The role of extracorporeal CO2 removal from pathophysiology to clinical applications with focus on potential combination with RRT: an expert opinion document

Technological advancements have facilitated the application of
extracorporeal-carbon-dioxide removal (ECCO2R) in managing acute
respiratory-failure (ARF), including both hypoxemic and hypercapnic forms. A
non-systematic literature review (PubMed, Medline, Embase, Google Scholar;
January 2000–November 2024) identified randomized-controlled-trials
(RCTs) and real-world evidence (RWE) on ECCO2R, alone or combined with
continuous renal replacement therapy (CRRT). A multidisciplinary panel of
intensivists, anesthesiologists, and nephrologists from Italy, Portugal, and
Spain assessed clinical integration of ECCO2R. Key considerations included
identifying ideal candidates, such as patients with acute respiratory distress
syndrome (ARDS), chronic obstructive pulmonary disease (COPD), asthma
exacerbations, alongside initiation timing and discontinuation criteria. For ARDS,
recommended initiation thresholds included driving pressure ≥15cm H2O,
plateau pressure ≥28cm H2O, pH < 7.28, and respiratory-rate >25 breaths/min.
In COPD or asthma exacerbations at risk of non-invasive ventilation (NIV)
failure, triggers included pH ≤ 7.25, RR ≥ 30 breaths/min, Intrinsic-PEEP ≥ 5cm
H2O, signs of respiratory fatigue, paradoxical abdominal motion, and severe
distress. Absolute contraindications were uncontrolled bleeding, refractory
hemodynamic instability, or lack of vascular access. Relative contraindications
included moderate coagulopathy and limited access. The panel concluded
ECCO2R may support selected adults with ARDS or obstructive lung disease,
though further RCTs and high-quality prospective studies are needed to
guide practice.