J Neurointensive Care Search


J Neurointensive Care > Volume 5(2); 2022 > Article
Janjua and Moscote-Salazar: Utility of Hemolung® in Acute Neurological Crisis with Ventilatory Failure
Extracorporeal carbon dioxide removal (ECCO2R) is a process where filtration of CO2 happens with the blood flow, a central filter, a pump, and an exchange of air/Oxygen mixture. The flow of the gas mixture decides the percentage removal of CO2. The late last century saw marked improvement in the technology, although initial efforts were flawed with the large size of the equipment, complications, and no major impact on the outcome. Recently FDA approved technology for ECCO2R from ALung® i.e Hemolung® device which was incorporated in the last decade. The key utility is mainly in patients with severe COPD with acute respiratory failure. Acute respiratory with a pulmonary complication like ARDS or edema requires reduction of driving pressure by keeping the tidal volume low and higher PEEP. This commonly leads to an increased level of partial pressure of CO2, hence direct impact to abnormal brain hemodynamics with acute brain injury1). Here we suggest early use of Hemolung® in such a situation.
Early use of ECCO2R can be used in COPD acute respiratory to avoid intubation. Most of these patients have bi-level positive pressure ventilation attempted before proceeding to intubation. There is evidence for the avoidance of invasive ventilation with intubation with early application of ECCO2R2-7). Retention of CO2 and anticipatory reduction in PH are commonly seen during the protected lung strategy in ARDS care. ECCO2R can be used to reduce the build of CO28). With an established pandemic of SARS-CoV2 and extensive ARDS care in the intensive care units, the need for ECCO2R is more obvious 9,10).
Cerebral hemodynamic is directly impacted by the arterial partial pressure of CO2 and O2. The impact of CO2 is steeper and more obvious. The oxygenation can be maintained with a higher range if adequate circulation is present. Acute respiratory failure with ARDS in acute neurological injury is commonly seen in the neurocritical care practice. There is a constant struggle to protect the lung from ventilatory-induced lung injury and the impact of rising CO2 on the injured brain (Fig. 1). The utility of ECCO2R can be a help. A lower dose of anticoagulation infusion can be used to avoid any further hemorrhage in an active condition of intracranial hemorrhage11). Hemolung® uses room airflow to remove CO2 without a need for a high flow oxygen supply. This device will be useful in conditions as mentioned with acute brain injury.
In conclusion, we suggest that Hemolung® device should be present in high capacity neurocritical care unit. Neurointensivist training and competency need to be maintained. Early inclusion of this device may be required where a lung-protective approach is used especially in ARDS patients. Further case series and prospective observational trials will probably show that this technology is useful.


Conflict of interest

No potential conflict of interest relevant to this article was reported.

Fig. 1.
A proposed flow chart to show the impact of ECCO2R in neurocritical care practice.


1. Deng RM, Liu YC, Li JQ, Xu JG, Chen G. The role of carbon dioxide in acute brain injury. Med Gas Res 2020;10:81–84.
crossref pmid pmc
2. Moss CE, Galtrey EJ, Camporota L, Meadows C, Gillon S, Ioannou N, Barrett NA. A Retrospective Observational Case Series of Low-Flow Venovenous Extracorporeal Carbon Dioxide Removal Use in Patients with Respiratory Failure. ASAIO J 2016;62:458–462.
crossref pmid
3. Tiruvoipati R, Buscher H, Winearls J, Breeding J, Ghosh D, Chaterjee S, et al. Early experience of a new extracorporeal carbon dioxide removal device for acute hypercapnic respiratory failure. Crit Care Resusc 2016;18:261–269.
crossref pmid
4. Braune S, Burchardi H, Engel M, Nierhaus A, Ebelt H, Metschke M, et al. The use of extracorporeal carbon dioxide removal to avoid intubation in patients failing non-invasive ventilation--a cost analysis. BMC Anesthesiol 2015;15:160.
crossref pmid pmc
5. Cole S, Barrett NA, Glover G, Chris ISL, Chris M, Kathleen D, et al. Extracorporeal carbon dioxide removal as an alternative to endotracheal intubation for non-invasive ventilation failure in acute exacerbation of COPD. J Intensive Care Soc 2014;15:344–346.
6. Mani RK, Schmidt W, Lund LW, Herth FJ. Respiratory dialysis for avoidance of intubation in acute exacerbation of COPD. ASAIO J 2013;59:675–678.
crossref pmid
7. Burki NK, Mani RK, Herth FJF, Schmidt W, Teschler H, Bonin F, et al. A novel extracorporeal CO(2) removal system: results of a pilot study of hypercapnic respiratory failure in patients with COPD. Chest 2013;143:678–686.
crossref pmid
8. Akkanti B, Rajagopal K, Patel KP, Aravind S, Nunez-Centanu E, Hussain R, et al. Low-flow extracorporeal carbon dioxide removal using the hemolung respiratory dialysis system® to facilitate lung-protective mechanical ventilation in acute respiratory distress syndrome. J Extra Corpor Technol 2017;49:112–114.
crossref pmid pmc
9. Saavedra-Romero R, Paz F, Litell JM, Weinkauf J, Benson CC, Tindell L, et al. Treatment of severe hypercapnic respiratory failure caused by SARS-CoV-2 lung injury with ECCO2R using the hemolung respiratory assist system. Case Rep Crit Care 2021;2021:9958343.
crossref pmid pmc
10. Akkanti B, Jagpal S, Darwish R, Saavedra Romero R, Scott LK, Dinh K, et al. Physiologic improvement in respiratory acidosis using extracorporeal Co2 removal with hemolung respiratory assist system in the management of severe respiratory failure from coronavirus disease 2019. Crit Care Explor 2021;3:e0372.
crossref pmid pmc
11. Janjua T, Nussbaum E, Lowary J, Babbini V. Bivalirudin as a bridge for anticoagulation in high risk neurosurgical patients with active DVT or high risk of thrombosis. Neurocrit Care 2013;18:349–353.
crossref pmid
Share :
Facebook Twitter Linked In Google+ Line it
METRICS Graph View
  • 0 Crossref
  • 1,752 View
  • 21 Download
Related articles in JNIC


Browse all articles >

Editorial Office
Department of Neurosurgery, Korea University College of Medicine
73, Inchon-ro, Seongbuk-gu, Seoul 02841, Korea
Tel: +82-2-920-6833    Fax: +82-2-929-0629    E-mail: jnic.editor@gmail.com                

Copyright © 2024 by Korean Neurointensive Care Society.

Developed in M2PI

Close layer
prev next