BackgroundThe use of extracorporeal carbon dioxide removal (ECCO2R) is less invasive than extracorporeal membrane oxygenation (ECMO), and intraoperative control of gas exchange could be feasible. The aim of this study in intermediate intraoperative severity patients undergoing LT was to assess the role of intraoperative ECCO2R on emergency ECMO requirement in patients.MethodsThirty-eight consecutive patients undergoing lung transplantation (LT) with “intermediate” intraoperative severity in the intervals 2007 to 2010 or 2011 to 2014 were analyzed as historical comparison of case-matched cohort retrospective study. The “intermediate” intraoperative severity was defined as the development of intraoperative severe respiratory acidosis with maintained oxygenation function (i.e., pH <7.25, PaCO2>60 mmHg, and PaO2/FiO2>150), not associated with hemodynamic instability. Of these 38 patients, twenty-three patients were treated in the 2007–2010 interval by receiving “standard intraoperative treatment,” while 15 patients were treated in the 2011–2014 interval by receiving “standard intraoperative treatment + ECCO2R.”ResultsECMO requirement was more frequent among patients that received “standard intraoperative treatment” alone than in those treated with “standard intraoperative treatment + ECCO2R” (17/23 vs. 3/15;p= 0.004). The use of ECCO2R improved pH and PaCO2while mean pulmonary artery pressure (mPAP) decreased.ConclusionIn intermediate intraoperative severity patients, the use of ECCO2R reduces the ECMO requirement.