Extracorporeal lung support to remove carbon dioxide

For the last three decades, extracorporeal lung assist (ECLA) has been employed as a life-saving therapy in few highly-specialised centres. A deeper understanding of acute respiratory distress syndrome (ARDS) pathophysiology, improved technology and the positive results of recent trials have led to a reassessment of ECLA in the clinical setting. The referral and transfer of sicker patients to specialised extracorporeal membrane oxygenation (ECMO) centres has been shown to improve clinical outcome. The CESAR (conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure) trial was the first positive randomised controlled trial to investigate ECMO use in adult patients with ARDS. In 2009, many healthcare systems worldwide successfully faced the influenza A (H1N1) pandemic, instituting networks of specialised intensive care units (ICUs), for transfer of the sickest patients and management with ECMO. There is also an increasing interest in new and less invasive extracorporeal techniques, primarily aimed at carbon dioxide removal, which may be more widely applied in combination with a strictly protective ventilatory strategy.