Maintaining Lung-Protective Ventilation in ARDS: Use of ECCO₂R to Manage Hypercapnia
Extracorporeal CO₂ Removal in Clinical Practice An Interactive Case Study
1/19
This interactive case study was organised and funded by Vantive Health LLC.
Technical and medical writing support was provided by EMJ.
GBU-AT00-260013 v1.0 04/26
These are hypothetical patient cases and outcomes may not be reflective of clinical studies or real-life circumstances. This includes reference to agents that may be used off-label or for unlicensed indications. The mention of these agents and their uses is intended solely for educational purposes and should not be considered an endorsement or recommendation for their use outside approved indications. Please always consult guidelines and local prescribing information in your country of practice, as information may vary.
These interactive case studies were developed with support from Jörg Kurz, Vantive Global Medical Director of Organ Support Therapies, Vantive Health LLC, Munich, Germany.
Case Presentation
The caregiver reported that skin symptoms had worsened over the past week.
Symptoms were associated with increased crying and disturbed sleep.
2/19
A 42-year-old woman presents with progressive shortness of breath and cough. On arrival, she is hypoxaemic and tachypnoeic, and chest imaging shows bilateral pulmonary infiltrates consistent with an acute inflammatory lung process.
Despite high-flow oxygen, her respiratory failure worsens, and she is admitted to intensive care for invasive mechanical ventilation.
3/19
Consider these clinical questions:
Can the ventilation be improved? Does the patient qualify for further reduction of tidal volume (Vt)? Could she benefit from a less intensive ventilation?
3.2 (high)1
This suggests marked ventilatory inefficiency, consistent with increased dead-space ventilation and impaired CO₂ clearance.
Fraction of inspired oxygen (FiO₂) 0.6 Positive end-expiratory pressure (PEEP) 12 cmH₂O Vt 6 mL/kg predicted body weight (PBW) Respiratory rate: 26 breaths/min Plateau pressure: 25 cmH₂0 Driving pressure: 13 cmH₂0
Intubated and mechanically ventilated
Obesity Smoking history (no evidence of chronic lung disease) Type 2 diabetes
Acute respiratory distress syndrome (ARDS)
The history does not indicate known chronic lung disease, supporting an acute process as the main contributor to the current respiratory failure.
Reference:
1. Dianti J et al. Determinants of effect of extracorporeal CO2 removal in hypoxemic respiratory failure. NEJM Evid. 2023;2(5):EVIDoa2200295.
Patient History/Symptoms:
Arterial blood gas on current settings: pH 7.28, partial pressure of arterial carbon dioxide (PaCO₂) 55 mmHg, partial pressure of arterial oxygen (PaO₂)/FiO₂=120 Interpretation:
4/19
Arterial Blood Gas (ABG)
Acute respiratory acidosis secondary to hypercapnia. Significant hypoxaemia despite FiO₂ 0.6 and PEEP 12 cmH₂O.1 The PaO₂/FiO₂ ratio of 120 indicates moderate acute respiratory distress syndrome (ARDS) physiology.1
In mechanically ventilated patients, hypercapnia is reflected by elevated PaCO2 and respiratory acidosis on arterial blood gas analysis.2
Hypercapnia
1. Nin N et al. Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome. Intensive Care Med. 2017;43(2):200-8. 2. Rawat D et al. Hypercapnea [Internet] (2024) Treasure Island (FL): StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK500012/. Last accessed: 11 February 2026.
ATS Care Guidelines
5/19
Clinical approach so far: The team has continued to follow American Thoracic Society (ATS) guidance for the management of acute respiratory distress syndrome, prioritising lung-protective ventilation (LPV).1 Key elements being applied:1
Low tidal volume ventilation (typically around 6 mL/kg PBW), adjusted to maintain lung-protective pressures. Limiting plateau pressure to around 30 cmH2O. Use of higher PEEP to prevent cyclical alveolar collapse.
