Extracorporeal carbon dioxide removal to avoid intubation in patients with COPD failing noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study) - multicentre case-control-study
Stephan Braune, MD, MPH1; Annekatrin Sieweke1; Franz Brettner, MD2, Thomas Staudinger, MD3; Michael Joannidis, MD4; Serge Verbrugge, MD5; Daniel Frings, MD1, Axel Nierhaus, MD1, Karl Wegscheider, MD, PhD6; Stefan Kluge, MD1
ELECTRONIC SUPPLEMENTARY MATERIAL
FURTHER DETAILS OF METHODS
Management of vv-ECCO2R
Percutaneous cannulation using the Seldinger technique was performed at the bedside by the attending intensivists. Blood flow through the extracorporeal circuit was held at the most tolerable flow not to exceed a maximum negative pressure of minus 70 mmHg in the venous pre-pump limb. Continuous intravenous heparin was commenced with a bolus of 1000 to 5000 units, depending of the body weight and the baseline activated partial thromboplastin time (aPTT) at the time of cannulation and thereafter titrated to an aPTT of 50–60 seconds. The fraction of oxygen of the sweep gas delivered through the membrane was fixed at 1.0. The sweep gas flow rate was adjusted between 1 to 10 L/min to achieve a pH between 7.35 and 7.45 based on regularly measured arterial blood gases.
The general strategy of weaning ECCO2R was to gradually reduce the sweep gas flow according to the improvement of the acute respiratory failure and the patients` ventilatory capacity. Once the sweep gas flow had been reduced to < 1L/min for at least 12 hours maintaining a respiratory rate < 25 breaths/min, a pH > 7.35, and not resulting in clinical signs of ventilatory failure the sweep gas was briefly discontinued. If this did not result in a decrease in pH or clinical signs of ventilatory failure, the ECCO2R circuit was stopped and bed-sided decannulation performed.
FIGURES
Figure 1 ESM: Flowchart of all COPD patients with acute hypercapnic respiratory failure screened in the principle study centre, the Department of Intensive Care Medicine at the University Medical Center Hamburg-Eppendorf, Germany from December 2012 to April 2015 with acute hypercapnic respiratory failure. * In 14 cases not possible and 2 patients declined, NIV = non-invasive ventilation.
TABLES
I. Results for all study patients
Table 1 ESM: Comorbidities
Comorbidities n (%) / ECCO2R group (n=25) / Control group (n=25) / p-value- Cardiovascular
- Diabetes mellitus
- Renal
- Neurological
- Immunosuppression
- Malignancy
- Abdominal surgery
- Gastrointestinal / 17 (68.0)
4 (16.0)
7 (28.0)
4 (16.0)
3 (12.0)
3 (12.0)
3 (12.0)
2 (8.0) / 20 (80.0)
6 (24.0)
6 (24.0)
8 (32.0)
1 (4.0)
2 (8.0)
2 (8.0)
2 (8.0) / 0.34
0.48
0.74
0.18
0.32
0.64
0.57
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Table 2 ESM: ECCO2R patients` individual details on pre-intubation circumstances
