Luis Alexander Peña-López, Guillermo Ortiz-Ruiz, Manuel Garay-Fernández, Henry Mauricio Parada-Gereda, David Ballesteros-Castro, Gonzalo Ramírez-Guerrero
• ECCO₂R enables ultraprotective ventilation by safely reducing tidal volume and driving pressure in ARDS. • Appropriate patient selection based on respiratory mechanics, hypercapnia, and ventilatory inefficiency is essential. • Integration of ECCO₂R requires protocolised monitoring across ventilatory, hemodynamic, renal, and hematologic domains. • ECCO₂R should be considered after lung-protective strategies, including prone positioning and PEEP titration, are exhausted. • ECCO₂R is not a substitute for ECMO; its role in ARDS is to enable ultraprotective ventilation.