ATS guidelines for the management of ARDS1
Current ATS guidelines for the management of acute respiratory distress syndrome.
*New or updated recommendations in current guideline.
†Recommendations addressed in 2017 guideline.
ARDS: acute respiratory distress syndrome; FiO2:fraction of inspired oxygen; PaO2: partial pressure of arterial oxygen; PBW: predicted body weight; PEEP: positive end-expiratory pressure; Pplat: plateau pressure; Vt: tidal volume; VV-ECMO: venovenous extracorporeal membrane oxygenation.
Reproduced with permission from the American Thoracic Society. Copyright © 2024 by the American Thoracic Society
These strategies aim to protect the lungs from harm caused by the ventilator by avoiding excessive stretch, excessive pressure, and repeated opening and closing of airspaces.
PEEP titration should be guided by oxygenation and respiratory mechanics, while monitoring haemodynamics and overall patient response.
1. Qadir N et al. An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024;209(1):24-36.
What is the most concerning feature in the case presentation that would cause you to consider alternate courses of action for this patient?
D
No concerns
C
Driving pressure increased to 18 cmH2O despite lung-protective ventilation
B
pH 7.28
A
PaCO₂ 55 mmHg
1. Augustin M et al. A practical algorithm for the treatment of mild-to-moderate atopic dermatitis (AD) in paediatric patients in Europe: expert recommendations. J Dermatolog Treat. 2025;36(1):2503281.
Footnote:
6/19
Why this is concerning?
Invasive medical ventilation (IMV) with high mechanical power can lead to ventilator-induced lung injury (VILI).1-6 Driving pressure of 18 cmH2O is considered high and associated with increased lung stress and a higher risk of VILI.
High mechanical power ventilation, characterised by high plateau pressure, high Vt, or high driving pressure, is linked to VILI.4,5
VILI can occur through barotrauma, volutrauma, atelectrauma, and biotrauma.2 This makes driving pressure a key variable to monitor and minimise.
By comparison, other features in this case, pH 7.28 and PaCO₂ 55 mmHg, represent mild respiratory acidosis and moderate hypercapnia, which are generally well tolerated in acute respiratory failure and under permissive hypercapnia strategies. These values are less immediately injurious than high driving pressures.
Therefore, the primary clinical focus should be on reducing driving pressure to lower the risk of VILI, rather than attempting aggressive correction of pH or PaCO₂.
1. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2013;369(22):2126-36. Erratum in: N Engl J Med. 2014;370(17):1668-9. 2. Gattinoni L et al. Ventilator-induced lung injury: the anatomical and physiological framework. Crit Care Med. 2010;38(10 Suppl):S539-48. 3. Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med. 1998;157(1):294-323. 4. von Düring S et al. Mechanical power and outcomes in critically ill patients: a multicentre cohort study. J Crit Care. 2025;85:154902. 5. Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med. 2011;365(20):1905-14. 6. Serpa Neto A et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012;308(16):1651-9.
Current Clinical Status
7/19
Exam and laboratory findings Oxygenation remains in the moderate ARDS range (PaO2/FiO2 approximately 100–200 mmHg).1
However, the patient is experiencing persistent hypercapnia and respiratory acidosis despite ongoing lung-protective ventilation.