Pre ECCO₂R / Pre Intubation / Clinical indicationPat / P/F Ratio (mmHg) / P/F Ratio (mmHg) / PaCO₂ (mmHg) Hg) / pH / RR (/min) / Ventilatory failure / Copious secretion / Neuro-logical / Haemod. instability
1 / 142 / 189 / 144 / 7.06 / 25 / yes / yes / yes / -
3 / 108 / 60 / 43.2 / 7.43 / 28 / - / yes / - / -
4 / 299 / 105 / 66.6 / 7.34 / 24 / - / yes / - / -
7 / 264 / 96 / 64.3 / 7.33 / 28 / - / yes / - / yes
8 / 192 / 60 / 63.7 / 7.26 / 26 / - / yes / yes / -
14 / 188 / 71 / 88 / 7.29 / 43 / yes / - / yes / -
18 / 138 / * / * / * / * / - / - / yes / yes
19 / 180 / * / * / * / * / yes / - / - / -
20 / 151 / 112 / 57.5 / 7.34 / 23 / - / - / - / yes
22 / 106 / 70 / 47 / 7.47 / - / - / - / - / yes
24 / 300 / 130 / 72 / 7.08 / - / yes / - / - / yes
Table 2 ESM:* = patient intubated on day 12 (patient 18) and day 1 (patient 19) after completion of ECCO2R, ECCO₂R = extracorporeal carbon dioxide removal, P/F Ratio = PaO2/FiO2, PaCO₂ = arterial partial pressure carbon dioxide, RR = respiratory rate
Table 3 ESM: Details of ECCO2R treatment
Cannula n (%)- 22 Fr DL right jugular vein / 11 (44.0)
- 24 Fr DL right/left femoral vein / 9/4 (52.0)
- 24/15 Fr single cannulas right jugular/femoral vein / 1 (4.0)
Membrane replacements n (%)
- No replacement / 24(96.0)
- 1 replacement / -
- 2 replacements / 1
Table 4 ESM: ECCO2R group– individual diagnoses, intubation and complications
ECCO2R group – diagnostic characteristics, intubation and complicationsPat / Age (yrs) / Sex
(m/f) / Comorbidities / ETT / Complications
Major Minor
1 / 75 / m / aHTN, DM, Mal / ves / AIC / 3x MIB, DGT, PT
2 / 62 / f / - / - / - / -
3 / 74 / f / aHTN, anaemia, RA, ASur / ves / 1x MAB: PH / 3x MIB, LO, PT
4 / 54 / f / aHTN, CAD / ves / 1x MAB: TS / 3x MIB, FPL
5 / 68 / m / CAD, BMTx, CMML, PT / - / ECC / Seizure
6 / 72 / m / CPS, ARF / - / 2x MAB, RU, RPH / LO
7 / 65 / m / Enc, aHTN, BMTx, PT / ves / 2x MAB: CIS, HT / 1x MIB, LO
8 / 60 / f / aHTN / ves / 1x MAB: TS / DET
9 / 53 / m / aHTN / - / - / -
10 / 69 / f / DM, ARF / - / - / -
11 / 69 / f / - / - / 1x MAB: HT / -
12 / 59 / m / - / - / 1x MAB: DLC, ECC / -
13 / 72 / m / aHTN, CHF, ARF / - / - / -
14 / 65 / f / - / ves / 1x MAB: GU / -
15 / 76 / m / CPS, GERD / - / - / -
16 / 83 / m / aHTN, CAD, DM, ARF / - / - / -
17 / 62 / f / - / - / - / -
18 / 63 / m / CPS, ASurg, Mal / ves / - / -
19 / 79 / m / CHF, Mal / ves / - / -
20 / 66 / f / aHTN, DM, anaemia / ves / 1x MAB: PH / -
21 / 69 / f / Liver fibrosis, CMP / - / - / -
22 / 75 / m / aHTN, AFib, HF, ARF, OSAS / ves / - / -
23 / 74 / f / aHTN, CAD, ASurg, ARF / - / -
24 / 68 / f / aHTN, CHD, ARF / ves / - / -
25 / 51 / f / aHTN, PT, PP, depression / - / VT
