Extracorporeal carbon dioxide removal with the Hemolung RAS to avoid intubation and invasive mechanical ventilation in an acute exacerbation of chronic obstructive pulmonary disease: A case report
Hergen Buscher, MD
This case report describes the use of extracorporeal carbon dioxide removal (ECCO2R) to successfully avoid intubation and mechanical ventilation in an 59-year old man who was experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD). Invasive mechanical ventilation was considered undesirable due to the potential prognosis of long-term ventilator dependency and its associated complications in patients with COPD. Using the Hemolung RAS, the patient was stabilized and his underlying exacerbation treated while intubation and mechanical ventilation were avoided. He was ultimately discharged to home.
A 59-year-old male presented at the emergency department after developing progressively worsening upper respiratory symptoms, including worsening cough and a mild fever. His medical history included emphysema and a previous smoking habit, but no hospital admissions over the last three years for related issues. The patient was admitted to the hospital’s respiratory ward with a diagnosis of acute exacerbation of COPD. The patient initially improved with standard treatments which included bronchodilators and antibiotics.
On the morning of his fourth day in the hospital, the patient acutely deteriorated, suffering respiratory arrest on the ward where he was emergently intubated and placed on invasive mechanical ventilation. He was subsequently transferred to the ICU. A treatment goal of rapid extubation was established due to the patient’s poor prognosis if extended mechanical ventilation ensued, which is common for patients with an established COPD diagnosis. Extubation was possible the next morning, and the patient was stable on high flow oxygen and escalated antibiotics. By the following day, however, his respiratory function had again deteriorated with the patient experiencing severe respiratory acidosis. Despite high-level non-invasive ventilatory support, the patient remained hypercapnic with an elevated work of breathing, as evidenced by concomitant tachycardia, dyspnea, and sweating. The patient was extremely distressed and disoriented, and unable to eat, drink, or communicate. Intubation was imminent, however, invasive mechanical ventilation was still considered undesirable, with worsened prognosis due to the prior intubation. The decision was made to initiate extracorporeal CO2 removal with the Hemolung RAS in order to avoid intubation.
The Hemolung RAS was primed and the patient quickly prepared. The Hemolung 15.5 Fr Femoral Catheter was inserted without complication in the right femoral vein with the patient in a half-sitting position, as he could not lie flat due to his severe respiratory distress. The Hemolung RAS circuit was then connected and extracorporeal CO2 removal established. The total time from making the decision to use ECCO2R to initiating therapy
was less than 30 minutes.
Within 30 minutes of achieving optimal ECCO2R settings, the patient’s respiratory distress was alleviated. No longer feeling short of breath, he became much calmer and his heart rate normalized. The patient soon requested that the non-invasive ventilation mask be removed. This was done, and he remained stable, now speaking in full sentences for the first time since his admission to the hospital. Supplemental oxygen was provided via nasal prongs but eventually discontinued.
By that evening, the patient continued to be comfortable and was able to eat dinner. Over the next two days on the Hemolung RAS, his overall condition continued to improve. Antibiotic treatment resulted in a reduction of infectious markers and he appeared to be in good condition overall, talking normally and having full meals daily. After approximately 2.5 days on the Hemolung RAS, a weaning process was initiated, and after two more days, Hemolung therapy was discontinued and the Catheter removed. At this point, the patient’s underlying exacerbation of COPD had improved sufficiently for him to breathe on his own. The total time on the Hemolung RAS was approximately 4.5 days with no device-related complications observed. The patient remained in the hospital under observation for another week, and 17 days after his initial admission he was discharged to home.
Change in Arterial Blood Gases After Initiating ECCO2R with the Hemolung RAS
|pH||PaCO2 (mmHg)||PaO2 (mmHg)|
Discussion with Dr. Buscher
Q: What other options did you consider for this patient and why did you decide to use the Hemolung RAS?
A: At the time when we determined to use extracorporeal carbon dioxide removal, we were quite familiar with this patient. He had already been on mechanical ventilation, and we had a good understanding of his respiratory mechanics. He was deteriorating quickly. Without having the Hemolung RAS, our options would have been to repeat invasive mechanical ventilation, which we felt carried a poor prognosis in his case; or to begin palliative care, which would have been premature. In our assessment, if this patient would have been again intubated and placed on mechanical ventilation, the overall long term outcome would have seen him bound to mechanical ventilation in the ICU with a tracheostomy, potentially for weeks. This scenario often leads to deconditioning, wasting, polyneuropathy, weakness, and exposes the patient to other complications like ventilator associated pneumonia.
Q: How did the patient react to treatment with the Hemolung RAS?
A: The patient became quite communicative once his respiration was restored, and he could recall being both intubated and on invasive mechanical ventilation, as well as being on non-invasive ventilation. Once stabilized on the Hemolung RAS, I had very open discussions with the patient about his potential options if he deteriorated again. The patient was very outspoken against being intubated again, but he would certainly have been willing to go back on the Hemolung RAS or some other extracorporeal device. His high comfort level corresponded to his ability to talk, eat, drink, and be partially mobilized in bed.
Q: What was the learning curve like for using the Hemolung RAS?
A: Prior to this case, which was our first, we did extensive training on the equipment, so we were very comfortable going into the procedure. Due to the patient’s respiratory distress, he could not lie flat and had to be cannulated in a half-sitting position. While this is not something we often perform, even for central lines, it went relatively smoothly and was actually quite easy to do. I opted to have one person on either side of the bed, so between one nurse and myself, we were able to prime, cannulate, and connect the circuit. The cannulation procedure took about 10 to 15 minutes, and within another few minutes, we connected the circuit and optimized the blood flow. Overall, it was a very smooth procedure for the first time.
Q: What was the impression of the nurses involved in this case?
A: Initially our nurses acted cautiously, being concerned about typical ECMO complications like bleeding. However, as the nurses watched the patient quickly emerge from respiratory distress, they became much more comfortable with the device. Over the next four days, there were literally no problems in terms of monitoring the device.
About the Author
Dr. Hergen Buscher is a Staff Specialist at St. Vincent’s Hospital, Sydney, Australia. He is also a Senior Lecturer at the University of New South Wales. He received no compensation in association with this case report and has no conflicts of interest to disclose. Dr. Buscher can be reached at firstname.lastname@example.org.
About the Hemolung RAS
The Hemolung RAS from ALung Technologies provides Respiratory Dialysis®, a simple, minimally-invasive form of extracorporeal carbon dioxide removal (ECCO2R). The system utilizes patented technology to provide highly efficient CO2 removal at dialysis-like blood flow rates which are achieved through a single 15.5 Fr venous catheter. For more information, please visit https://old.alung.com/products/hemolung-ras/
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