Combined Extracorporeal Carbon Dioxide Removal (ECCO2R) With Renal Replacement Therapy and Blood Purification in a Severe Inhalation Injury Patient—Case Report

Abstract

Severe burns complicated by inhalational trauma represent a clinically challenging combination, particularly in elderly patients with multiple comorbidities. The following case report highlights the successful management of an elderly patient with second-degree burns and inhalational trauma following a residential fire. Given the severity of the clinical presentation, a combined approach incorporating extracorporeal CO₂ removal (ECCO2R) to allow for early protective ventilation, continuous renal replacement therapy for precise hydroelectrolytic management, and blood purification for early immunomodulation was implemented. The case report describes a 75-year-old male patient with multiple comorbidities, including obesity and Parkinson’s disease, who presented with severe burns and inhalational injury following a residential fire. The patient was admitted to the intensive care unit (ICU) with severe respiratory compromise, requiring invasive mechanical ventilation and hemodynamic support. After a multidisciplinary assessment, preemptive installation of ECCO2R combined with renal replacement therapy and blood purification filter was decided upon. Multi-organ extracorporeal support was maintained for 96 h, resulting in substantial improvement in respiratory and hemodynamic functions. After discontinuation of extracorporeal support, the patient’s renal function fully recovered, obviating the need for subsequent hemodialysis. The patient was weaned off mechanical ventilation and discharged from the ICU after a 14-day stay. He is currently under outpatient follow-up, demonstrating favorable recovery. This report underscores the efficacy and safety of the combined approach of ECCO2R, renal replacement therapy, and blood purification in patients with severe inhalational injury and burns. Early intervention showed a positive impact on the patient’s clinical progression, highlighting the importance of multidisciplinary evaluation and integrated management in complex cases. Although further studies are necessary to validate these findings, this case illustrates promising potential for this therapeutic strategy in similar scenarios.

INTRODUCTION

In the complex clinical landscape of treating elderly patients with preexisting comorbidities, severe burns accompanied by inhalational injury pose significant challenges.^1,2

These patients often present limited physiological reserve, and the systemic inflammatory response triggered by thermal injury and smoke inhalation can rapidly lead to multisystem organ dysfunction. Timely recognition and implementation of organ support strategies are therefore essential for improving outcomes in this vulnerable population.

Extracorporeal blood purification has emerged as a promising adjunct in critical care, particularly in conditions marked by excessive systemic inflammation.³ These therapies aim to reduce the burden of circulating inflammatory mediators—such as cytokines and endotoxins—potentially mitigating organ dysfunction and stabilizing hemodynamics. While robust clinical evidence is still evolving, recent meta-analyses suggest a possible association between the use of blood purification filters during continuous renal replacement therapy (CRRT) and improved short-term outcomes in critically ill patients with sepsis, including reduced mortality and shorter intensive care unit (ICU) stays.⁴

Extracorporeal carbon dioxide removal (ECCO2R) is a form of partial respiratory support designed to facilitate the elimination of CO₂ from the bloodstream, thereby enabling the use of ultraprotective ventilation strategies in patients with acute or impending respiratory failure. Unlike extracorporeal membrane oxygenation (ECMO), ECCO2R operates at lower blood flow rates and focuses primarily on CO₂ clearance rather than oxygenation. This allows for a less invasive approach that can be particularly useful in patients with hypercapnic respiratory acidosis but preserved oxygenation, such as those with inhalational injury without advanced acute respiratory distress syndrome (ARDS).^5,6 Extracorporeal carbon dioxide removal can be integrated with renal replacement therapy platforms, offering a combined solution for respiratory and renal support.^5,6

In this context, an integrated treatment approach—comprising ECCO2R, CRRT, and blood purification using a cytokine-adsorbing filter—was employed in managing an elderly patient who suffered second-degree burns and inhalational injury following a residential fire. This case report underscores the importance of multidisciplinary assessment and the potential benefits of early implementation of extracorporeal therapies in complex clinical scenarios.² These interventions significantly improved the patient’s respiratory and hemodynamic functions, highlighting their potential in similar challenging clinical situations.

The case was reported following informed consent and in compliance with the Helsinki Declaration. In addition, the report adheres to the CARE guidelines⁷ for case reports, ensuring a comprehensive and ethical presentation of the patient’s clinical journey.