Why not use extracorporeal membrane oxygenation (ECMO)? ECMO is a form of extracorporeal life support in which deoxygenated blood is pumped through an artificial lung outside the body and returned oxygenated. Its use requires a fully staffed, specialised team and substantial institutional resources.2 Guidelines recommend considering veno-venous ECMO (VV-ECMO) for refractory severe hypoxaemia, typically defined as a PaO₂/FiO₂ ratio <80 mmHg (despite optimal ventilation and rescue therapies) or uncompensated hypercapnia with severe acidosis. In this case, although the patient has significant hypercapnia and respiratory acidosis, her level of hypoxaemia does not clearly meet the threshold to qualify for ECMO, resulting in a therapeutic grey zone where alternative adjunctive strategies may be considered before initiating ECMO.2-4
Why not simply increase ventilation? Trade off Increasing Vt or airway pressures could improve CO2 clearance and pH, but would likely increase lung stress and risk further VILI. LPV strategies are important to maintain (low tidal volume around 6 mL/kg PBW, limitation of plateau pressure, controlled respiratory rate, and appropriately titrated PEEP) as they limit pressure and volume during mechanical ventilation to reduce the risk of VILI.5-7
1. Ranieri VM et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012;307:2526-33. 2. Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med. 2011;365(20):1905-14. 3. Qadir N et al. An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024;209(1):24-36. 4. Combes A et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378(21):1965-75. 5. Amato MB et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747-55. 6. Ferrer Gómez C et al. Ultraprotective ventilation via ECCO2R in three patients presenting an air leak: is ECCO2R effective? J Pers Med. 2023;13(7):1081. 7. Costa ELV et al. Ventilatory variables and mechanical power in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2021;204(3):303-11.
8/19
Compared with traditional ventilation, lung-protective strategies are associated with lower mortality, fewer days of non-pulmonary organ failure, less barotrauma, more ventilator-free days, and earlier weaning.1-6 However, acute hypercapnia can be a barrier to the use of LPV.7-9 Severe hypercapnia during lung-protective ventilation has been associated with higher mortality in observational studies, highlighting a clinical challenge rather than a direct causal effect.10
Current guidelines continue to recommend LPV for ARDS, even in the presence of moderate hypercapnia.11 In this patient, LPV is already in use, but the high driving pressure and elevated minute ventilation indicate that she could benefit from reducing the mechanical intensity of ventilation to minimise lung stress and VILI.
References:
1. Serpa Neto A et al. Association between use of lung protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta analysis. JAMA. 2012;308(16):1651-9. 2. Ferrer Gómez C et al. Ultraprotective ventilation via ECCO2R in three patients presenting an air leak: is ECCO2R effective? J Pers Med. 2023;13(7):1081. 3. ARDSNet; Brower RG et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8. 4. Putensen C et al. Meta analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med. 2009;151(8):566-76. 5. Petrucci N, De Feo C. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev. 2013;2013(2):CD003844. 6. Amato MB et al. Effect of a protective ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347-54.
7. Grasselli G et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023;49(7):727-59. 8. Papazian L et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):69. 9. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2026. Available at: https://goldcopd.org/wp-content/uploads/2026/01/GOLD-REPORT-2026-v1.3-8Dec2025_WMV2.pdf Last accessed: 10 March 2026. 10. Nin N et al. Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome. Intensive Care Med. 2017;43(2):200-8. 11. Gendreau S et al. The role of acute hypercapnia on mortality and short-term physiology in patients mechanically ventilated for ARDS: a systematic review and meta-analysis. Intensive Care Med. 2022;48(5):517-34.
Alternative Pathway: ECCO2R
9/19
Extracorporeal CO₂ removal (ECCO2R) is a therapy that removes CO₂ directly from the blood, allowing clinicians to further reduce Vt and RR as part of LPV or ultra-LPV (ULPV) without inducing hypercapnia and acidosis.1-3 ECCO2R has been shown to reduce PaCO2 and support control of hypercapnia in selected patients with ARDS, including COVID‑19–associated ARDS, primarily in feasibility and observational studies.4-6 ECCO₂R is considered an adjunctive support strategy in selected patients, rather than a replacement for established ARDS therapies.
What does ECCO2R enable?
