Extracorporeal carbon dioxide removal

Extracorporeal carbon dioxide removal (ECCO2R) is a form of extracorporeal life support (ECLS) that provides lung support by eliminating excess carbon dioxide (CO2) from the blood. In contrast to extracorporeal membrane oxygenation (ECMO), ECCO2R works with lower blood flows where no significant blood oxygenation takes place.[1]

ECCO2R can be performed[1]:

  • by using an ECMO machine with peripheral veno-venous (VV) cannulation and low target blood flow,
  • by incorporating a membrane oxygenator into a continuous kidney replacement therapy (CKRT) circuit where blood flow is limited by the CKRT circuit,
  • pumpless with peripheral arteriovenous cannulation where blood flow is driven and limited by the patient’s cardiac output.

ECCO2R has been demonstrated to[1]:

  • help avoid intubation for mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease (AECOPD) when non-invasive ventilation has failed,
  • enable lung-protective mechanical ventilation in patients with acute respiratory distress syndrome (ARDS),
  • correct respiratory acidosis in ventilated patients with hypercapnic respiratory failure.

Ongoing studies for ECCO2R use in ARDS patients include the SUPERNOVA trial[2], and in AECOPD patients the X-COPD study[3], and the ORION study[4].

Important completed ECCO2R studies include the REST trial[5], the ECLAIR study[6], and the SUPERNOVA study[7,8].

[1] Staudinger, T. (2020). Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion, 35(6), 492-508

[2] University of Bologna. Strategy of Ultra-Protective Lung Ventilation With Extracorporeal CO2 Removal for New-Onset Moderate ARDS: A Prospective Multicenter Randomized Clinical Trial: NCT04903262, SUPERNOVA. Published March 31, 2022. Accessed June 29, 2022. https://clinicaltrials.gov/ct2/show/NCT04903262

[3] Fresenius Medical Care Deutschland GmbH. Early Extubation by ECCO2R Compared to IMV in Patients With Severe Acute Exacerbation of COPD – Full Text View – ClinicalTrials.gov. Published June 29, 2022. Accessed June 29, 2022. https://clinicaltrials.gov/ct2/show/NCT03584295?term=dioxide+removal&draw=2&rank=7

[4] University of Bologna, University of Milan, University of Turin I, University of Roma La Sapienza. Extra-Corporeal Carbon Dioxide Removal for Acute Decompensation of Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial (The ORION Study): NCT04582799, ORION. Published March 31, 2022. Accessed June 30, 2022. https://clinicaltrials.gov/ct2/show/NCT04582799 (Study was conducted without Xenios devices)

[5] McNamee, J. J. et al. (2021). Effect of Lower Tidal Volume Ventilation Facilitated by Extracorporeal Carbon Dioxide Removal vs Standard Care Ventilation on 90-Day Mortality in Patients With Acute Hypoxemic Respiratory Failure: The REST Randomized Clinical Trial. JAMA, 326(11), 1013-1023

[6] Braune, S. et al. (2016). 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, 42(9), 1437-1444

[7] Combes, A. et al. (2019). Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med, 45(5), 592-600

[8] Combes, A. et al. (2019). Efficacy and safety of lower versus higher CO2 extraction devices to allow ultraprotective ventilation: secondary analysis of the SUPERNOVA study. Thorax, 74(12), 1179-1181