CASE REPORT

A 75-year-old male patient with obesity (body mass index [BMI]: 31), Parkinson’s disease, and obstructive sleep apnea syndrome was admitted to the emergency department with altered consciousness, tachypnea, and second-degree burns on his neck and upper limbs following a house fire. Exposure to the fire and resultant smoke inhalation was significantly prolonged due to the patient’s Parkinson’s disease, which impaired his mobility and led to festination, thereby delaying rescue efforts by firefighters. During the initial medical assessment, orotracheal intubation was deemed necessary due to the presence of glottic edema and soot in the oropharynx and larynx, observed during laryngoscopy. The extent of burns covered approximately 5% of the total body surface area (both arms and neck), as determined by established burn quantification protocols (Figure 1).^1,2

Figure 1.

(a) Patient Had Second-Degree Burns in the Cervical Region and Upper Limbs (Arm and Forearm); (b) Appearance of Sputum Obtained After Bronchoalveolar Lavage (Carbonaceous Sputum)

Volume replacement was administered using the Parkland formula,^8,9 and the plastic surgery team assessed the patient, performing debridement and escharotomy in the surgical center. Subsequent days in the intensive care unit (ICU—Simplified Acute Physiology Score 3 [SAPS3] 84 points^10,11) involved alternating between lesion debridement and secondary dressing changes. An initial hypothesis for consciousness impairment was carbon monoxide (CO) poisoning; however, serum carboxyhemoglobin was only 2.2%. Initial chest radiography showed no infiltrates.

On the second day of hospitalization in the ICU, still under invasive mechanical ventilation and receiving continuous infusions of benzodiazepine and ketamine, bedside bronchoscopy revealed persistent airway edema, mucosal friability, and carbonaceous deposits throughout the tracheobronchial tree, classifying the inhalational injury as grade 3 (severe) according to the inhalation injury score¹² (Figure 2). Bronchoalveolar lavage during bronchoscopy yielded carbonaceous secretion (Figure 1). That same day, the patient exhibited progressive and persistent hemodynamic deterioration requiring noradrenaline support. Infectious screening was repeated, and a chest X-ray showed new alveolar opacity at the right base. Given the clinical worsening and suspicion of sepsis/septic shock, cultures were taken and empirical antibiotic therapy with moxifloxacin was initiated. From a gasometric perspective, there was a decrease in the PaO₂/FiO₂ ratio associated with respiratory acidemia (pH = 7.27, PaCO₂ = 48, and HCO₃⁻ = 22) and worsening respiratory mechanics (driving pressure/△P of 15 and static compliance of 38 mL/cmH₂O). Ventilatory adjustments were made by reducing the tidal volume (VC) from 6 to 5 mL/kg, resulting in a △P of 12, increasing positive end-expiratory pressure (PEEP) from 6 to 10 cmH₂O, and increasing the respiratory rate from 18 to 25 breaths per minute, with an appropriate gasometric response.

Figure 2.

Bronchoscopic Findings: (a) Severe Laryngeal Edema; (b) Pale Bronchial Mucosa and Presence of Carbonaceous Deposit

The following day witnessed a further decline in gas exchange (PaO₂/FiO₂ = 138), prompting an increase in respiratory rate to 30 breaths per minute due to persistent respiratory acidemia while maintaining a VC of 5 mL/kg, achieving a driving pressure (△P) of 12 cmH₂O and static compliance of 38 mL/cmH₂O. In addition, there was an increase in nitrogenous waste and a reduction in urine output (severe acute kidney injury, Kidney Disease: Improving Global Outcomes [KDIGO] 3^13,14), associated with a cumulative positive fluid balance of 4.8 L.

A new chest X-ray revealed worsening infiltrate patterns, now with bilateral opacity and vascular cephalization, although echocardiographic evaluation of the patient showed no signs of elevated chamber filling pressures or ventricular dysfunction, leading to a diagnosis of moderate ARDS as defined by actual Berlin criteria.¹⁵ The team, including the ECMO group specialist, discussed and decided on the preemptive installation of extracorporeal CO₂ removal (ECCO2R) rather than ECMO. This decision was based on the patient’s gasometric profile, which showed respiratory acidosis with moderate impairment (pO₂/FiO₂ > 100) in oxygen exchange, indicating that ECCO2R would be an appropriate option. The decision also considered the patient’s limited functional reserve due to advanced age and comorbidities, allowing for combined treatment with renal replacement therapy and the oXiris blood purification filter before exhausting other rescue measures (Figure 3).^3,16 The PrismaLung+ system was installed via a 12Fr triple-lumen hemodialysis catheter punctured into the left femoral vein in a sterile procedure guided by ultrasonography.

