<qa>  What is the potential solution for tidal volume reduction to less than 6mlExtracorporeal carbon dioxide removal ECCO2R in association with mechanical ventilation offers a potentially attractive solution to permit tidal volume reduction to less than 6mlkg PBW and to achieve low plateau pressures 25cmH2O. Using these extracorporeal circuits, carbon dioxide can be dialysed out of the blood while the lungs are ventilated in a more protective manner. In recent years, more efficient veno-venous devices have become available. These have replaced arterio-venous devices and have the advantage of not requiring arterial puncture. These can achieve carbon dioxide removal with relatively low extracorporeal blood flows 0.41 lmin requiring only a smaller dual lumen venous catheter. In addition these ECCO2R devices use more biocompatible materials making the device more resistant to clot formation and cause less platelet and clotting factor consumption. Therefore only minimal systemic anticoagulation is required which reduces the likelihood of bleeding complications. These devices are now comparable to renal dialysis equipment, which is routinely used safely as standard care in ICUs in the United Kingdom. 