Maintenance or intensification of LPV Correction of severe hypercapnia and respiratory acidosis Potential reduction in mechanical power delivered to the lung
1. Combes A et al. Expert perspectives on ECCO2R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting. Ann Intensive Care. 2024;14:132. 2. Dianti J et al. Determinants of effect of extracorporeal CO2 removal in hypoxemic respiratory failure. NEJM Evid. 2023;2(5):EVIDoa2200295. 3. Ferrer Gomez C et al. Extracorporeal membrane oxygenation in acute respiratory distress syndrome: current evidence and future directions. J Pers Med. 2023;13:1081. 4. Winiszewski H et al. Daily changes in extracorporeal membrane oxygenation blood flow and outcomes in severe acute respiratory distress syndrome. J Intensive Care. 2018;6:36. 5. Combes A et al. Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med. 2019;45:592-600. 6. Tiruvoipati R et al. Extracorporeal membrane oxygenation in adults: a single-centre experience and outcome analysis. Eur J Med Res. 2023;28(1):291.
What is the alternative approach to managing this patient?
Consider ECCO₂R with prone positioning to enable LPV
Escalate to ECMO immediately
Maintain LPV and tolerate hypercapnia
Increase Vt to improve CO₂ clearance
10/19
The optimal approach is to preserve LPV while addressing problematic hypercapnia and respiratory acidosis. ECCO₂R removes CO₂ directly from the blood, allowing Vt and respiratory rate to remain low without worsening acidosis. Adjunctive strategies such as prone positioning may further improve oxygenation and lung recruitment, complementing the benefits of ECCO₂R while maintaining lung-protective ventilation.1-4
1. Combes A et al. Expert perspectives on ECCO2R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting. Ann Intensive Care. 2024;14:132. 2. Dianti J et al. Determinants of effect of extracorporeal CO2 removal in hypoxemic respiratory failure. NEJM Evid. 2023;2(5):EVIDoa2200295. 3. Ferrer Gomez C et al. Extracorporeal membrane oxygenation in acute respiratory distress syndrome: current evidence and future directions. J Pers Med. 2023;13:1081 4. Qadir N et al. An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024;209(1):24-36.
ECCO₂R Mechanism of Action1-3
11/19
ECCO₂R Circuit Integrated in a Continuous Renal Replacement Therapy Machine4
ECCO₂R circulates venous blood through a small artificial lung or membrane where CO₂ diffuses out of the blood into a controlled sweep gas flow, lowering PaCO₂ without significant oxygenation.
Because CO₂ is more soluble and removable at lower blood flow rates than oxygen, ECCO₂R systems operate with substantially lower extracorporeal blood flows than ECMO, typically in the range of a few hundred millilitres per minute (for low-flow ECCO2R) and focus primarily on CO2 clearance.
By reducing CO₂ burden extracorporeally, ECCO₂R allows the native lungs to be ventilated with lower Vt and pressures, decreasing ventilator stress and supporting ultra-protective ventilation strategies.
1. Combes A et al. Expert perspectives on ECCO2R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting. Ann Intensive Care. 2024;14:132. 2. Dianti J et al. Determinants of effect of extracorporeal CO2 removal in hypoxemic respiratory failure. NEJM Evid. 2023;2(5):EVIDoa2200295. 3. Ferrer Gomez C et al. Extracorporeal membrane oxygenation in acute respiratory distress syndrome: current evidence and future directions. J Pers Med. 2023;13:1081 4. Tiruvoipati R et al. Evaluation of the safety and efficacy of extracorporeal carbon dioxide removal in the critically ill using the PrismaLung+device. Eur J Med Res. 2023;28(1):291.
What concerns might you have with initiating ECCO₂R therapy?
