New technology for mini invasive slow continuous ultrafiltration to avoid mechanical ventilation in cardiorespiratory failure: preliminary experience

Introduction

Chronic obstructive pulmonary disease (COPD) and heart disease are often associated. Cardiorespiratory decompensation can be related to fluid overload status with increased LVEDVI, LVEDP, airway resistance and work of breathing. This often requires tracheal intubation with a difficult weaning from mechanical ventilation (MV). The basis to treat an overload status consists of diuretic administration, which has been demonstrated to be able to reduce airway edema and resistance. Loop diuretics can induce tolerance. Their use may be associated with increased morbidity due to deleterious effects, particularly on neurohormonal activation of the renin–angiotensin–aldosterone system with increase of sympathetic renal tone, sodium and water retention, progression of cardiac dysfunction and maintenance of cardiorespiratory decompensation.

Methods

An alternative approach to remove sodium and water is slow continuous ultrafiltration (SCUF), which has been demonstrated to be effective in congestive heart failure (CHF) treatment. The major hindrance to an extensive early application of SCUF is the requirement of a central venous large-bore catheter and the involvement of specialized medical and paramedical staff. Recently, a new device (Aquadex Flex Flow) for mini-SCUF able to overcome the drawbacks of traditional devices has been developed. It operates with peripheral small-bore venous catheters and does not require specialized staff. We present two cases of our initial experience.

Results

Case 1

An 82-year-old female admitted to the ICU for anasarca, dyspnea and decompensated COPD underwent mini-SCUF. A negative fluid balance of 16 l was obtained in 55 hours, diuresis was maintained, blood gas exchanges (BGE) improved and tracheal intubation and MV was avoided.

Case 2

A 78-year-old male was admitted to the ICU for respiratory failure and decompensated CHF. Anasarca, obesity and OSAS were associated. He was treated with MV, dobutamine, diuretics and mini-SCUF. A negative fluid balance of 18 l was obtained in 60 hours without diuresis reduction; edema was markedly reduced, BGE improved and weaning from MV was obtained 3 days after admission.

Conclusion

We suggest that early aggressive fluid removal through mini-SCUF in severe cardiorespiratory failure could avoid tracheal intubation or could accelerate MV weaning.