Figure 3.

Extracorporeal CO₂ Removal (PrismaLung+) Combined With Renal Replacement Therapy and Blood Purification Filter (Oxiris)

Therapeutically, treatment began with a blood flow of 250 mL/min and a sweep gas of 2 L/min. Systemic anticoagulation was administered with unfractionated heparin under continuous infusion aiming for an activated partial thromboplastin time between 1.5 and 2.5 times the normal. The prescribed CRRT was continuous venovenous hemodiafiltration# (CVVHDF) at a dose of 30 mL/kg/h, with half of the dose achieved via convective clearance (pre- and postcapillary) and the remainder via diffusive clearance using balanced solutions (sodium 140 mmol/L, bicarbonate 22 mmol/L, potassium 4 mmol/L, magnesium 0.75 mmol/L, and phosphorus 1 mmol/L) with external bicarbonate supplementation.

After 30 min of therapy initiation, PaCO₂ dropped to 36 cmH₂O, allowing a reduction in mandatory respiratory rate to 22 breaths per minute. For hypoxemia management, prone positioning was avoided due to the burns, and a recruitment maneuver followed by PEEP titration for optimal compliance and driving pressure was performed (ideal PEEP of 12 cmH₂O), achieving a PaO₂/FiO₂ of 263, △P of 8 cmH₂O, plateau pressure of 20 cmH₂O, and static compliance of 50 mL/cmH₂O.

After 36 h of support, pH and HCO₃⁻ normalized, and both hemodynamic (vasoactive drugs) and respiratory conditions (pO₂/FiO₂) showed substantial improvement, with serum polymerase chain reaction levels beginning to decline (Figure 4—table with lab results). On the third day of therapy, sedation and analgesia weaning commenced, and the ventilatory mode transitioned to support pressure. The evolution of therapy over the days, as reflected by pH and the CO₂ extraction rate through pre- and post-PrismaLung+ blood gas analyses, is shown in Figures 4 and 5. In addition, Figure 6 illustrates the downward trend of C-reactive protein (CRP) levels observed throughout the duration of extracorporeal support, reflecting a progressive reduction in systemic inflammation during therapy. Unfortunately, it was not possible to measure additional inflammatory markers such as interleukin-6 (IL-6), due to unavailability at the institution.

Figure 4.

pH Control During ECCO2R Therapy: CVVHDF—continuous venovenous hemodiafiltration, ECCO2R—extracorporeal CO₂ removal, VCV—volume controlled ventilation, PSV—pressure support ventilation, BFR—blood flow rate, BicNa—sodium bicarbonate solution

Figure 5.

Carbon Dioxide Removal During ECCO2R; CO2 Extraction Rate Calculations Based on the Study by Gattinoni et al. (1979)²³: BFR—blood flow rate, ECCO2R—extracorporeal CO₂ removal

Figure 6.

C-Reactive Protein (mg/dL) Kinetics Before, During, and After Triple Combination Therapy: CVVHDF—continuous venovenous hemodiafiltration, ECCO2R: extracorporeal CO₂ removal

The multi-organ extracorporeal support was maintained for a total duration of 96 h without any occurrences of bleeding, hemolysis, or premature filter loss. The choice of the oXiris filter for blood purification was based on its local availability at the time of clinical decision-making, rather than on comparative device selection. Filter changes were performed on a scheduled basis every 72 h, or earlier if clotting or circuit failure occurred. As no premature losses were observed during therapy, only 2 complete sets were required, each comprising the CVVHDF filter with oXiris for blood purification and the ECCO2R component (PrismaLung+).

Following completion of therapy, the patient’s renal function fully recovered, and no further hemodialysis sessions were necessary. Invasive mechanical ventilation was discontinued on day 8, and ICU discharge occurred on day 14 of admission. He was discharged from the hospital 19 days after the index burn event.

