 Extracorporeal carbon dioxide removal ECCO2R may be used in association with mechanical ventilation to permit VT reduction to 6 mlkg and to achieve very low Pplat 20-25 cm H2O. In an observational study conducted in the 80s, Gattinoni showed that use of venovenous ECCO2R at a flow of 1.5-2.5 lmin in addition to quasi apneic mechanical ventilation with peak inspiratory pressures limited to 35-45 cmH2O and PEEP set at 15-25 cmH2O resulted in lower than expected mortality in an observational cohort of severe ARDS patients. However, a randomized, controlled single-center study using that same technology and conducted in the 1990s by Morriss group in Utah was stopped early for futility after only 40 patients had been enrolled and failed to demonstrate a mortality benefit with this device 58 in the control group vs. 70 in the treatment group. 