The Evolving Role of Extracorporeal Carbon Dioxide Removal in Acute Respiratory Failure: A Narrative Review

Extracorporeal carbon dioxide removal (ECCO₂R) has emerged as a supportive therapy for patients with acute respiratory failure, particularly when refractory hypercapnia and respiratory acidosis persist despite standard management. This narrative review summarizes the physiological rationale, current evidence, and clinical applications of ECCO₂R in modern critical care practice. ECCO₂R removes carbon dioxide directly from the bloodstream, thereby facilitating lung-protective ventilation strategies and potentially reducing ventilator-induced lung injury. The technique has been primarily evaluated in patients with acute respiratory distress syndrome (ARDS) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In these settings, ECCO₂R may enable the use of lower tidal volumes and reduced airway pressures, and in selected patients, it may decrease the need for invasive mechanical ventilation. Although ECCO₂R has been shown to improve carbon dioxide clearance, correct respiratory acidosis, and optimize ventilatory parameters, randomized trials have not demonstrated a definitive mortality benefit. Its clinical application is also limited by device-related complications, including bleeding, thrombosis, and hemolysis. Furthermore, outcomes are influenced by technical factors such as cannula configuration, blood flow rate, membrane efficiency, and anticoagulation strategy. Ongoing technological advancements and well-designed clinical trials are needed to better define the role of ECCO₂R in contemporary critical care practice.