Low-Flow Extracorporeal CO2 Removal Managed with a Renal Replacement Platform

Acute respiratory distress syndrome (ARDS) is a common condition necessitating intensive care, with invasive mechanical ventilation being the primary treatment. However, mechanical ventilation itself can induce lung injury, contributing to high mortality. Extracorporeal carbon dioxide removal (ECCO2R), initially conceptualized in the 1970s, offers an alternative approach to CO2 removal without exacerbating lung injury. This manuscript reviews the historical evolution of ECCO2R, detailing its development from the early concepts to modern clinical applications. It emphasizes the combination of ECCO2R with continuous renal replacement therapy (CRRT) and its potential benefits in patients with ARDS, chronic obstructive pulmonary disease (COPD), and severe asthma and as a bridge to lung transplantation. The manuscript describes various ECCO2R setups, including stand-alone and combined ECCO2R with CRRT. Operational parameters and settings, such as blood flow, anticoagulation, and CO2 removal efficiency, are discussed based on both literature data and clinical experiences. Furthermore, ECCO2R, with its evolving circuit configurations and expanding clinical applications, presents a promising avenue in the management of acute respiratory failure. Future research should focus on overcoming current challenges and refining ECCO2R technology for broader clinical utility.