Recent Advances and Future Directions in Extracorporeal Carbon Dioxide Removal.

Extracorporeal carbon dioxide removal (ECCO2R) is an emerging technique designed to reduce carbon dioxide (CO2) levels in venous blood while enabling lung-protective ventilation or alleviating the work of breathing. Unlike high-flow extracorporeal membrane oxygenation (ECMO), ECCO2R operates at lower blood flows (0.4-1.5 L/min), making it less invasive, with smaller cannulas and simpler devices. Despite encouraging results in controlling respiratory acidosis, its broader adoption is hindered by complications, including haemolysis, thrombosis, and bleeding. Technological advances, including enhanced membrane design, gas exchange efficiency, and anticoagulation strategies, are essential to improving safety and efficacy. Innovations such as wearable prototypes that adapt CO2 removal to patient activity and catheter-based systems for lower blood flow are expanding the potential applications of ECCO2R, including as a bridge-to-lung transplantation and in outpatient settings. Promising experimental approaches include respiratory dialysis, carbonic anhydrase-coated membranes, and electrodialysis to maximise CO2 removal. Further research is needed to optimise device performance, develop cost-effective systems, and establish standardised protocols for safe clinical implementation. As the technology matures, integration with artificial intelligence (AI) and machine learning may personalise therapy, improving outcomes. Ongoing clinical trials will be pivotal in addressing these challenges, ultimately enhancing the role of ECCO2R in critical care and its accessibility across healthcare settings.