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August 15, 1986, Vol 256, No. 7 >
ARTICLE | August 15, 1986

Low-Frequency Positive-Pressure Ventilation With Extracorporeal CO2 Removal in Severe Acute Respiratory Failure FREE

Luciano Gattinoni, MD; Antonio Pesenti, MD; Daniele Mascheroni, MD; Roberto Marcolin, MD; Roberto Fumagalli, MD; Francesca Rossi, MD; Gaetano lapichino, MD; Giuliano Romagnoli, MD; Ljli Uziel, MD; Angelo Agostoni, MD; Theodor Kolobow, MD; Giorgio Damia, MD
[+] Author Affiliations

Reprint requests to Istituto di Anestesia e Rianimazione, Via F Sforza 35, 20122-Milano, Italy (Dr Gattinoni).


JAMA. 1986;256(7):881-886. doi:10.1001/jama.1986.03380070087025
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References

Forty-three patients were entered in an uncontrolled study designed to evaluate extracorporeal membrane lung support in severe acute respiratory failure of parenchymal origin. Most of the metabolic carbon dioxide production was cleared through a low-flow venovenous bypass. To avoid lung injury from conventional mechanical ventilation, the lungs were kept "at rest" (three to five breaths per minute) at a low peak airway pressure of 35 to 45 cm H2O (3.4 to 4.4 kPa). The entry criteria were based on gas exchange under standard ventilatory conditions (expected mortality rate, >90%). Lung function improved in thirty-one patients (72.8%), and 21 patients (48.8%) eventually survived. The mean time on bypass for the survivors was 5.4 ± 3.5 days. Improvement in lung function, when present, always occurred within 48 hours. Blood loss averaged 1800±850 mL/d. No major technical accidents occurred in more than 8000 hours of perfusion. Extracorporeal carbon dioxide removal with low-frequency ventilation proved a safe technique, and we suggest it as a valuable tool and an alternative to treating severe acute respiratory failure by conventional means.

(JAMA 1986;256:881-886)

