intubation and IPPV were needed. The endogenous positive end-expiratory pressure (PEEPi) was measured at 19 cmH2O. The IPPV parameters were in A/C mode, tidal volume 170 mL, respiratory rate 15 times/min, PEEP 3 cmH2O, and FiO2 0.35. Four days later, the subcutaneous emphysema was relieved. The PEEPi was reduced to 8 cmH2O. The patient’s pH was maintained at 7.43 – 7.51, and PaCO2 was maintained at 35 – 45 mmHg. After 11 days of effective treatment, the endotracheal tube was removed, and ECCO2R was successfully ended 2 days later. During treatment, the patient had a slight increase in transaminase and bilirubin and subcutaneous congestion at the puncture site.
Discussion on ECCO2R
Advantages over traditional mechanical ventilation
Traditional mechanical ventilation has several problems. NPPV treatment can fail, barotrauma can occur, and there can be ventilator weaning failure. ECCO2R offers a new approach. With technological advancements, the current ECCO2R system is a simpler in vitro life support technology with lower risk. In the cases presented, based on domestic equipment conditions, a 22F double-lumen venous catheter was chosen to establish vascular access and connect to ECMO. This met the ECCO2R treatment requirements and facilitated early rehabilitation for the patients.
Purposes of ECCO2R in AECOPD
The main purposes of ECCO2R treatment for AECOPD patients are to avoid intubation and assist in the removal of IPPV. The criteria for NPPV failure and intubation include worsening respiratory acidosis (PaCO2 >55 mmHg or pH 30 breaths/min), and clinical signs of respiratory muscle fatigue and/or increased work of breathing. ECCO2R can also be used to assist in the removal of IPPV for patients who have failed two or more weaning attempts or failed a weaning attempt and do not wish to continue IPPV. In the first case, the patient successfully weaned from IPPV with the help of ECCO2R and carried out rehabilitation. In the second case, the support conditions of IPPV were reduced during ECCO2R-assisted treatment, and barotrauma was effectively improved.
Limitations of ECCO2R
However, ECCO2R is not without limitations. Tracheal intubation sometimes cannot be avoided due to difficult expectoration, low hypoxemia, increased incidence of bleeding, and the need for effective respiratory therapy. Therefore, it is crucial to grasp the appropriate indications for ECCO2R treatment. Rational selection of ECCO2R for AECOPD patients can effectively improve their prognoses. Additionally, ECCO2R can be used as a bridge-treatment for lung transplantation, providing a new respiratory support strategy and treatment option.
Conclusion
In conclusion, the use of ECCO2R in treating AECOPD patients as demonstrated in these two cases shows its potential. While it has limitations, it offers a new hope in the management of these challenging cases. Further research and larger-scale studies are needed to better understand its long-term outcomes and optimal use in different patient populations.
References
- Tabak YP, Sun X, Johannes RS, Gupta V, Shorr AF. Mortality and need for mechanical ventilation in acute exacerbations of chronic obstructive pulmonary disease: development and validation of a simple risk score. Arch Intern Med 2009;169:1595–1602. doi: 10.1001/archinternmed.2009.270.
- Terragni P, Maiolo G, Ranieri VM. Role and potentials of low-flow CO2 removal system in mechanical ventilation. Curr Opin Crit Care 2012;18:93–98. doi: 10.1097/MCC.0b013e32834f17ef.
- Kluge S, Braune SA, Engel M, Nierhaus A, Frings D, Ebelt H, et al. Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilation. Intensive Care Med 2012;38:1632–1639. doi: 10.1007/s00134-012-2649-2.
- Burki NK, Mani RK, Herth FJF, Schmidt W, Teschler H, Bonin F, et al. A novel extracorporeal CO2 removal system extracorporeal CO2 removal in COPD results of a pilot study of hypercapnic respiratory failure in patients with COPD. Chest 2013;143:678–686. doi: 10.1378/chest.12-0228.
- Braune S, Sieweke A, Brettner F, Staudinger T, Joannidis M, Verbrugge S, et al. The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case–control study. Intensive Care Med 2016;42:1437–1444. doi: 10.1007/s00134-016-4452-y.
doi: 10.1097/CM9.0000000000000461
Was this helpful?
0 / 0