At 1-year follow-up, the patient remains clinically stable. He has fully recovered from burn-related injuries, with preserved pulmonary function and no residual respiratory compromise. However, as expected from the natural progression of Parkinson’s disease, he has become increasingly dependent on assistance for instrumental activities of daily living. He ambulates with support and requires a caregiver for some basic activities such as hygiene, transfers, and feeding. Despite these limitations, he has not experienced new hospitalizations and continues regular outpatient follow-up with neurology and rehabilitation specialists.

DISCUSSION

Burns are a type of injury caused by exposure to high-temperature substances, including liquids, solids, gases, and objects radiating thermal energy. In 2019, over 8 300 000 new cases of burn victims were reported worldwide, according to the Global Burden of Disease study.¹⁷ Beyond the high mortality rates, burns cause significant sequelae and markedly affect the quality of life of surviving patients.^1,2,8,10,17

Initial management of major burns includes protocolized approaches to airway management and gas exchange, hemodynamic resuscitation, pain and anxiety control, and addressing the injuries.^1,2,8,18 Beyond the first 24 h, these patients undergo a significant cascade of inflammation and immune activation that impacts vital systems such as hemodynamic dysfunction, immune dysregulation, acute kidney injury, and secondary lung injury.¹⁹ In the case of the reported patient, in addition to the secondary lung injury due to inflammation from major burns, criteria for severe thermal injury induced by the inhalation of smoke and soot were also present.^12,20,21

In the pathophysiology of multi-organ dysfunction associated with burns, both proinflammatory cytokines (such as IL-6, IL-8, tumor necrosis factor [TNF]-α, IL-1β, and interferon [IFN]-γ) and anti-inflammatory mediators (including IL-10 and IL-17) play a central role, with their levels directly correlating with the depth and extent of injury. This overwhelming and dysregulated immune response contributes significantly to systemic inflammation and early organ failure, posing a major therapeutic challenge.^8,19

Extracorporeal blood purification has been proposed as a potential strategy to attenuate this hyperinflammatory state through the nonselective removal of circulating cytokines and endotoxins. While robust evidence in patients with burns is still limited, this approach has been explored in critically ill populations with encouraging results.^3,4,22 Although evidence specific to patients with burns remains limited, recent data from critically ill populations provide mechanistic and clinical support for the use of blood purification therapies as a means of modulating systemic inflammation and improving organ support.³

A meta-analysis that included only septic patients treated with the oXiris membrane during CRRT suggested potential clinical benefits, including reductions in 28-day mortality, Sequential Organ Failure Assessment (SOFA) scores, and vasopressor requirements.⁴ These findings support the hypothesis that selective membrane adsorption of endotoxins and cytokines may attenuate the severity of organ dysfunction in hyperinflammatory states. Complementarily, another meta-analysis evaluating blood purification in critically ill patients with multiple organ dysfunction, regardless of the specific device used—found no significant reduction in short-term mortality but demonstrated a consistent association with improved hemodynamic status and lower IL-6 levels.²² Together, these studies reinforce the potential clinical value of blood purification therapies in critically ill patients, demonstrating consistent improvements in hemodynamic parameters, including reduced vasopressor requirements and lactate levels, as well as significant decreases in circulating IL-6 concentrations. While the impact on mortality may vary across populations and study designs, the overall evidence suggests that early implementation of these therapies can contribute meaningfully to stabilizing patients with severe systemic inflammation and multi-organ dysfunction.

In this case, considering the patient’s critical condition and limited physiological reserve, blood purification therapy was initiated early as part of a comprehensive extracorporeal support strategy. Although inflammatory cytokine levels were not measured, the patient’s clinical evolution, marked by progressive discontinuation of vasopressors, improvement in CRP kinetics (Figure 6), and recovery of organ function, suggests a favorable response likely associated with the intervention.

