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Background  With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO 2  removal (ECCO 2 R). However, current evidence in these indications is limited. A European ECCO 2 R Expert Round Table Meeting was convened to further explore the potential for this treatment approach.    Methods  A modified Delphi-based method was used to collate European experts’ views to better understand how ECCO 2 R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus.    Results  Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO 2 R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO 2 R therapy ( n  = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO 2 R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO 2  levels. Driving pressure (≥ 14 cmH 2 O) followed by plateau pressure ( P  plat ; ≥ 25 cmH 2 O) was considered the most important criteria for ECCO 2 R initiation. Key treatment targets for patients with ARDS undergoing ECCO 2 R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH 2 O) and  P  plat  (< 25 cmH 2 O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO 2  and no decrease in respiratory rate were key criteria for initiating ECCO 2 R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30–7.35), respiratory rate (< 20–25 breaths/min), decrease of PaCO 2  (by 10–20%), weaning from NIV, decrease in HCO 3  −  and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group.    Conclusions  Insights from this group of experienced physicians suggest that ECCO 2 R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.

ECCO2R therapy in the ICU: consensus of a European round table meeting