Table 4 ESM: AECOPD = acute exacerbation of chronic obstructive pulmonary disease, AFib = atrial fibrillation, aHTN = arterial hypertension, AIC = air in circuit, ARF = acute renal failure, ASurg = abdominal surgery, BMTx = bone marrow transplantation, CAD = coronary artery disease, CAP = community acquired pneumonia, CHF = chronic heart failure, CIS = cannula insertion site , CMML = chronic myelomonocytic leukaemia, CMP = cardiomyopathy, CPS = chronic pain syndrome, DET = dislocation of endotracheal tube, DGT = disconnection of the sweep gas tube, DLC = double lumen catheter, DM = diabetes mellitus Type II,DVT = deep vein thrombosis, ECC = extracorporeal clotting of the circuit, ECCO₂R = extracorporeal carbon dioxideremoval, Enc = encephalopathy, ETT = endotracheal tube intubation, f = female, FPL = facial pressure lesions, GU = gastric ulcer, GERD = gastroesophageal reflux disease, HT = haematothorax, LO = laryngeal oedema, m = male, Mal = malignancy, MAB = major bleeding, MIB = minor bleeding, OSAS = obstructive sleep apnea syndrome, PF = pulmonary fibrosis, PH = pulmonary haemorrhage, PT = pneumothorax, PP = partial pneumonectomy, RA = rheumatoid arthritis, RPH = retroperitoneal haematoma, RU = rectal ulcer, SVT = sinus vein thrombosis, TS = tracheostomy, VT = ventricular tachycardia
Table 5 ESM: ECCO2R group – individual time courses of outcomes
Number of dayspost ECCO₂Rstart / Day of
ETT /PDTpost
ECCO2R start / LOS
(days) / 90-day
survival / Day of death
post ECCO2R start
/ cause of death
Pat / ECCO2R / NIV / SB / ETT / PDT / ICU / H / y/n / Death / Cause
1 / 10 / 10 / 0 / 12 / 26 / 32 / 32 / no / 30 / PC
2 / 6 / 7 / 6 / - / - / 12 / 20 / yes / - / -
3 / 27 / 11
3 / 1 / 13 / 23 / 36 / 46 / yes / - / -
4 / 9 / 3 / 0 / 3 / 5 / 20 / 20 / yes / - / -
5 / 6 / 1 / 5 / - / - / 39 / 60 / yes / - / -
6 / 11 / 10 / 10 / - / - / 37 / 58 / yes / - / -
7 / 14 / 9 / 0 / 9 / - / 13 / 18 / no / 13 / MOF
8 / 10 / 6 / 0 / 1 / 2 / 25 / 25 / yes / - / -
9 / 6 / 0 / 6 / - / - / 14 / 16 / yes / - / -
10 / 8 / 0 / 7 / - / - / 16 / 16 / yes / - / -
11 / 4 / 0 / 4 / - / - / 8 / 46 / no / 46 / PC
12 / 22 / 22 / 5 / - / - / 53 / 58 / yes / - / -
13 / 2 / 0 / 2 / - / - / 10 / 10 / yes / - / -
14 / 4 / 2 / 0 / 3 / 5 / 21 / 26 / no / 24 / CA
15 / 1 / 1 / 0 / - / - / 28 / 44 / no / 27 / MOF
16 / 4 / 2 / 1 / - / - / 11 / 13 / yes / - / -
17 / 4 / 1 / 4 / - / - / 9 / 13 / yes / - / -
18 / 7 / 0 / 7 / 19 / - / 8 / 9 / no / 20 / CPR,HBD
19 / 6 / 4 / 2 / 7 / 10 / 25 / 27 / yes / - / -
20 / 12 / 11 / 1 / 10 / 34 / 44 / 44 / no / 44 / MOF
21 / 4 / 1 / 3 / - / - / 8 / 25 / yes / - / -
22 / 6 / 0 / 0 / 1 / 5 / 71 / 90 / yes / - / -
23 / 5 / 3 / 4 / - / - / 49 / 49 / yes / - / -
24 / 11 / 1 / 0 / 1 / 10 / 100 / 100 / yes / - / -
25 / 15 / 12 / 4 / - / - / 35 / 59 / yes / - / -
Table 5 ESM:CA = cardiac arrest, CPR = cardiopulmonary resuscitation, ECCO₂R = extracorporeal carbon dioxideremoval, ETT = endotracheal tube intubation, H = hospital, HBD = hypoxic brain damage, ICU = intensive care unit, LOS = length of stay, MOF = multi organ failure, NIV = non-invasive ventilation, Pat = patient, PC = palliative care, PDT = percutaneous dilatational tracheostomy, SB = spontaneous breathing
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