Hypercapnia in late-phase ALI/ARDS: providing spontaneous breathing using pumpless extracorporeal lung assist.

OBJECTIVE: The fibroproliferative phase of late ALI/ARDS as described by Hudson and Hough (Clin Chest Med 27:671-677, 2006) is associated with pronounced reductions in pulmonary compliance and an accompanying hypercapnia complicating low tidal volume mechanical ventilation. We report the effects of extracorporeal CO(2) removal by means of a novel pumpless extracorporeal lung assist (p-ECLA) on tidal volumes, airway pressures, breathing patterns and sedation management in pneumonia patients during late-phase ARDS.
DESIGN: Retrospective analysis.
SETTING: Fourteen-bed university hospital ICU. PATIENTS: Ten consecutive late-phase ALI/ARDS patients with low pulmonary compliance, and severe hypercapnia. INTERVENTION: Gas exchange, tidal volumes, airway pressures, breathing patterns and sedation requirements before (baseline) and after (2-4 days) initiation of treatment with p-ECLA were analysed. Patients were ventilated in a pressure-controlled mode with PEEP adjusted to pre-defined oxygenation goals.
MEASUREMENTS AND MAIN RESULTS: Median reduction in pCO(2) was 50% following institution of p-ECLA. Extracorporeal CO(2) removal enabled significant reduction in tidal volumes (to below 4 ml/kg predicted body weight) and inspiratory plateau pressures [30 (28.5/32.3) cmH(2)O, median 25, 75% percentiles]. Normalization of pCO(2) levels permitted significant reduction in the dosages of analgesics and sedatives. The proportion of assisted spontaneous breathing increased within 24 h of instituting p-ECLA.
CONCLUSION: Elimination of CO(2) by p-ECLA therapy allowed reduction of ventilator-induced shear stress through ventilation with tidal volumes below 4 ml/kg predicted body weight in pneumonia patients with severely impaired pulmonary compliance during late-phase ARDS. p-ECLA treatment supported control of breathing pattern while sedation requirements were reduced and facilitated the implementation of assisted spontaneous breathing.