[Update: acute hypercapnic respiratory failure].

BACKGROUND

Hypercapnic respiratory failure is a frequent problem in critical care and mainly affects patients with acute exacerbation of COPD (AECOPD) and acute respiratory distress syndrome (ARDS). In recent years, the usage of extracorporeal CO removal (ECCOR) has been increasing.

OBJECTIVE

Summarizing the state of the art in the management of hypercapnic respiratory failure with special regard to the role of ECCOR.

METHODS

Review based on a selective literature search and the clinical and scientific experience of the authors.

RESULTS

Noninvasive ventilation (NIV) is the therapy of choice in hypercapnic respiratory failure due to AECOPD, enabling stabilization in the majority of cases and generally improving prognosis. Patients in whom NIV fails have an increased mortality. In these patients, ECCOR may be sufficient to avoid intubation or to shorten time on invasive ventilation; however, corresponding evidence is sparse or even missing when it comes to hard endpoints. Lung-protective ventilation according to the ARDS network is the standard therapy of ARDS. In severe ARDS, low tidal volume ventilation may result in critical hypercapnia. ECCOR facilitates compensation of respiratory acidosis even under "ultra-protective" ventilator settings. Yet, no positive prognostic effects could be demonstrated so far.

CONCLUSION

Optimized use of NIV and lung-protective ventilation remains standard of care in the management of hypercapnic respiratory failure. Currently, ECCOR has to be considered an experimental approach, which should only be provided by experienced centers or in the context of clinical trials.