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Extracorporeal carbon dioxide removal for acute respiratory failure: a review of potential indications, clinical practice and open research questions

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Abstract

Extracorporeal carbon dioxide removal (ECCO2R) is a form of extracorporeal life support (ECLS) largely aimed at removing carbon dioxide in patients with acute hypoxemic or acute hypercapnic respiratory failure, so as to minimize respiratory acidosis, allowing more lung protective ventilatory settings which should decrease ventilator-induced lung injury. ECCO2R is increasingly being used despite the lack of high-quality evidence, while complications associated with the technique remain an issue of concern. This review explains the physiological basis underlying the use of ECCO2R, reviews the evidence regarding indications and contraindications, patient management and complications, and addresses organizational and ethical considerations. The indications and the risk-to-benefit ratio of this technique should now be carefully evaluated using structured national or international registries and large randomized trials.

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Authors and Affiliations

  1. Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France

    Alain Combes & Matthieu Schmidt

  2. Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, boulevard de l’Hôpital, 75013, Paris, France

    Alain Combes & Matthieu Schmidt

  3. Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, USA

    Daniel Brodie

  4. Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York, USA

    Daniel Brodie

  5. Assistance publique des hopitaux de Paris (APHP), Cochin Hospital, Intensive Care Medicine, Université de Paris and Paris Cardiovascular Research Center, INSERM U970, Paris, France

    Nadia Aissaoui

  6. Faculty of Medicine, University of Regensburg, Regensburg, Germany

    Thomas Bein

  7. CHU Besançon, Réanimation Médicale, 2500, Besançon, France

    Gilles Capellier

  8. Université de Franche Comte, EA, 3920, Besançon, France

    Gilles Capellier

  9. Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive, Care Research Centre, Monash University, Melbourne, Australia

    Gilles Capellier

  10. Heart and Vascular Institute and Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA, USA

    Heidi J. Dalton

  11. Medical Intensive Care Unit and Biosurgical Research Lab (Carpentier Foundation), HEGP Hospital, Assistance Publique-Hôpitaux de Paris-Centre (APHP-Centre), Paris, France

    Jean-Luc Diehl

  12. Université de Paris, INSERM, Innovative Therapies in Haemostasis, 75006, Paris, France

    Jean-Luc Diehl

  13. Department of Intensive Care, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Stefan Kluge

  14. Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, UK

    Daniel F. McAuley

  15. Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, UK

    Daniel F. McAuley

  16. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Arthur S. Slutsky

  17. Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada

    Arthur S. Slutsky

  18. PhyMedExp, University of Montpellier, Institut National de La Santé Et de La Recherche Médicale (INSERM), Centre National de La Recherche Scientifique (CNRS), Centre Hospitalier Universitaire (CHU) Montpellier, Montpellier, France

    Samir Jaber

  19. Département d’Anesthésie-Réanimation, Hôpital Saint-Eloi, Montpellier Cedex, France

    Samir Jaber

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  1. Alain Combes
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  2. Daniel Brodie
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  3. Nadia Aissaoui
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  4. Thomas Bein
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  7. Jean-Luc Diehl
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  8. Stefan Kluge
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  9. Daniel F. McAuley
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  10. Matthieu Schmidt
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Correspondence to Alain Combes.

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Conflicts of interest

AC reports grants and personal fees from MAQUET, Xenios, and Baxter. AC was a past president of EuroELSO and is a member of the executive and scientific committees of ECMONet. DB reports research support from ALung Technologies, and personal fees from Abiomed, Xenios, Medtronic, Inspira and Cellenkos. DB is the President-elect of the Extracorporeal Life Support Organization (ELSO) and the Chair of the Executive Committee of the International ECMO Network (ECMONet). GC reports personal fees, travel expenses from Baxter and Fresenius. JLD reports research supports, grants and personal fees from ALung Technologies, Xenios, Fresenius Medical Care and Baxter. SK received research support from Cytosorbents and Daiichi Sankyo. He also received lecture fees from Astra, Bard, Baxter, Biotest, Cytosorbents, Daiichi Sankyo, Fresenius Medical Care, Gilead, Mitsubishi Tanabe Pharma, MSD, Pfizer, Philips and Zoll. He received consultant fees from Fresenius, Gilead, MSD and Pfizer. DFM reported receiving a grant from the NIHR HTA Programme for the conduct of the REST study. Outside of the submitted work, DFM has received funding to his institution for other studies from the NIHR, Wellcome Trust, Innovate UK, Northern Ireland Health and Social Care Research and Development Office and Randox. DFM has a patent application for an anti-inflammatory treatment issued to his institution. DFM has received fees for consultancy from Bayer, GSK, Boehringer Ingelheim, Eli Lilly and Novartis and SOBI and for being a member of the data monitoring and ethics committee for Vir Biotechnology and Faron studies and as an educational seminar speaker for GSK. MS reports personal fees from Getinge, Xenios, Fresenius Medical Care, Drager, and Baxter. MS is the chair of the scientific committee of EuroELSO. ASS reports personal fees from Xenios and Baxter; he is Chair of the Scientific Committee of the International ECMO Network (ECMONet). SJ reports SJ consulting fees from Drager, Fresenius-Xenios, Baxter, Medtronic, Mindray and Fisher & Paykel. Other authors declare no competing interest.

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Combes, A., Brodie, D., Aissaoui, N. et al. Extracorporeal carbon dioxide removal for acute respiratory failure: a review of potential indications, clinical practice and open research questions. Intensive Care Med 48, 1308–1321 (2022). https://doi.org/10.1007/s00134-022-06796-w

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