Interventional Lung Assist – Effective Removal of Carbon Dioxide in Acute Respiratory Failure

Interventional Lung Assist – Effective Removal of Carbon Dioxide in Acute Respiratory Failure

Kuhlen Ralf
European Respiratory Disease - Volume 4 - Issue I
Published: November 2008
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Acute respiratory failure is still one of the most important diagnoses in intensive care therapy. Although recent years have seen major advances in ventilator techniques, pharmacological treatment and general intensive care, the overall mortality rate in acute respiratory failure leading to mechanical ventilation is still high.1 The most effective intervention to reduce mortality has been the reduction of tidal volumes and the application of an adequate positive end-expiratory pressure level to prevent further ventilator-induced lung injury.2 This protective ventilation mode has been widely accepted for clinical use in recent years.3 However, in the most severe cases of acute respiratory failure profound hypoxaemia or respiratory acidosis may contradict the sole use of protective ventilation strategies and necessitate additional strategies such as positioning manoeuvres, inhaled vasodilators, partial liquid ventilation or high-frequency ventilation techniques.4–6 Another approach is the application of extracorporeal gas-exchange devices to facilitate oxygenation and carbon dioxide (CO2) removal without the harm associated with aggressive mechanical ventilation. Depending on its technical modifications, the blood flow rate and the route of extracorporeal blood flow, these techniques are called extracorporeal lung assist (ECLA), extracorporeal membrane oxygenation (ECMO) or interventional lung assist (ILA).

History of Extracorporeal Lung Assist
With the first successful application of a modified cardiopulmonary bypass system for a young patient with traumatic lung injury, the concept of ECLA/ECMO was introduced to clinical practice.7 A milestone in the technical evolution of cardiopulmonary bypass and ECLA was the development of membrane oxygenators instead of bubble oxygenators in the 1960s, leading to increased short- and long-term biocompatibility.8 Promising results in different case reports led to the first prospective, randomised, controlled study in the early 1970s,9 in which 90 patients with severe acute respiratory distress syndrome (ARDS) were randomised to either conventional therapy with mechanical ventilation or to additional ECMO therapy; there was no significant effect on mortality, which was as high as 90 and 92% in the respective groups. A veno–arterial perfusion with reduced pulmonary blood flow, no adjustment of mechanical ventilation to protect the lungs after starting ECMO, high-dose heparinisation with a daily blood loss of 2.5l and termination of ECMO after five days regardless of lung function are possible reasons for the disappointing results in this trial.

Gattioni et al. developed an alternative approach: a veno–venous perfusion route and a blood flow of only 20–30% of cardiac output combined with low-frequency mechanical ventilation and additional oxygen insufflations, known as extracorporeal CO2 removal (ECCO2R).10 Forty-three patients with severe ARDS according to the same entry criteria as used in the first ECMO study were treated with ECCO2R, demonstrating a 51.2% mortality rate. A subsequent prospective, randomised trial failed to confirm these results, but an injurious ventilation strategy during the extracorporeal treatment, a low blood flow despite ongoing hypoxia and high blood loss were profound technical problems in the ECMO group.11 For newborns with severe respiratory failure, a prospective, randomised study clearly demonstrated that ECMO improved clinical outcome and is cost-effective compared with conservative therapy.12,13

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