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We read with interest the article by Karagiannidis and colleagues reporting the effects of extracorporeal CO2 removal (ECCO2R) in a pig model of severe respiratory acidosis [1]. However, their conclusion that blood flow rates between 750 and 1,000 ml/minute are necessary to correct severe acidosis using ECCO2R may have been biased by limitations in experimental methodology.  Firstly, the authors report CO2 removal rates for various blood flow rates using 19Fr and 14Fr catheters. However, the data clearly demonstrated blood recirculation using the 14Fr catheter, reducing CO2 removal efficiency. Although the authors mention this limitation, it is curious why the 14Fr data were presented at all, since recirculation confounds meaningful interpretation.  Secondly, a 15-minute equilibration time was used between experimental set points, but no evidence is provided that equilibrium was achieved. It is reasonable to expect equilibration within 15 minutes when the entire cardiac output participates in gas exchange, but in this study blood flow rates of only 200 to 1,000 ml/minute passed through the gas exchanger. Longer equilibration times may have resulted in continued pH correction, as demonstrated in a human ECCO2R pilot study using approximately 450 ml/minute blood flows [2].  Finally, this study demonstrates reductions of partial pressure of CO2 from 107.9 to 76.9 mmHg with blood flows of 500 ml/minute. In clinical practice this may be sufficient, a reduction from 80-85 to 60-65 mmHg in chronic obstructive pulmonary disease patients with respiratory acidosis normalized pH, allowing intubation to be avoided [2].  Although ECCO2R with higher blood flows clearly increases CO2 removal, lower flows with appropriately designed catheters may provide sufficient support for severe hypercapnic respiratory failure.

Veno-venous extracorporeal CO2 removal for the treatment of severe respiratory acidosis