No major concerns
Limited effectiveness in reducing PaCO2 and correcting respiratory acidosis
Membrane clotting
Bleeds
12/19
All three options represent recognised clinical concerns with ECCO₂R, including bleeding related to anticoagulation, circuit clotting, and variable effectiveness in reducing PaCO2 and correcting acidosis. Contemporary systems and protocols (including those described in published post-market clinical follow-up data and observational studies such as Cobetta et al., 20251) aim to mitigate these risks, but they remain important considerations in clinical decision‑making.1,2
A 2024 meta-analysis suggests that many historical complications of ECCO₂R were related to older pump technology rather than the concept itself. Earlier studies, such as REST and VENT-AVOID, predominantly used centrifugal pumps, whereas contemporary ECCO₂R systems use peristaltic pumps, which provide more stable flow, reduce shear stress, and are associated with fewer bleeding and clotting complications.3
Why older trials may not reflect current ECCO₂R
1. Cobeta P et al. Extracorporeal CO2 removal in severe respiratory acidotic intubated patients: a seven year experience observational study. Respir Med. 2025;240:108011.3. 2. Combes A et al. A prospective clinical evaluation of new ECCO2R technology in mild to moderate ARDS patients: assessing ultra-lung-protective ventilation with PRISMALUNG. Crit Care. 2026;30(1):15. 3. Barbič B et al. The failure of extracorporeal carbon dioxide removal may be a failure of technology. Am J Respir Crit Care Med. 2024;209(7):884-7.
13/19
There is no single universal protocol for starting ECCO₂R. Practice is guided by published protocols and expert consensus.
Tiruvoipati et al., 20231 Clinical criteria, timing of initiation, and ventilator adjustments during ECCO₂R.
In real‑world practice, clinical teams may draw on these publications, together with local expertise and institutional policies, to inform decisions regarding ECCO2R initiation, circuit settings, anticoagulation, and ventilator adjustments.
Konopasek et al., 20232 Stepwise approach to patient selection, anticoagulation, and circuit management.
Elmasry et al., 20253 Regional protocol describing indications, flow targets, and monitoring.
Selected initiation approaches:
Selected consensus guidance:
These publications include protocolised approaches from individual centers as well as consensus and expert opinion documents, reflecting variability in clinical practice.
2020 international consensus4 Definitions, indications, and safety considerations for ECCO₂R.
2022/2024 expert statements5 Practical recommendations on patient selection, ventilator strategy, and complications.
2025 consensus update6 Contemporary view on indications, monitoring, and integration with lung-protective ventilation.
1. Tiruvoipati R et al. Evaluation of the safety and efficacy of extracorporeal carbon dioxide removal in the critically ill using the PrismaLung+ device. Eur J Med Res. 2023;28(1):291. 2. Konopasek SM et al. Increased longevity of a novel gas exchanger system for low-flow veno-venous extracorporeal CO2 removal in acute hypercapnic respiratory failure. Blood Purif. 2023;52(3):275-84. 3. Elmasry D et al. Protocol-based implementation of combined extracorporeal carbon dioxide removal and continuous renal replacement therapy using the PrismaLung platform: a critical care innovation. J Anesth Crit Care Open Access. 2025;17(5):140-4. 4. Combes A et al. ECCO2R therapy in the ICU: consensus of a European round table meeting. Crit Care. 2020;24(1):490. 5. Combes A et al. Expert perspectives on ECCO2R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting. Ann Intensive Care. 2024;14(1):132. 6. Parrilla-Gómez FJ et al. The role of extracorporeal CO2 removal from pathophysiology to clinical applications with focus on potential combination with RRT: an expert opinion document. Front Med (Lausanne). 2025;12:1651213.
What ECCO₂R Set Up Looks Like at the Bedside1
14/19
Once a decision to start ECCO₂R is made, teams follow device-specific initiation settings to establish safe and effective extracorporeal CO₂ removal. Below are typical starting settings for an ECCO₂R system, which can be optimised to achieve suitable CO₂ clearance.
Actual ECCO2R settings vary depending on patient characteristics, clinical goals, and device configuration.
1. Elmasry D et al. Protocol-based implementation of combined extracorporeal carbon dioxide removal and continuous renal replacement therapy using the PrismaLung platform: a critical care innovation. J Anesth Crit Care Open Access. 2025;17(5):140-4.
Treatment Progressions and Patient Outcomes
15/19
pH: 7.36 PaCO₂: 48 mmHg PaO₂/FiO₂: 150
Reduce Vₜ to 4 mL/kg PBW Lower respiratory rate from 28 to 20 breaths/min Increase PEEP to 15 cmH₂O for oxygenation Monitor driving pressure (ΔP), aiming to keep values as low as clinically feasible (E.g. <14 cmH2O).