REFERENCES

1 +
Hill JD, O'Brien TG, Murray JT:  Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome) . N Engl J Med 1972;;286:629-634.
2 +
Gille JP, Bagniewski A:  Ten years of use of extracorporeal membrane oxygenation (ECMO) in treatment of acute respiratory insufficiency . Trans Am Soc Artif Intern Organs 1976;;22:102-108.
3 +
Protocol for Extracorporeal Support for Respiratory Insufficiency . Bethesda, Md, National Heart, Lung, and Blood Institute, 1974;.
4 +
Gattinoni L, Kolobow T, Damia G, et al:  Extracorporeal carbon dioxide removal (ECCO2R): A new form of respiratory assistance . Int J Artif Organs 1979;;2:183-185.
5 +
Gattinoni L, Kolobow T, Agostoni A, et al:  Clinical application of low frequency positive pressure ventilation with extracorporeal CO2 removal (LFPPV-ECCO2R) in the treatment of adult respiratory distress syndrome (ARDS) . Int J Artif Organs 1979;;2:282-283.
6 +
Gattinoni L, Kolobow T, Tomlinson T, et al:  Low frequency positive pressure ventilation with extracorporeal carbon dioxide removal (LFPPV-ECCO2R): An experimental study . Anesth Analg 1978;;57:470-477.
7 +
Frumin MJ, Epstein RM, Cohen G:  Apneic oxygenation in man . Anesthesiology 1959;;20:789-798.
8 +
Zapol WM, Snider MT, Hill JD, et al:  Extracorporeal membrane oxygenation in severe acute respiratory failure . JAMA 1979;;242:2193-2196.
9 +
Gattinoni L, Pesenti A, Caspani ML, et al:  The role of total static lung compliance in the management of severe ARDS unresponsive to conventional treatment . Intensive Care Med 1984;;10:121-126.
10 +
Extracorporeal Support for Respiratory Insufficiency. A Collaborative Study in Response to RFP-NHLBI-73-20 . Bethesda, Md, National Heart, Lung, and Blood Institute, 1979;.
11 +
Pesenti A, Pelizolla A, Mascheroni D, et al:  Low frequency positive pressure ventilation with extracorporeal CO2 removal (LFPPV-ECCO2R) in acute respiratory failure (ARF): Technique . Trans Am Soc Artif Intern Organs 1981;;27:263-266.
12 +
Gattinoni L, Pesenti A, Kolobow T, et al:  A new look at therapy of the adult respiratory distress syndrome: Motionless lungs . Int Anaesth Clin 1983;;21:97-117.
13 +
Pesenti A, Kolobow T, Riboni A, et al:  Single vein cannulation for extracorporeal respiratory support . Life Support Syst 1982;;1( (suppl) ):165-167.
14 +
Pesenti A, Romagnoli G, Fox U, et al:  Sapheno-saphenous cannulation for LFPPV-ECCO2R (low frequency positive pressure ventilation with extracorporeal CO2 removal) , in Tenth Congress of European Society of Artificial Organs . Bologna, Italy, European Society of Artificial Organs, 1983;, p 97.
15 +
Uziel L, Agostoni A, Pirovano E, et al:  Hematologic survey during low frequency positive pressure ventilation with extracorporeal CO2 removal . Trans Am Soc Artif Intern Organs 1982;;28:359-363.
16 +
Iapichino G, Pesenti A, Radrizzani D, et al:  Nutritional support to long term anesthetized and curarized patients under extracorporeal respiratory assist for terminal pulmonary failure . JPEN 1983;;7:50-54.
17 +
Suter PM:  Syndrome de detresse respiratoire aigue d l'adulte: Moyens therapeutiques , in Lemaire M (ed): Le syndrome de detresse respiratoire aigue de l'adulte . Paris, Masson, 1984;, pp 111-123.
18 +
Greene R, Zapol W, Snider MT, et al:  Early bedside detection of pulmonary vascular occlusion during acute respiratory failure . Am Rev Respir Dis 1981;;124:593-601.
19 +
Gattinoni L, Agostoni A, Pesenti A, et al:  Treatment of acute respiratory failure with low frequency positive pressure ventilation and extracorporeal CO2 removal . Lancet 1980;;2:292-294.
20 +
Zapol WM, Snider MT, Schneider R:  Extracorporeal membrane oxygenation for acute respiratory failure . Anesthesiology 1977;;46:272-285.
21 +
Ratliff JL, Hill JD, Fallat RJ, et al:  Complications associated with membrane lung support by veno-arterial perfusion . Ann Thorac Surg 1975;; 19:537-539.
22 +
Kolobow T, Spragg R, Pierce J:  Massive pulmonary infarction during total cardiopulmonary bypass in unanesthetized spontaneously breathing lambs . Int J Artif Organs 1981;;4:76-81.
23 +
Deneke SM, Fanburg BL:  Oxygen toxicity of the lung: An update . Br J Anaesth 1982;;54:737-749.
24 +
Webb H, Tierney DF:  Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures: Protection by positive end-expiratory pressure . Am Rev Respir Dis 1974;;110:556-565.
25 +
Kolobow T, Moretti M, Fumagalli R, et al:  Adult respiratory distress syndrome following mechanical pulmonary ventilation at high peak airway pressures , abstracted. Am Rev Respir Dis 1985;;131( (suppl) ):137.
26 +
Woodring JH:  Pulmonary interstitial emphysema in the adult respiratory distress syndrome . Crit Care Med 1985;;13:786-791.
27 +
Dreyfuss D, Basset G, Soler P, et al:  Intermittent positive pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats . Am Rev Respir Dis 1985;; 132:880-884.
28 +
Mascheroni D, Kolobow T, Fumagalli R, et al:  Respiratory failure following induced hyperventilation: An experimental study . Crit Care Med 1985;;13:330.
29 +
Wyszogrodski I, Kyei-Aboagye K, Taensch HW Jr, et al:  Surfactant inactivation by hyperventilation: Conservation by end-expiratory pressure . J App Physiol 1975;;38:461-466.

