title: The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case-control study.
abstract: BACKGROUND
  The aim of the study was to evaluate the feasibility and safety of avoiding invasive mechanical ventilation (IMV) by using extracorporeal CO2 removal (ECCO2R) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and acute hypercapnic respiratory failure refractory to noninvasive ventilation (NIV).
  
  
  METHODS
  Case-control study. Patients with acute hypercapnic respiratory failure refractory to NIV being treated with a pump-driven veno-venous ECCO2R system (iLA-Activve(®); Novalung, Heilbronn, Germany) were prospectively observed in five European intensive care units (ICU). Inclusion criteria were respiratory acidosis (pH ≤ 7.35, PaCO2 > 45 mmHg) with predefined criteria for endotracheal intubation (ClinicalTrials.gov NCT01784367). The historical controls were patients with acute hypercapnic respiratory failure refractory to NIV who were treated with IMV. The matching criteria were main diagnosis, age, SAPS-II score and pH.
  
  
  RESULTS
  Twenty-five cases (48.0 % male, mean age 67.3 years) were matched with 25 controls. Intubation was avoided in 14 patients (56.0 %) in the ECCO2R group with a mean extracorporeal blood flow of 1.3 L/min. Seven patients were intubated because of progressive hypoxaemia and four owing to ventilatory failure despite ECCO2R and NIV. Relevant ECCO2R-associated adverse events were observed in 11 patients (44.0 %), of whom 9 (36.0 %) suffered major bleeding complications. The mean time on IMV, ICU stay and hospital stay in the case and control groups were 8.3 vs. 13.7, 28.9 vs. 24.0 and 36.9 vs. 37.0 days, respectively, and the 90-day mortality rates were 28.0 vs. 28.0 %.
  
  
  CONCLUSIONS
  The use of veno-venous ECCO2R to avoid invasive mechanical ventilation was successful in just over half of the cases. However, relevant ECCO2R-associated complications occurred in over one-third of cases. Despite the shorter period of IMV in the ECCO2R group there were no significant differences in length of stay or in 28- and 90-day mortality rates between the two groups. Larger, randomised studies are warranted for further assessment of the effectiveness of ECCO2R.
authors.affiliation: Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Braune
authors.affiliation: Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
authors.forename: Annekatrin
authors.initials: A
authors.lastname: Sieweke
authors.affiliation: Department of Intensive Care Medicine, Hospital Barmherzige Brueder, Munich, Germany.
authors.forename: Franz
authors.initials: F
authors.lastname: Brettner
authors.affiliation: Department of Medicine I, General Hospital Vienna, Medical University of Vienna, Vienna, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Staudinger
authors.affiliation: Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria.
authors.forename: Michael
authors.initials: M
authors.lastname: Joannidis
authors.affiliation: Department of Intensive Care Medicine, St. Franciscus-Hospital, Rotterdam, The Netherlands.
authors.forename: Serge
authors.initials: S
authors.lastname: Verbrugge
authors.affiliation: Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Frings
authors.affiliation: Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
authors.forename: Axel
authors.initials: A
authors.lastname: Nierhaus
authors.affiliation: Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Karl
authors.initials: K
authors.lastname: Wegscheider
authors.affiliation: Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. skluge@uke.de.
authors.forename: Stefan
authors.initials: S
authors.lastname: Kluge
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002245:Carbon Dioxide; D016022:Case-Control Studies; D005112:Extracorporeal Circulation / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D006935:Hypercapnia / Q000209:etiology / Q000628:therapy; D007362:Intensive Care Units; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D063087:Noninvasive Ventilation / Q000009:adverse effects; D010865:Pilot Projects; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications; D012121:Respiration, Artificial / Q000009:adverse effects* / Q000706:statistics & numerical data; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*
chemical_list: D002245:Carbon Dioxide
keywords: Acute respiratory failure; COPD; Endotracheal intubation; Extracorporeal carbon dioxide removal; Hypercapnia; Mechanical ventilation