Ventilator adjustments post ECCO₂R:
In this illustrative case, the use of ECCO2R was associated with a transition to ultra-protective ventilation with lower tidal volume and respiratory rate, alongside improvement in PaCO2 and pH, while maintaining acceptable oxygenation.
ABG after 6 hours on ECCO₂R:
What is your weaning trigger for ECCO₂R?
All of the above considerations, assessed together in the clinical context
Reduced ventilatory requirements, with consistently lower driving pressure
Stable oxygenation without deterioration
Achievement of acceptable gas exchange (near-normal pH and improved PaCO2) with continued lung-protective ventilation
16/19
1. Parrilla-Gómez FJ et al. The role of extracorporeal CO2 removal from pathophysiology to clinical applications with focus on potential combination with RRT: an expert opinion document. Front Med (Lausanne). 2025;12:1651213 2. Combes A et al. ECCO2R therapy in the ICU: consensus of a European round table meeting. Crit Care. 2020;24(1):490.
All three criteria together indicate that the patient can maintain acceptable gas exchange and safe ventilator settings without extracorporeal support, making it appropriate to consider weaning ECCO₂R.1,2
Clinical Trajectory
17/19
Ventilator settings stable; ECCO₂R sweep gas gradually tapered.
This timeline reflects the clinical course of a single illustrative case and should not be interpreted as a typical or expected outcome.
ECCO₂R discontinued.
Extubated to high-flow nasal cannula.
Discharged from the ICU.
Day 3
Day 5
Day 7
Day 14
The patient demonstrated progressive improvement in gas exchange and ventilatory requirements, allowing stepwise liberation from extracorporeal support and mechanical ventilation.
Key Takeaways/Teaching Points
18/19
Current guidelines recommend LPV for patients with ARDS receiving invasive mechanical ventilation to reduce mortality and VILI. One important barrier to LPV is the development of acute hypercapnia and respiratory acidosis during low Vt ventilation. ECCO₂R can facilitate continued use of LPV or ultra-protective ventilation by enabling control of PaCO₂ without increasing ventilator pressures or volumes. In this illustrative case, the use of ECCO2R was associated with preservation of LPV while supporting gas exchange, without immediate escalation to ECMO.
Learning Resources
19/19
Combes A et al. A prospective clinical evaluation of new ECCO2R technology in mild to moderate ARDS patients: assessing ultra-lung-protective ventilation with PRISMALUNG. Crit Care. 2026;30(1):15. Cobeta P et al. Extracorporeal CO2 removal in severe respiratory acidotic intubated patients: a seven year experience observational study. Respir Med. 2025;240:108011.
Published protocols for ECCO₂R initiation
Tiruvoipati R et al. Evaluation of the safety and efficacy of extracorporeal carbon dioxide removal in the critically ill using the PrismaLung+ device. Eur J Med Res. 2023;28(1):291. Konopasek SM et al. Increased longevity of a novel gas exchanger system for low-flow veno-venous extracorporeal CO₂ removal in acute hypercapnic respiratory failure. Blood Purif. 2023;52(3):275-84. Elmasry D et al. Protocol-based implementation of combined extracorporeal carbon dioxide removal and continuous renal replacement therapy using the PrismaLung platform: a critical care innovation. J Anesth Crit Care Open Access. 2025;17(5):140-4.
Combes A et al. ECCO₂R therapy in the ICU: consensus of a European round table meeting. Crit Care. 2020;24(1):490. Combes A et al. Expert perspectives on ECCO₂R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting. Ann Intensive Care. 2024;14(1):132. Parrilla-Gómez FJ et al. The role of extracorporeal CO₂ removal from pathophysiology to clinical applications with focus on potential combination with RRT: an expert opinion document. Front Med (Lausanne). 2025;12:1651213.