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1 +
Hill JD, O'Brien TG, Murray JT:  Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome) . N Engl J Med 1972;;286:629-634.
2 +
Gille JP, Bagniewski A:  Ten years of use of extracorporeal membrane oxygenation (ECMO) in treatment of acute respiratory insufficiency . Trans Am Soc Artif Intern Organs 1976;;22:102-108.
3 +
Protocol for Extracorporeal Support for Respiratory Insufficiency . Bethesda, Md, National Heart, Lung, and Blood Institute, 1974;.
4 +
Gattinoni L, Kolobow T, Damia G, et al:  Extracorporeal carbon dioxide removal (ECCO2R): A new form of respiratory assistance . Int J Artif Organs 1979;;2:183-185.
5 +
Gattinoni L, Kolobow T, Agostoni A, et al:  Clinical application of low frequency positive pressure ventilation with extracorporeal CO2 removal (LFPPV-ECCO2R) in the treatment of adult respiratory distress syndrome (ARDS) . Int J Artif Organs 1979;;2:282-283.
6 +
Gattinoni L, Kolobow T, Tomlinson T, et al:  Low frequency positive pressure ventilation with extracorporeal carbon dioxide removal (LFPPV-ECCO2R): An experimental study . Anesth Analg 1978;;57:470-477.
7 +
Frumin MJ, Epstein RM, Cohen G:  Apneic oxygenation in man . Anesthesiology 1959;;20:789-798.
8 +
Zapol WM, Snider MT, Hill JD, et al:  Extracorporeal membrane oxygenation in severe acute respiratory failure . JAMA 1979;;242:2193-2196.
9 +
Gattinoni L, Pesenti A, Caspani ML, et al:  The role of total static lung compliance in the management of severe ARDS unresponsive to conventional treatment . Intensive Care Med 1984;;10:121-126.
10 +
Extracorporeal Support for Respiratory Insufficiency. A Collaborative Study in Response to RFP-NHLBI-73-20 . Bethesda, Md, National Heart, Lung, and Blood Institute, 1979;.
11 +
Pesenti A, Pelizolla A, Mascheroni D, et al:  Low frequency positive pressure ventilation with extracorporeal CO2 removal (LFPPV-ECCO2R) in acute respiratory failure (ARF): Technique . Trans Am Soc Artif Intern Organs 1981;;27:263-266.
12 +
Gattinoni L, Pesenti A, Kolobow T, et al:  A new look at therapy of the adult respiratory distress syndrome: Motionless lungs . Int Anaesth Clin 1983;;21:97-117.
13 +
Pesenti A, Kolobow T, Riboni A, et al:  Single vein cannulation for extracorporeal respiratory support . Life Support Syst 1982;;1( (suppl) ):165-167.
14 +
Pesenti A, Romagnoli G, Fox U, et al:  Sapheno-saphenous cannulation for LFPPV-ECCO2R (low frequency positive pressure ventilation with extracorporeal CO2 removal) , in Tenth Congress of European Society of Artificial Organs . Bologna, Italy, European Society of Artificial Organs, 1983;, p 97.
15 +
Uziel L, Agostoni A, Pirovano E, et al:  Hematologic survey during low frequency positive pressure ventilation with extracorporeal CO2 removal . Trans Am Soc Artif Intern Organs 1982;;28:359-363.
16 +
Iapichino G, Pesenti A, Radrizzani D, et al:  Nutritional support to long term anesthetized and curarized patients under extracorporeal respiratory assist for terminal pulmonary failure . JPEN 1983;;7:50-54.
17 +
Suter PM:  Syndrome de detresse respiratoire aigue d l'adulte: Moyens therapeutiques , in Lemaire M (ed): Le syndrome de detresse respiratoire aigue de l'adulte . Paris, Masson, 1984;, pp 111-123.
18 +
Greene R, Zapol W, Snider MT, et al:  Early bedside detection of pulmonary vascular occlusion during acute respiratory failure . Am Rev Respir Dis 1981;;124:593-601.
19 +
Gattinoni L, Agostoni A, Pesenti A, et al:  Treatment of acute respiratory failure with low frequency positive pressure ventilation and extracorporeal CO2 removal . Lancet 1980;;2:292-294.
20 +
Zapol WM, Snider MT, Schneider R:  Extracorporeal membrane oxygenation for acute respiratory failure . Anesthesiology 1977;;46:272-285.
21 +
Ratliff JL, Hill JD, Fallat RJ, et al:  Complications associated with membrane lung support by veno-arterial perfusion . Ann Thorac Surg 1975;; 19:537-539.
22 +
Kolobow T, Spragg R, Pierce J:  Massive pulmonary infarction during total cardiopulmonary bypass in unanesthetized spontaneously breathing lambs . Int J Artif Organs 1981;;4:76-81.
23 +
Deneke SM, Fanburg BL:  Oxygen toxicity of the lung: An update . Br J Anaesth 1982;;54:737-749.
24 +
Webb H, Tierney DF:  Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures: Protection by positive end-expiratory pressure . Am Rev Respir Dis 1974;;110:556-565.
25 +
Kolobow T, Moretti M, Fumagalli R, et al:  Adult respiratory distress syndrome following mechanical pulmonary ventilation at high peak airway pressures , abstracted. Am Rev Respir Dis 1985;;131( (suppl) ):137.
26 +
Woodring JH:  Pulmonary interstitial emphysema in the adult respiratory distress syndrome . Crit Care Med 1985;;13:786-791.
27 +
Dreyfuss D, Basset G, Soler P, et al:  Intermittent positive pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats . Am Rev Respir Dis 1985;; 132:880-884.
28 +
Mascheroni D, Kolobow T, Fumagalli R, et al:  Respiratory failure following induced hyperventilation: An experimental study . Crit Care Med 1985;;13:330.
29 +
Wyszogrodski I, Kyei-Aboagye K, Taensch HW Jr, et al:  Surfactant inactivation by hyperventilation: Conservation by end-expiratory pressure . J App Physiol 1975;;38:461-466.

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