 Pathophysiological, experimental and clinical data suggest that an ultraprotective mechanical ventilation strategy may further reduce VILI and ARDS-associated morbidity and mortality. Severe hypercapnia induced by VT reduction in this setting might be efficiently controlled by ECCO2R devices. A proof-of-concept study conducted on a limited number of ARDS cases indicated that ECCO2R allowing VT reduction to 3.5-5 mlkg to achieve Pplat25 cm H2O may further reduce VILI. 