Extracorporeal CO2 removal in acute exacerbations of

COPD

Lorenzo Del Sorbo, MD

CCCF, Toronto, Nov 1st 2016

NO CONFLICT OF INTEREST

Outline

-Severe COPD exacerbation: the clinical issue -Patho-physiological principles of ECCO2R in COPDe -Clinical application of ECCO2R in COPDe -Future perspective

COPD exacerbation

•  COPD is the fourth leading cause of death in western countries

•  COPD is expected to become the third by 2020

•  COPD exacerbations are the most common cause of death in COPD patients

•  COPD is a leading cause of morbidity worldwide resulting in a social and economical burden that is substantial and increasing

GOLD Report, update 2009; MacIntyre N. et al. Proc Am Thorac Soc, 2008

Dynamic hyperinflation

O’Donnell DE. et al. Thorax 2006

Keenan SP, Ann Intern Med 2003 - Ram FSF, Cochrane 2009

NIV and COPD exacerbation

NIV and COPD exacerbation

Keenan SP, Ann Intern Med 2003 - Ram FSF, Cochrane 2009

CCM 2015

Retrospective, multicenter cohort study Setting: 38 hospitals 2008-2012 13.7%

(of 561 pts not DNR )

COPDe and ECCO2R

V(trapped) = VT x τ

TE

Hypothesis: the decrease of the native lung VE results in reduction of alveolar hyperinflation

Kolobov T, Gattinoni L et al. Anesthesiology 1977 Laghi F et al. Minerva Anestesiol 2012

ECCO2R devices

19F, bullous emphysema 28 days of IMV failed various attempts of weaning (Vt 450 mL, RR 20 b/m, ZEEP, FiO2 0.4, pH 7.39, PaO2 68 mmHg and PaCO2 48 mmHg)

ECCO2R improves pulmonary hypertension in acute exacerbation of severe COPD

Karagiannidis C. et al. ICM 2015

Diehl JL. et al. ICM 2016

Effects of ECCO2R on work of breathing in patients with COPD

Pisani L. et al. AJRCCM 2015

Effects of ECCO2R on Inspiratory Effort and Respiratory Pattern in Patients Who Fail

Weaning from Mechanical Ventilation

Crit Care Med 2015

2 Italian ICUs (University of Torino and University of Bologna) May 2011-November 2013

Inclusion criteria for the “NIV plus ECCO2R” group

ECCO2R was added to NIV in patients “at risk of failure of NIV” after at least two hours of NIV with:

-arterial pH ≤7.30 and -PaCO2 (PaCO2) >20% of the baseline value

and one of the following:

-respiratory rate ≥30 breaths/min

-use of accessory muscles or paradoxical abdominal movements

Confalonieri M. Eur Respir J 2005;25(2):348-355.

Cumulative incidence of endotracheal intubation during the

28 days after ICU admission

Primary Endpoint

Del Sorbo L. CCM 2015

Characteristics of patients

Data are mean (standard deviation) or median and inter-quartile range. Comparisons between groups were made using the Mann-Wilcoxon-Whitney test.

Del Sorbo L. CCM 2015

Respiratory variables

Data are expressed as median and inter-quartile range. Comparisons between groups were made using the Mann-Wilcoxon-Whitney test.

Del Sorbo L. CCM 2015

HR 0.27 95% CI 0.07-0.98

P=0.047 ETT rate:

12% (3/25) NIV plus ECCO2R vs

33% (7/21) NIV only

Cumulative incidence of ETT

Primary outcome was assessed considering death as a competing event using the method of Gooley. Adjusted HR and 95% CI were estimated using the Fine and Grey model. Del Sorbo L. CCM 2015

Operational characteristics of ECCO2R

Data are expressed as mean (standard deviation)

Del Sorbo L. CCM 2015

Complications in “NIV-plus-ECCO2R”

Del Sorbo L. CCM 2015

Conclusions/limitations

•  NIV plus ECCO2R was associated with a lower cumulative incidence of ETT compared to NIV only

•  Observational trial with matched controls

•  Very selected group of patients (High risk of NIV failure – only 33% of ETT rate in controls)

•  High incidence of complications

Del Sorbo L. CCM 2015

Braune S. et al. ICM 2016

Braune S. et al. ICM 2016

Braune S. et al. ICM 2016

- Intubation was avoided in 14/25 patients (56.0 %) 7 patients: intubated for progressive hypoxaemia 5 patients: intubation associated with severe secretions

- Relevant ECCO2 R-associated adverse events in 11 patients (44.0 %) - Mean extracorporeal blood flow of 1.3 L/min

ECLAIR: limitations

NIV plus ECCO2R was associated with an intubation rate of 44% vs 100 of historical matched controls

•  Observational trial with matched controls

•  Very selected group of patients -  Too sick (SAPSII>40), too late to see ECCO2R benefit? -  Hypoxemia: surprisingly high incidence -  Secretions: relative contraindication to NIV?

•  High incidence of complications

- ECCO2R blood flow 1.3 L/min (too high?: contributing to hypoxemia and PLTs damage?)

Del Sorbo L. et al. ICM 2016

Ten studies (87 patients), primarily case series

Future perspective in ECCO2R for COPDE

•  Strong pathophysiologic rational •  High incidence of ECCO2R related complications

•  Increasing definition of potential mechanisms of action/benefit

•  RCTs: in the right patients with the right

strategy Del Sorbo L. et al. CCM 2015 – ICM 2016, Braune S. et al. ICM 2016,

Contou D. et al. CCM 2015, Roncon-Albuquerque R Jr. and Brodie D. CCM 2015

Thank you