Role and potentials of low-flow CO2 removal system in mechanical ventilation

Purpose of review An analysis of the technological implementation of extracorporeal CO2 removal (ECCO2R) techniques and of its clinical application. A new classification of ECCO2R, based on technological aspects, clinical properties and physiological performance, is proposed. Recent findings The use of a ventilation with lower tidal volumes has been proved successful in acute respiratory distress syndrome (ARDS) patients but can be extremely problematic, especially when dealing with respiratory acidosis. The implementation of ECCO2R devices can represent the missing link between the prevention of ventilator-induced lung injury and pH control. ECCO2R has attracted increasing interest because of new less-invasive approaches allowing an easier management of ARDS patients. Recent studies have also shown that ECCO2R can also be used in patients with exacerbation of chronic obstructive pulmonary disease (COPD) and as a bridge to lung transplantation. Summary The future ventilatory management of patients with acute respiratory failure may include a minimally invasive extracorporeal carbon dioxide removal circuit associated with the least amount of ventilatory support (noninvasive in COPD and/or invasive in ARDS) to minimize sedation, prevent ventilator-induced acute lung injury and nosocomial infections. Randomized clinical trials in the pipeline will confirm this fascinating hypothesis.