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

FRANCISCO JOSE PARRILLA-GOMEZ^1*Antonio Castelli²Riccardo Colombo²Antero do Vale-Fernandes³Federico Nalesso⁴David Pestaña-Lagunas⁵Fernando Suarez Sipmann⁶Pierpaolo Terragni⁷

• ¹Infectious Diseases Unit, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain, Barcelona, Spain
• ²3Anesthesia and Intensive Care Unit, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy, Milan, Italy
• ³Serviço de Medicina Intensiva, Unidade Local de Saúde Almada - Seixal (ULSAS) - Hospital Garcia de Orta Almada, Portugal., Almada, Portugal
• ⁴Nephrology, Dialysis and Transplantation Unit, Department of Medicine, University of Padova, 35128 Padova, Italy, Padova, Italy
• ⁵Department of Anaesthesia and Intensive Care, Hospital Universitario Ramon y Cajal, IRYCIS, Madrid, Spain., Madrid, Spain
• ⁶Department of Critical Care, University Hospital La Princesa, ISS La princesa, Autonomous University of Madrid, Madrid, Spain., Madrid, Spain
• ⁷University of Sassari, Department of Medicine, Surgery and Pharmacy, Sassari, Italy., Sassari, Italy

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 ≥15 cmH₂O, plateau pressure ≥28 cmH₂O, pH <7.28, and respiratory-rate >25 breaths/min. In COPD or asthma exacerbations at risk of noninvasive ventilation (NIV) failure, triggers included pH ≤7.25, RR ≥30 breaths/min, Intrinsic-PEEP ≥ 5 cmH2O, 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.