ECCO 2 R therapy in the ICU: consensus of a European round table meeting.

Background: With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO ₂ removal (ECCO ₂ R). However, current evidence in these indications is limited. A European ECCO ₂ R Expert Round Table Meeting was convened to further explore the potential for this treatment approach.
Methods: A modified Delphi-based method was used to collate European experts' views to better understand how ECCO ₂ R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus.
Results: Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO ₂ R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO ₂ R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO ₂ R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO ₂ levels. Driving pressure (≥ 14 cmH ₂ O) followed by plateau pressure (P _plat ; ≥ 25 cmH ₂ O) was considered the most important criteria for ECCO ₂ R initiation. Key treatment targets for patients with ARDS undergoing ECCO ₂ R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH ₂ O) and P _plat (< 25 cmH ₂ O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO ₂ and no decrease in respiratory rate were key criteria for initiating ECCO ₂ R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30-7.35), respiratory rate (< 20-25 breaths/min), decrease of PaCO ₂ (by 10-20%), weaning from NIV, decrease in HCO ₃ ^- and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group.
Conclusions: Insights from this group of experienced physicians suggest that ECCO ₂ R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.