Diehl J-L, Piquilloud L, Vimpere D, Aissaoui N, Guerot E, Augy J L, Pierrot M, Hourton D, Arnoux A, Richard C, Mancebo J, Mercat A
Assistance Publique - Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Médecine Intensive - Réanimation, 20 rue Leblanc, 75015, Paris, France.
INSERM UMR-S1140, Paris Descartes University, Paris, France.
Ann Intensive Care. 2020 Sep 29;10(1):126. doi: 10.1186/s13613-020-00743-y.
Extracorporeal CO removal (ECCOR) could be a valuable additional modality for invasive mechanical ventilation (IMV) in COPD patients suffering from severe acute exacerbation (AE). We aimed to evaluate in such patients the effects of a low-to-middle extracorporeal blood flow device on both gas exchanges and dynamic hyperinflation, as well as on work of breathing (WOB) during the IMV weaning process.
Open prospective interventional study in 12 deeply sedated IMV AE-COPD patients studied before and after ECCOR initiation. Gas exchange and dynamic hyperinflation were compared after stabilization without and with ECCOR (Hemolung, Alung, Pittsburgh, USA) combined with a specific adjustment algorithm of the respiratory rate (RR) designed to improve arterial pH. When possible, WOB with and without ECCOR was measured at the end of the weaning process. Due to study size, results are expressed as median (IQR) and a non-parametric approach was adopted.
An improvement in PaCO, from 68 (63; 76) to 49 (46; 55) mmHg, p = 0.0005, and in pH, from 7.25 (7.23; 7.29) to 7.35 (7.32; 7.40), p = 0.0005, was observed after ECCOR initiation and adjustment of respiratory rate, while intrinsic PEEP and Functional Residual Capacity remained unchanged, from 9.0 (7.0; 10.0) to 8.0 (5.0; 9.0) cmHO and from 3604 (2631; 4850) to 3338 (2633; 4848) mL, p = 0.1191 and p = 0.3013, respectively. WOB measurements were possible in 5 patients, indicating near-significant higher values after stopping ECCOR: 11.7 (7.5; 15.0) versus 22.6 (13.9; 34.7) Joules/min., p = 0.0625 and 1.1 (0.8; 1.4) versus 1.5 (0.9; 2.8) Joules/L, p = 0.0625. Three patients died in-ICU. Other patients were successfully hospital-discharged.
Using a formalized protocol of RR adjustment, ECCOR permitted to effectively improve pH and diminish PaCO at the early phase of IMV in 12 AE-COPD patients, but not to diminish dynamic hyperinflation in the whole group. A trend toward a decrease in WOB was also observed during the weaning process. Trial registration ClinicalTrials.gov: Identifier: NCT02586948.
对于患有严重急性加重（AE）的慢性阻塞性肺疾病（COPD）患者，体外二氧化碳清除（ECCOR）可能是有创机械通气（IMV）的一种有价值的辅助方式。我们旨在评估在这类患者中，中低流量体外血液灌注装置在IMV撤机过程中对气体交换、动态肺过度充气以及呼吸功（WOB）的影响。
对12例深度镇静的IMV AE-COPD患者进行开放前瞻性干预研究，在启动ECCOR前后进行研究。在稳定状态下，比较未使用ECCOR和使用ECCOR（美国匹兹堡Alung公司的Hemolung）联合旨在改善动脉血pH值的特定呼吸频率（RR）调整算法时的气体交换和动态肺过度充气情况。在可能的情况下，在撤机过程结束时测量使用和未使用ECCOR时的WOB。由于研究规模，结果以中位数（四分位间距）表示，并采用非参数方法。
启动ECCOR并调整呼吸频率后，观察到动脉血二氧化碳分压（PaCO₂）从68（63；76）mmHg改善至49（46；55）mmHg，p = 0.0005，pH值从7.25（7.23；7.29）改善至7.35（7.32；7.40），p = 0.0005，而内源性呼气末正压（PEEP）和功能残气量保持不变，分别从9.0（7.0；10.0）cmH₂O降至8.0（5.0；9.0）cmH₂O，从3604（2631；4850）mL降至3338（2633；4848）mL，p = 0.1191和p = 0.3013。5例患者可进行WOB测量，表明停止ECCOR后WOB值近乎显著升高：分别为11.7（7.5；15.0）与22.6（13.9；34.7）焦耳/分钟，p = 0.0625，以及1.1（0.8；1.4）与1.5（（0.9；2.8）焦耳/升，p = 0.0625。3例患者在重症监护病房（ICU）死亡。其他患者成功出院。
采用RR调整的正式方案，ECCOR能够在12例AE-COPD患者IMV的早期阶段有效改善pH值并降低PaCO₂，但未能降低整个组的动态肺过度充气。在撤机过程中也观察到WOB有下降趋势。试验注册ClinicalTrials.gov：标识符：NCT02586948。
