Extracorporeal Carbon Dioxide Removal as a Multimodal Strategy for Severe Acute Respiratory Distress Syndrome: A Case Series

Severe acute respiratory distress syndrome (ARDS) is associated with substantial morbidity and mortality ranging from 37 to 44%. Although extracorporeal membrane oxygenation (ECMO) is often indicated in ARDS, it is an invasive and resource-intensive intervention and may be contraindicated when the anticipated survival benefit is low. We describe two patients with severe ARDS with multiorgan failure for whom ECMO could not be provided. The first patient was deemed ineligible for ECMO due to advanced multiorgan dysfunction. The second was considered suitable, but the family declined transfer to an ECMO-capable center. In both cases, low-flow extracorporeal carbon dioxide removal (ECCO2R) was instituted as part of a multimodal strategy that included renal replacement therapy, prone-position ventilation, and inhaled nitric oxide. ECCO2R facilitated effective control of hypercapnic acidemia and allowed lung-protective ventilation. Both patients fully recovered and were discharged home. These cases provide proof of concept for ECCO2R as part of a multimodal strategy and suggest a potential role as an adjunctive therapy in selected patients when escalation of conventional ventilation is constrained by lung-protective limits, and ECMO is unavailable or contraindicated. These observations represent a descriptive feasibility experience and warrant further evaluation in resource-limited and clinically complex settings.