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Management of severe ARDS due to SARS-CoV-2 pneumonia using low-flow extracorporeal CO2 extraction

Extracorporeal CO2 extraction (ECCO2R) is a technique that uses an extracorporeal device to extract excess CO2 from the blood by passing it through an air exchange membrane using low blood flows and requiring systemic anticoagulation for its use. The main technical difference with extracorporeal membrane oxygenation system (ECMO) is the reduced blood flow (between 300 and 500 ml/min), achieving the elimination of most of the CO2 produced by metabolism, thanks to the greater solubility of this gas in plasma.

This technique emerged from the need to decouple the oxygenation support from the ventilation support provided by ECMO with the main objective of optimising lung protection during mechanical ventilation (MV) [1]. There is currently no strong evidence regarding the benefit provided by the use of ECCO2R in this clinical context [2].

We present a series of 8 cases of patients with severe global respiratory failure due to COVID-19, admitted in ICU between December 2020 and May 2021. Regarding patients’ characteristics, we highlight mean values of ICU stay of 45.8 days (± standard deviation 15.8), PaFi of 75.1 (± 10.4) and pH 7.25 (± 0.03), despite endotracheal intubation (ETI) and protective MV with Pplat 29.1 (± 1.61). Prone position was necessary in all cases, both before and after ECCO2R placement. The mean number of days in prone position prior to ECCO2R was 3.75 days (± 1.08). Mean number of days from the start of ETI to the start of ECCO2R was 14.5 days, PaO2/FiO2 of 75.1 and SOFA score 6.6. Transfer to ECMO was not possible in any of the 8 cases, following to the current recommendations of the receiving centres [3].

All cases had positive SARS-CoV-2 polymerase-chain-reaction detection and severe respiratory failure without severe dysfunction of other organs or documented infections.

During ICU admission, selected patients presented persistent hypoxaemia and hypercapnia refractory to lung protective measures (TV 6–8 ml/kg, Pplat < 30) and proning. ECCO2R support was considered then, preserving the level of lung protection and correcting the expected deterioration of ventilation with worsening respiratory acidosis obtained after achieving an increase in PEEP. Our objectives were also to decrease Pplat in a range of less than 28, to decrease respiratory rate under 25 bpm and to decrease TV (under 7 ml/kg).

Table 1 shows the respiratory status prior to initiation of therapy, and Table 2 shows the results obtained 12–24 h after initiation of the ECCO2R.

Table 1 Characteristics
Table 2 Data before and after 24-h initiating ECCO2R

The therapeutic objectives of ProLUNG® (blood flow 400 ml/min and air flow 15 L/min), with a rise in pH (7.32–7.35), were achieved in the first 12 h of treatment. Results are shown in Table 2. Regarding technical complications, thrombocytopenia not induced by heparin was observed in one of the cases, requiring withdrawal of treatment after 5 days.

Regarding the outcome data on the ECCO2R device, the mean duration of therapy was 5.25 days, with a mean blood flow of 400 ml/min and air flow of 12 lpm. Fifty percentage of the patients survived, with an ICU discharge of 25 days (average value) after disconnection from the ECCO2R. Case number 8 died within a day after removal of the CO2 extractor.

These cases, as in previous studies, show us the possible usefulness of applying ECCO2R based on individual clinical and physiological criteria [4], without development of serious complications, although other known published series report relevant complications [5].

ECCO2R system could be applied as a tool to optimise the degree of lung protection, essential in patients with severe ARDS. In our experience, ECCO2R is a simple and feasible therapeutic option for patients with severe respiratory diseases in whom conventional treatment has been maximised. Further studies are needed to strengthen the scientific evidence in this context [6].

Availability of data and materials

All data generated or analysed during this study are included in this published article.


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We would like to thank all clinical members of the ICU team at H.U del Henares, who actively helped gather the data for the present article.


No financial support was required for the study. Financial support will be available in case of publication (through Fundación para la Investigación e Innovación Biomédica of Hospital Universitario Infanta Sofia and Hospital Universitario del Henares; Director: Marta Neira Álvarez).

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RML did investigation, writing original draft; BLV was involved in writing—reviewing and editing. FG performed methodology, project administration, supervision and validation. All authors read and approved the final manuscript.

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Correspondence to Federico Gordo.

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Informed consent from patients or family member for the inclusion of medical data in our prospective ICU Registry was obtained. This study was conducted in accordance with the amended Declaration of Helsinki. Local institutional review boards and independent ethics committees (Healthcare Ethics Committee of the Francisco de Vitoria University) approved the protocol, and written informed consent was obtained from all patients.

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Consent for publication was forwarded by next of akin / family member through informed consent.

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Authors declare no potential financial or ethical conflicts of interest.

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Molina Lobo, R., Lobo-Valbuena, B. & Gordo, F. Management of severe ARDS due to SARS-CoV-2 pneumonia using low-flow extracorporeal CO2 extraction. Crit Care 25, 362 (2021).

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