Among the secondary dysfunctions related to the postburn inflammatory process, lung injury is characteristically severe, and its management presents a significant challenge for intensive care in patients with burns. Various therapies have been attempted to mitigate or prevent secondary lung injury due to inflammation, however, none have proven highly effective in this regard, leaving the recommendation for protective ventilatory management to prevent and manage burn-related ARDS.^15,21

Extracorporeal CO₂ removal systems (ECCO2R) are devices that provide partial respiratory support, requiring lower blood flows and membrane surface areas than those required by ECMO therapy,²³ with the potential to be used in conjunction with CRRT.¹⁶ The aim of ECCO2R therapy is to facilitate the use of protective ventilatory strategies, thereby reducing and preventing the potential deleterious effects of non-protective ventilation (ventilator-induced lung injury [VILI]).^6,16,24

The literature documents the use of ECCO2R in various scenarios such as mild to moderate ARDS, severe asthma crises (status asthmaticus), exacerbated COPD, bridge to lung transplantation, and even airway fistulae.⁶ Indeed, in the patient described earlier, ECCO2R was preemptively employed based on the rationale that his advanced age and comorbidities necessitated early intervention. This case marks the first documented clinical success of modern ECCO2R in a patient with burn injuries and inhalational thermal injury, illustrating the promising role of this therapy in complex clinical scenarios where traditional approaches may fall short. This strategic integration of ECCO2R into the patient’s care highlights its pivotal role in both the mitigation of secondary lung injury and the enhancement of overall respiratory management in severely burned patients.

Several studies have shown the safety of combining ECCO2R with continuous venovenous hemofiltration, the main benefits of which include appropriate blood purification and the ability to apply protective or ultraprotective ventilation effectively.^25–27 Our case report reinforces this favorable experience in using the therapy in critically ill patients, even with CO₂ extraction rates lower than those reported in the literature, considering that in the case described in this document, the use of the device was carried out preemptively, still without critical values of pH and pCO₂.²⁴

A significant highlight of this publication is the presentation of the first case report that demonstrates the combined use of blood purification on the oXiris platform and CO₂ removal therapy via PrismaLung+ (ECCO2R). This combination was employed early and successfully, despite alarming prognostic factors such as the type of thermal injury, SAPS3 score, and patient age. This case underscores the potential of these therapies to enhance patient outcomes through improved respiratory and renal support, even in the face of severe clinical challenges.

However, our report also underscores a notable limitation: the inability to measure inflammatory and anti-inflammatory cytokines to confirm the effectiveness of the blood purification therapy in modulating the immune response after the burn. This gap highlights the need for further research to validate the immunomodulatory effects of such treatments. In addition, our findings raise questions about the impact of the timing of therapy on the clinical response, suggesting that the early intervention may be critical in managing severely injured patients. This aspect warrants further exploration to optimize treatment protocols and improve patient outcomes in similar clinical scenarios.

CONCLUSION

The case report presented underscores the effectiveness of early and integrated management in an elderly patient with severe burns and inhalational injury. The combination of ECCO2R, renal replacement therapy, and blood purification demonstrated significant improvements in respiratory and hemodynamic functions, leading to substantial clinical recovery. This case highlights the importance of a multidisciplinary approach and the strategic use of advanced therapies in patients with challenging clinical conditions, contributing to a favorable outcome despite reserved prognostic risk factors.

Author contributions: Roosevelt Santos Nunes (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration [lead], Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing [equal]), Kamila da Grazia Iazzetta (Conceptualization, Formal analysis, Investigation, Methodology, Validation [supporting]), Paulo Ricardo Gessolo Lins (Conceptualization, Data curation, Formal analysis [supporting], Supervision [equal], Validation [supporting], Writing—original draft, Writing—review & editing [equal]), Mariana Longa Rizzo (Conceptualization, Data curation, Supervision, Validation [supporting]), Ivo Marçal Vieira (Conceptualization, Data curation, Formal analysis, Writing—review & editing [supporting]), Viviane Barbosa Silva (Conceptualization, Data curation, Formal analysis, Investigation [supporting]), Gil Cezar Teixeira Alkmin (Conceptualization, Supervision, Validation, Visualization, Writing—review & editing [supporting]), Federico Enrique Garcia Cipriano (Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing [supporting]), Gustavo Prata Misiara (Supervision, Validation, Visualization [supporting], Writing—original draft, Writing—review & editing [equal]), and Osvaldo Merege Vieira Neto (Supervision, Validation, Writing—review & editing [lead])

Funding: The open access fees were supported by Vantive Health.

Conflict of interest statement: The authors declare no conflicts of interest related to this case report, except for Dr Paulo Ricardo Gessolo Lins, who is employed as Medical Affairs Manager—Brazil at Vantive [Substitute Baxter to Vantive Health].