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ECCO₂R: Advancing Lung-Protective Ventilation in Acute Respiratory Failure

Extracorporeal carbon dioxide removal (ECCO₂R) can help manage hypercapnia and respiratory acidosis in patients with acute respiratory failure (ARF) who require invasive mechanical ventilation (IMV). By removing CO₂ directly from the bloodstream, ECCO₂R supports the achievement of guideline-recommended lung-protective ventilation (LPV) strategies.

The burden of ARF and risks of IMV

ARF affects more than half of ICU patients and is often caused by acute respiratory disease syndrome (ARDS), pneumonia, chronic obstructive pulmonary disease (COPD), cardiovascular complications or sepsis.¹⁻⁶

ARDS carries high mortality; even mild cases of ARDS carry a substantial mortality risk of 35%.⁴⁻⁷

IMV is often essential when spontaneous breathing fails, but traditional high mechanical power ventilation can lead to ventilator-induced lung injury (VILI), which is associated with increased morbidity, multi-organ dysfunction and higher mortality risk.8-17

ARF and IMV in the ICU

A large national study examined trends in ARF hospitalizations, treatments and outcomes over nearly a decade, showing increased use of noninvasive ventilation and improvements in survival.

See study

High mechanical power and outcomes

A multicenter trial found that using lower tidal volumes for patients with acute lung injury and ARDS significantly reduced mortality and increased ventilator-free days compared to high mechanical power ventilation.

See study

Clinical guidelines support lung-protective strategies

To improve survival, guidelines recommend LPV strategies, including low tidal volume (~6 mL/kg PBW), controlled plateau pressure and higher positive end-expiratory pressure (PEEP) to reduce VILI risk.18-22 

Compared to traditional IMV, LPV is associated with:

  • Reduced mortality13,16,23-25
  • More ventilator-free days16
  • Fewer days with non-pulmonary organ failure16
  • Improved weaning outcomes and reduced hospital stays16,25

Yet, up to one-third of ARDS patients on LPV still show signs of tidal hyperinflation and VILI.26

Two healthcare professionals discuss data on a tablet device

ARDS management guidelines

See how the 2017 ATS/ESICM recommendations support lung-protective strategies and why ECCO₂R is gaining clinical interest.

Read more

LPV can cause hypercapnia and acidosis

While LPV reduces lung stress, it can impair CO₂ clearance. This leads to hypercapnia and respiratory acidosis, which:

  • Are more frequent and prolonged with LPV than traditional ventilation16,27,28
  • Are associated with significantly increased ICU and in-hospital mortality29-31
  • May become a barrier to effective LPV implementation, especially in patients with cardiovascular or renal risk18,19,32

How ECCO₂R supports protective ventilation

ECCO₂R is an extracorporeal therapy that removes CO₂ from the blood, helping to facilitate LPV or ultra-protective LPV (UPLV) while avoiding the complications of hypercapnia and acidosis.33-35

  • Shown to effectively control hypercapnia in ARDS, including COVID-19-associated ARDS36-42
  • Enables LPV and UPLV in moderate ARDS, demonstrating improved survival (day 60 survival: 63.4% with LPV + ECCO₂R vs. 57.1% with IMV alone)41

Patient-centered ICU advantages

In patients likely to benefit, ECCO₂R offers additional advantages:

  • Customizable LPV/UPLV support depending on individual patient factors like dead space and lung elastance43
  • Mortality benefit may be more pronounced in patients with worse CO₂ exchange (VR ≥3) and less severe hypoxemia (PaO₂:FiO₂ ≥110 mm Hg)34
  • Compatible anticoagulation targets similar to those used in RRT circuits may ease ICU integration38

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References

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