Expert perspectives on ECCO₂R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting - 08/01/26

Doi : 10.1186/s13613-024-01353-8

Alain Combes ^1,^2,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.} , Georg Auzinger ^3,^4,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Luigi Camporota ^5,^6,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Gilles Capellier ^7,^8,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Guglielmo Consales ^9,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Antonio Gomis Couto ^10,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Wojciech Dabrowski ^11,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Roger Davies ^12,^13,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Oktay Demirkiran ^14,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Carolina Ferrer Gómez ^15,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Jutta Franz ^16,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Matthias Peter Hilty ^17,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, David Pestaña ^18,^19,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Nikoletta Rovina ^20,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Redmond Tully ^21,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Franco Turani ^22,^23,^{*
Georg Auzinger, Luigi Camporota, Gilles Capellier, Guglielmo Consales, Antonio Gomis Couto, Wojciech Dabrowski, Roger Davies, Oktay Demirkiran, Carolina Ferrer Gómez, Jutta Franz, Matthias Peter Hilty, David Pestaña, Nikoletta Rovina, Redmond Tully and Franco Turani contributed equally to this manuscript.}, Joerg Kurz ²⁴, Kai Harenski ²⁴

¹ Institute of Cardiometabolism and Nutrition, INSERM Unité Mixte de Recherche (UMRS) 1166, Sorbonne Université, 47, Boulevard de l’Hôpital, 75013, Paris, France

² Service de Médecine Intensive-Réanimation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 75013, Paris, France

³ Department of Critical Care, King’s College Hospital, SE5 9RS, London, UK

⁴ Department of Critical Care, Cleveland Clinic, SW1Y 7SW, London, UK

⁵ Department of Critical Care, Guy’s & St Thomas’ NHS Foundation Trust, SE1 7EH, London, UK

⁶ Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King’s College London, SE1 1UL, London, UK

⁷ University of Franche-Comté, 25000, Besançon, France

⁸ Department of Epidemiology and Health, Monash University, 3004, Melbourne, VIC, Australia

⁹ Anesthesia, Intensive Care and Emergency Department, Prato Hospital, Azienda Toscana Centro, Prato, Italy

¹⁰ Servicio de Nefrología, Hospital Universitario Ramón y Cajal, 28033, Madrid, Spain

¹¹ First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, 20-954, Lublin, Poland

¹² Chelsea and Westminster Hospital NHS Foundation Trust, SW10 9NH, London, UK

¹³ Division of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea and Westminster Hospital Campus, SW10 9NH, London, UK

¹⁴ Department of Anesthesiology and Intensive Care, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, 34098, Istanbul, Turkey

¹⁵ Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014, Valencia, Spain

¹⁶ Department of Cardiology and Internal Intensive Care, Rems-Murr-Kliniken Winnenden, 71364, Winnenden, Germany

¹⁷ Institute of Intensive Care Medicine, University Hospital Zurich, 8091, Zurich, Switzerland

¹⁸ Servicio de Anestesia-Reanimación, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Km 9, 28034, Madrid, Spain

¹⁹ Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, 28034, Madrid, Spain

²⁰ 1st Respiratory Department, National and Kapodistrian University of Athens Medical School, “Sotiria” Chest Hospital, 152 Mesogion Av, 11527, Athens, Greece

²¹ Royal Oldham Hospital, Northern Care Alliance NHS Trust, OL1 2JH, Oldham, UK

²² Department of Intensive Care, Aurelia Hospital, Via Aurelia 860, 00165, Rome, Italy

²³ Cardiac Anaesthesia European Hospital, Via Portuense, 760, 00416, Rome, Italy

²⁴ Baxter Healthcare, Edisonstr 4, 85716, Unterschleißheim, Germany

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Abstract

Background

By controlling hypercapnia, respiratory acidosis, and associated consequences, extracorporeal CO ₂ removal (ECCO ₂ R) has the potential to facilitate ultra-protective lung ventilation (UPLV) strategies and to decrease injury from mechanical ventilation. We convened a meeting of European intensivists and nephrologists and used a modified Delphi process to provide updated insights into the role of ECCO ₂ R in acute respiratory distress syndrome (ARDS) and to identify recommendations for a future randomized controlled trial.

Results

The group agreed that lung protective ventilation and UPLV should have distinct definitions, with UPLV primarily defined by a tidal volume (V _T ) of 4–6 mL/kg predicted body weight with a driving pressure (ΔP) ≤ 14–15 cmH ₂ O. Fourteen (93%) participants agreed that ECCO ₂ R would be needed in the majority of patients to implement UPLV. Furthermore, 10 participants ( majority , 63%) would select patients with PaO ₂ :FiO ₂ > 100 mmHg ( > 13.3 kPa) and 14 ( consensus , 88%) would select patients with a ventilatory ratio of > 2.5–3. A minimum CO ₂ removal rate of 80 mL/min delivered by continuous renal support machines was suggested (11/14 participants, 79%) for this objective, using a short, double-lumen catheter inserted into the right internal jugular vein as the preferred vascular access. Of the participants, 14/15 (93%, consensus ) stated that a new randomized trial of ECCO ₂ R is needed in patients with ARDS. A ΔP of ≥ 14–15 cmH ₂ O was suggested by 12/14 participants (86%) as the primary inclusion criterion.

Conclusions

ECCO ₂ R may facilitate UPLV with lower volume and pressures provided by the ventilator, while controlling respiratory acidosis. Since recent European Society of Intensive Care Medicine guidelines on ARDS recommended against the use of ECCO ₂ R for the treatment of ARDS outside of randomized controlled trials, new trials of ECCO ₂ R are urgently needed, with a ΔP of ≥ 14–15 cmH ₂ O suggested as the primary inclusion criterion.

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Keywords : Acidosis, ECCO ₂ R , Hypercapnia, Lung protective ventilation, Mechanical ventilation, Ultra-protective lung ventilation

Keywords : Medical and Health Sciences, Clinical Sciences

Plan

Data collection and analysis

Results

Participant experience

Definitions of lung protective ventilation and ultra-protective lung ventilation

Use of ECCO ₂ R to facilitate protective ventilation in patients with ARDS

Initiation and discontinuation of ECCO ₂ R

Anticoagulation strategy for ECCO ₂ R

Optimal blood flow rate for ECCO ₂ R and vascular access

Use of neuromuscular blocking agents and prone positioning during ECCO ₂ R

Need for and design of another randomized trial of ECCO ₂ R for patients with acute hypoxemic respiratory failure

Discussion

Conclusions

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Expert perspectives on ECCO₂R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting - 08/01/26

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