Avoidance Of Intubation For A Lung Transplant Candidate Using Extracorporeal Carbon Dioxide Removal With The Hemolung During An Acute COPD Exacerbation – A Case Report
M. Irlbeck, MD, M. Zoller, MD, T. Weig, MD, Presenting author T. Klaus, MD
Department of Anaesthesiology, Hospital of the University of Munich, Munich, Germany
This case report describes the use of a novel extracorporeal carbon dioxide removal (ECCO2R) device to facilitate avoidance of intubation in a lung transplant candidate experiencing an acute exacerbation of COPD. A 57 year old female with severe COPD (GOLD grade 4) awaiting lung transplant was admitted to the ICU at the University Hospital of Munich-Grosshadern with an acute exacerbation requiring noninvasive ventilatory (NIV) support. Following ICU admission, the patient deteriorated over the next 24 hours on NIV with increasing dyspnea, hypercapnia and marked increase in work of breathing. Avoidance of intubation and invasive mechanical ventilation was essential to maintain the patient’s status and prospects of success on the transplant list. The patient was placed on ECCO2R using the Hemolung Respiratory Assist System (Pittsburgh, Pennsylvania).
The Hemolung is a new, minimally invasive, ECCO2R device which utilizes veno-venous cannulation through a single, dual-lumen, 15.5 Fr catheter, and provides partial CO2 removal at blood flows of 350 – 550 mL/min. Ultrasound guided cannulation was performed via the right internal jugular vein in a semi-upright position since supine position was not tolerated by the patient. Within 24 hours of ECCO2R initiation, arterial CO2 tension decreased from 60.1 to 46 mmHg, and within 48 hours, pH increased from 7.37 to 7.42. While on Hemolung therapy, the patient was able to breathe spontaneously for 19 – 24 hours per day. Dyspnea and work of breathing were diminished and the patient was able to eat with sufficient daily intake of calories after 24 hours. Participation in active rehabilitation and physical therapy was maintained after 24 hours.
On Day 7, weaning from ECCO2R began by reducing the rate of CO2 removal over the course of 5 days based on patient response. The patient was fully weaned on Day 12, and was discharged from the ICU 5 days later to the intermediate care ward of the referring hospital. Anticoagulation was initially achieved using unfractionated heparin with a target aPTT of 40 – 50 seconds. During the first day of therapy, platelet count dropped from a baseline of 177 to 72 x 109/liter. Anticoagulation was switched to Argatroban due to suspected HIT, which was subsequently found to be negative. Function of the initial extracorporeal circuit was sufficient throughout the 13 days of treatment. Use of ECCO2R with the Hemolung succeeded in avoiding the need for intubation. The patient remains on the transplant list 3 months after her exacerbation.
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