Extracorporeal Carbon Dioxide Removal Combined With Inhaled Nitric Oxide for Hypercapnic Acute Respiratory Distress Syndrome With Active Airway Hemorrhage: A Case Report

Low-flow extracorporeal carbon dioxide removal (ECCO ₂ R) may be useful when severe hypercapnia limits ultra-protective ventilation but full venovenous extracorporeal membrane oxygenation (VV-ECMO) is not pursued. We describe a 68 year old man with metastatic lung adenocarcinoma who developed amivantamab-associated immune-related interstitial lung disease complicated by acute respiratory distress syndrome (ARDS) and active airway hemorrhage. After endotracheal intubation, the dominant physiologic problem was hypercapnic acidosis (pH 7.12; PaCO ₂ 83.4 mm Hg) with very poor respiratory system compliance, whereas oxygenation impairment was moderate (PaO ₂ /FiO ₂ 160 mm Hg). Because of terminal malignancy and the burden of large-bore cannulation, VV-ECMO was not pursued. Electrical impedance tomography showed no benefit from prone positioning. A hybrid strategy was then initiated: inhaled nitric oxide to improve ventilation-perfusion (V/Q) matching and ECCO ₂ R to control carbon dioxide clearance. Within 2 hours, PaCO ₂ fell to 60.7 mm Hg and pH rose to 7.32; oxygenation also improved. The circuit remained functional for 13 days without recurrent airway bleeding or documented circuit thrombosis. This case illustrates the feasibility of concurrently applying inhaled nitric oxide and low-flow ECCO ₂ R as a physiology-guided, low-intensity rescue approach in a highly selected patient when VV-ECMO was not pursued.