Extracorporeal CO2 removal to reduce lung hyperinflation in a nonintubated patient with acute COPD exacerbation: case report

Introduction. COPD exacerbation is treated with CPAP or non-invasive ventilation (NIV). If the non-invasive approach fails, tracheal intubation and mechanical ventilation (MV) become mandatory, despite their detrimental side effects in the COPD hyperinflated lungs. Case report. In a patient with severe respiratory acidosis due to COPD exacerbation (pH 7.22, pCO2 98, pO2 71, FiO2 0,45, RR 40 on NIV), we decided to reduce the need to ventilate using the extracorporeal CO2 removal by an artificial lung (ECCO2-R), so allowing the natural deflation of the lungs, avoiding tracheal intubation and leaving the patient in spontaneous breathing. Dyspnoea immediately improved after starting the veno-venous (V-V) femoro-femoral bypass: blood flow 2 L/min and slow increase of gas flow from 1 up to 4 L/min. After 48 hours, almost complete extracorporeal clearance of CO2 production was obtained, leading to sharp decrease of RR and oesophageal pressure swing. Chest X-ray confirmed the reduction of the lung hyperinflation. We then reduced the extracorporeal CO2 removal, by progressive decrease of gas flow. The patient maintained an acceptable equilibrium with no dyspnea, good breathing coordination and gas exchange (pH 7.45, pCO2 61, pO2 74, FiO2 0,45). The V-V by-pass was removed on day 6 and the patient discharged from the ICU the day after. At six months she is well and has no oxygen need. Conclusion. In patients with acute severe COPD exacerbation, who fail NIV, the use of V-V ECCO2-R on spontaneous breathing may treat respiratory failure and reduce dynamic hyperinflation, avoiding the detrimental effects of tracheal intubation and MV.