ECCO₂R therapy in the ICU: consensus of a European round table meeting

With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO₂ removal (ECCO₂R). However, current evidence in these indications is limited. A European ECCO₂R Expert Round Table Meeting was convened to further explore the potential for this treatment approach.

A modified Delphi-based method was used to collate European experts' views to better understand how ECCO₂R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus.

Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO₂R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO₂R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO₂R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO₂ levels. Driving pressure (≥ 14 cmH₂O) followed by plateau pressure (P_plat; ≥ 25 cmH₂O) was considered the most important criteria for ECCO₂R initiation. Key treatment targets for patients with ARDS undergoing ECCO₂R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH₂O) and P_plat (< 25 cmH₂O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO₂ and no decrease in respiratory rate were key criteria for initiating ECCO₂R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30-7.35), respiratory rate (< 20-25 breaths/min), decrease of PaCO₂ (by 10-20%), weaning from NIV, decrease in HCO₃^- and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group.

Insights from this group of experienced physicians suggest that ECCO₂R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.