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Introduction  While non-invasive ventilation aimed at avoiding intubation has become the modality of choice to treat mild to moderate acute respiratory acidosis, many severely acidotic patients (pH <7.20) still need intubation. Extracorporeal veno-venous CO 2  removal (ECCO 2 R) could prove to be an alternative. The present animal study tested in a systematic fashion technical requirements for successful ECCO 2 R in terms of cannula size, blood and sweep gas flow.    Methods  ECCO 2 R with a 0.98 m 2  surface oxygenator was performed in six acidotic (pH <7.20) pigs using either a 14.5 French (Fr) or a 19Fr catheter, with sweep gas flow rates of 8 and 16 L/minute, respectively. During each experiment the blood flow was incrementally increased to a maximum of 400 mL/minute (14.5Fr catheter) and 1000 mL/minute (19Fr catheter).    Results  Amelioration of severe respiratory acidosis was only feasible when blood flow rates of 750 to 1000 mL/minute (19Fr catheter) were used. Maximal CO 2 -elimination was 146.1 ± 22.6 mL/minute, while pH increased from 7.13 ± 0.08 to 7.41 ± 0.07 (blood flow of 1000 mL/minute; sweep gas flow 16 L/minute). Accordingly, a sweep gas flow of 8 L/minute resulted in a maximal CO 2 -elimination rate of 138.0 ± 16.9 mL/minute. The 14.5Fr catheter allowed a maximum CO 2  elimination rate of 77.9 mL/minute, which did not result in the normalization of pH.    Conclusions  Veno-venous ECCO 2 R may serve as a treatment option for severe respiratory acidosis. In this porcine model, ECCO 2 R was most effective when using blood flow rates ranging between 750 and 1000 mL/minute, while an increase in sweep gas flow from 8 to 16 L/minute had less impact on ECCO 2 R in this setting.

Veno-venous extracorporeal CO2 removal for the treatment of severe respiratory acidosis: pathophysiological and technical considerations