The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Extracorporeal membrane carbon dioxide removal.

This document replaces previous guidance on Arterio–venous extracorporeal membrane carbondioxide removal (NICE interventional procedure guidance 250, January 2008).


Extracorporeal membrane carbon dioxide removal (ECCO2R) is a  treatment for patients with severe acute respiratory failure usually used together with mechanical ventilation. Severe acute respiratory failure can result from a number of different disease processes.  A common type is associated with acute respiratory distress syndrome (ARDS), which may be caused by sepsis, pneumonia or chest trauma.

Patients with severe acute respiratory failure are conventionally treated by mechanical ventilation. However, in some patients gas exchange is not good enough at maximal tolerable ventilation pressures. If this is the case, extracorporeal membrane gas exchange systems can be used. They include extracorporeal membrane oxygenation (ECMO) and ECCO2R.

ECMO  systems   use a high rate of extracorporeal flow (using a large fraction of cardiac output) to achieve almost complete oxygenation as well as carbon dioxide removal. ECMO systems therefore always require a pump.

ECCO2R systems remove CO2 from the blood, but oxygenation is limited. Because only a small percentage of cardiac output is treated, complete pulmonary support is not possible, unlike ECMO. In arteriovenous ECCO2R blood flow is maintained by the patient’s own blood pressure rather than a pump. Arteriovenous ECCO2R is associated with a risk of poor limb perfusion. There may also be inadequate flow in patients with low cardiac output. For these reasons, venovenous ECCO2R systems have been developed that use a low-flow pump.

In some patients, ventilation parameters such as inspired oxygen concentration, tidal volume, and peak and end-expiratory pressures can be reduced after starting ECCO2R. This contributes to a reduced risk of ventilation-induced lung injury.

Patients may be treated with ECCO2R support for up to several weeks, depending on clinical need.

Coding recommendations

X58.8 Other specified artificial support for body system

Y73.2 Extracorporeal circulation NEC