随着技术的进步，急性呼吸窘迫综合征(ARDS)和慢性阻塞性肺疾病严重急性加重(ae-COPD)患者可从体外CO2清除(ECCO2R)中获益.然而,目前这些适应症的证据是有限的。召开了一次欧洲ECCO2R专家圆桌会议，以进一步探索这种治疗方法的潜力。
使用基于德尔菲的改进方法来整理欧洲专家的观点，以更好地了解ECCO2R治疗的应用方式，确定如何选择患者以及如何做出治疗决定，以及确定任何共识。
根据重症监护和ECCO2R或体外膜氧合提供呼吸支持的已知临床专业知识，选择了14名参与者。ARDS被认为是ECCO2R治疗的主要指征（n=7），而3名参与者认为AE-COPD是主要适应症。该小组同意，ECCO2R治疗ARDS患者的主要治疗目标是通过控制CO2水平来应用超保护性肺通气。驱动压力（≥14cmH2O），然后是平台压力（Pplat；≥25cmH2O）被认为是ECCO2R启动的最重要标准。接受ECCO2R的ARDS患者的关键治疗目标包括pH（>7.30），呼吸频率（<25或<20次呼吸/分钟），驱动压力(<14cmH2O)和Pplat(<25cmH2O)。在AE-COPD中，人们一致认为，在有无创通气（NIV）失败风险的患者中，PaCO2无降低和呼吸频率无降低是开始ECCO2R治疗的关键标准.AE-COPD的关键治疗目标是患者舒适度，pH值（>7.30-7.35），呼吸频率（<20-25次呼吸/分钟），PaCO2减少（10-20%），从NIV断奶，降低HCO3-并保持血流动力学稳定。就这两种适应症的断奶协议达成了共识。静脉内普通肝素抗凝是该组首选的策略。
这组经验丰富的医生的见解表明，ECCO2R治疗可能是成人ARDS或ae-COPD的有效支持治疗。需要来自随机临床试验和/或高质量前瞻性研究的进一步证据来更好地指导决策。
With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO2 removal (ECCO2R). However, current evidence in these indications is limited. A European ECCO2R Expert Round Table Meeting was convened to further explore the potential for this treatment approach.
A modified Delphi-based method was used to collate European experts\' views to better understand how ECCO2R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of
consensus.
Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO2R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO2R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO2R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO2 levels. Driving pressure (≥ 14 cmH2O) followed by plateau pressure (Pplat; ≥ 25 cmH2O) was considered the most important criteria for ECCO2R initiation. Key treatment targets for patients with ARDS undergoing ECCO2R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH2O) and Pplat (< 25 cmH2O). In ae-COPD, there was
consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO2 and no decrease in respiratory rate were key criteria for initiating ECCO2R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30-7.35), respiratory rate (< 20-25 breaths/min), decrease of PaCO2 (by 10-20%), weaning from NIV, decrease in HCO3- and maintaining haemodynamic stability.
Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group.
Insights from this group of experienced physicians suggest that ECCO2R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.
PDF(Sci-hub)