title: Extracorporeal Co2 removal in hypercapnic patients at risk of noninvasive ventilation failure: a matched cohort study with historical control.
abstract: OBJECTIVE
  To assess efficacy and safety of noninvasive ventilation-plus-extracorporeal Co2 removal in comparison to noninvasive ventilation-only to prevent endotracheal intubation patients with acute hypercapnic respiratory failure at risk of failing noninvasive ventilation.
  
  
  METHODS
  Matched cohort study with historical control.
  
  
  METHODS
  Two academic Italian ICUs.
  
  
  METHODS
  Patients treated with noninvasive ventilation for acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease (May 2011 to November 2013).
  
  
  METHODS
  Extracorporeal CO2 removal was added to noninvasive ventilation when noninvasive ventilation was at risk of failure (arterial pH ≤ 7.30 with arterial PCO2 > 20% of baseline, and respiratory rate ≥ 30 breaths/min or use of accessory muscles/paradoxical abdominal movements). The noninvasive ventilation-only group was created applying the genetic matching technique (GenMatch) on a dataset including patients enrolled in two previous studies. Exclusion criteria for both groups were mean arterial pressure less than 60 mm Hg, contraindications to anticoagulation, body weight greater than 120 kg, contraindication to continuation of active treatment, and failure to obtain consent.
  
  
  RESULTS
  Primary endpoint was the cumulative prevalence of endotracheal intubation. Twenty-five patients were included in the noninvasive ventilation-plus-extracorporeal CO2 removal group. The GenMatch identified 21 patients for the noninvasive ventilation-only group. Risk of being intubated was three times higher in patients treated with noninvasive ventilation-only than in patients treated with noninvasive ventilation-plus-extracorporeal CO2 removal (hazard ratio, 0.27; 95% CI, 0.07-0.98; p = 0.047). Intubation rate in noninvasive ventilation-plus-extracorporeal CO2 removal was 12% (95% CI, 2.5-31.2) and in noninvasive ventilation-only was 33% (95% CI, 14.6-57.0), but the difference was not statistically different (p = 0.1495). Thirteen patients (52%) experienced adverse events related to extracorporeal CO2 removal. Bleeding episodes were observed in three patients, and one patient experienced vein perforation. Malfunctioning of the system caused all other adverse events.
  
  
  CONCLUSIONS
  These data provide the rationale for future randomized clinical trials that are required to validate extracorporeal CO2 removal in patients with hypercapnic respiratory failure and respiratory acidosis nonresponsive to noninvasive ventilation.
authors.affiliation: 1Dipartimento di Anestesiologia e Rianimazione, Azienda Ospedaliera Città della Salute e della Scienza e di Torino, Università di Torino, Torino, Italy. 2Respiratory and Critical Care Unit, Department of Specialist, Diagnostic and Experimental Medicine (DIMES), Sant'Orsola Malpighi Hospital, Alma Mater University, Bologna, Italy. 3Thoracic Surgery Unit, Sant'Orsola Malpighi Hospital, Alma Mater University, Bologna, Italy. 4Unit of Clinical Epidemiology, Azienda Ospedaliera Città della Salute e della Scienza e di Torino and CPO Piemonte, Torino, Italy. 5Dipartimento di Emergenza ed Accettazione, Unità di Medicina d'Urgenza, Azienda Ospedaliera Città della Salute e della Scienza e di Torino, Università di Torino, Torino, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Del Sorbo
authors.forename: Lara
authors.initials: L
authors.lastname: Pisani
authors.forename: Claudia
authors.initials: C
authors.lastname: Filippini
authors.forename: Vito
authors.initials: V
authors.lastname: Fanelli
authors.forename: Luca
authors.initials: L
authors.lastname: Fasano
authors.forename: Pierpaolo
authors.initials: P
authors.lastname: Terragni
authors.forename: Andrea
authors.initials: A
authors.lastname: Dell'Amore
authors.forename: Rosario
authors.initials: R
authors.lastname: Urbino
authors.forename: Luciana
authors.initials: L
authors.lastname: Mascia
authors.forename: Andrea
authors.initials: A
authors.lastname: Evangelista
authors.forename: Camillo
authors.initials: C
authors.lastname: Antro
authors.forename: Raffaele
authors.initials: R
authors.lastname: D'Amato
authors.forename: Maria José
authors.initials: MJ
authors.lastname: Sucre
authors.forename: Umberto
authors.initials: U
authors.lastname: Simonetti
authors.forename: Pietro
authors.initials: P
authors.lastname: Persico
authors.forename: Stefano
authors.initials: S
authors.lastname: Nava
authors.forename: V Marco
authors.initials: VM
authors.lastname: Ranieri
mesh_terms: D000368:Aged; D002245:Carbon Dioxide / Q000378:metabolism; D015331:Cohort Studies; D015199:Extracorporeal Membrane Oxygenation; D006801:Humans; D006935:Hypercapnia / Q000209:etiology / Q000628:therapy*; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data; D063087:Noninvasive Ventilation / Q000379:methods*; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications; D012307:Risk Factors; D017211:Treatment Failure
chemical_list: D002245:Carbon Dioxide