Extrakorporale CO₂-Elimination (ECCO₂R): von der Pathophysiologie zur klinischen Anwendung beim hyperkapnischen respiratorischen Versagen

Zusammenfassung

Die extrakorporale CO₂-Elimination (ECCO₂R) hat sich in den letzten Jahren zu einer Behandlungsalternative in der Therapie des schweren hyperkapnischen respiratorischen Versagens entwickelt. Prinzipiell stehen technisch pumpenlose arterio-venöse Systeme, die den natürlichen Druckgradienten zwischen der Arteria und Vena femoralis nutzen, sowie pumpengetriebene veno-venöse Systeme zur Verfügung. Aufgrund der besseren Regulationsmöglichkeiten und des insgesamt geringeren Nebenwirkungsprofils haben sich pumpengetriebene Systeme zunehmend durchgesetzt. Mit veno-venösen Systemen mit Blutflüssen bis 450 ml/min lassen sich etwa 60 – 80 ml CO₂/min entsprechend 20 – 30 % der Gesamtproduktion unter Ruhebedingungen eliminieren, während zur Beherrschung einer schweren respiratorischen Azidose mit einem pH-Wert um 7.1 Blutflüsse von etwa 1000 ml/min notwendig sind. Hiermit lassen sich etwa 50 – 60 % des gesamten CO₂ eliminieren und auch schwere respiratorische Azidosen beherrschen. Relevante Nebenwirkungen liegen insbesondere in der Gerinnungsaktivierung und der damit verbundenen Blutungsneigung. Besonderes Augenmerk sollte diesbezüglich bei pumpengetriebenen Systemen auf einen Thrombozytenabfall, Hämolyse sowie die Bildung von Thrombosen gelegt werden. Aus klinischer Sicht stehen neben vielen kleinen Fallbeschreibungen zwei Case-control-Studien bei exazerbierter COPD zur Verfügung. In den Studien konnte die Intubation zwar häufig verhindert werden, allerdings mit einem signifikanten Nebenwirkungsprofil. Hier sind dringend randomisierte Studien notwendig, um das Nutzen/Risiko-Verhältnis einer Intubationsvermeidung oder Verkürzung der Dauer der invasiven Beatmung durch extrakorporale Systeme gegeneinander abzuwägen.

Abstract

Extracorporeal CO₂ removal (ECCO₂R) is becoming an increasingly established treatment option for patients with acute severe hypercapnic respiratory failure. Technically, pumpless arterio-venous systems using the natural arterio-venous pressure gradient and also pump-driven veno-venous systems are available. Here, veno-venous ECCO₂R has become the preferred technique, as settings for arterio-venous ECCO₂R are restricted and side effects are more common with arterio-venous ECCO₂R. Using veno-venous ECCO₂R with blood flow rates up to 450 ml/min 60 to 80 ml CO₂ can be removed per minute corresponding to 20 to 30 % of the total amount of CO₂ production. However, in case of very severe hypercapnic respiratory failure with severe respiratory acidosis (pH 7.1 or less) blood flow rates of around 1000 ml/min are required for compensating severe respiratory acidosis corresponding to the elimination of 50 to 60 % of the total amount of CO₂ production. Relevant side effects include the activation of blood coagulation and associated bleeding complications. Two recent case-control studies in severely exacerbated COPD patients could demonstrate that intubation rates can be reduced by the application of ECCO₂R, but this was associated with non-ignorable side effects. Therefore, randomized controlled trials are urgently needed to more precisely establish the risks and benefits of ECCO₂R when aimed at avoiding intubation.

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