Minimally invasive extracorporeal CO2 removal in hypercapnic respiratory failure: a prospective observational study

Abstract Background Lung-protective ventilation in acute respiratory distress syndrome (ARDS) can lead to hypercapnia, an independent risk factor for increased mortality. Extracorporeal CO 2 removal (ECCO 2 R) enables further reduction of ventilator intensity, but its routine use is limited due to safety concerns. In the current study, we evaluated the feasibility, efficacy, and safety of minimally invasive ECCO 2 R (miECCO 2 R) implemented via a renal replacement therapy (RRT) platform in patients with mild-to-moderate ARDS and refractory hypercapnia. Methods In this prospective single-center observational study, 20 ICU patients with persistent hypercapnia despite escalated ventilation received either standalone miECCO 2 R (n = 11) or miECCO 2 R combined with continuous RRT (n = 9). As a primary outcome, efficacy of miECCO 2 R was assessed. Moreover, ventilator parameters, disease severity, renal function, and adverse events were evaluated as secondary outcome parameters over a time-course of five days upon initiation of miECCO 2 R. Results miECCO 2 R led to a rapid and sustained reduction in PaCO 2 levels from 71.4 mm Hg to 51.6 mm Hg within 24 h. This was accompanied by normalization of pH, and the median CO 2 clearance rate was 64.5 mL/min. Driving pressure decreased significantly from 22 cm H 2 O to 15 cm H 2 O by day 5, while oxygenation remained stable. The standalone miECCO 2 R treatment group demonstrated faster CO 2 reduction, probably due to higher blood flow rates. There were no severe adverse events related to either the device or the therapy. Circuit clotting was managed by system exchange, without clinical consequences for the patients. Platelet counts declined moderately, but no major bleeding complications occurred. Conclusions miECCO 2 R delivered via an RRT platform appears to be a safe and effective method of controlling hypercapnia and facilitating lung-protective ventilation in patients with ARDS. These findings need to be supported by further randomized controlled trials that can more definitely demonstrate the impact of miECCO 2 R on clinical outcomes.