As a result of technical improvements, extracorporeal carbon dioxide removal (ECCO 2 R) now has the potential to play an important role in the management of adults with acute respiratory failure. There is growing interest in the use of ECCO 2 R for the management of both hypoxaemic and hypercapnic respiratory failure. However, evidence to support its use is scarce and several questions remain about the best way to implement this therapy, which can be associated with serious side-effects. This Review reflects the consensus opinion of an international group of clinician scientists with expertise in managing acute respiratory failure and in using ECCO 2 R therapies in this setting. We concisely review clinically relevant aspects of ECCO 2 R, and provide a series of recommendations for clinical practice and future research, covering topics that include the practicalities of ECCO 2 R delivery, indications for use, and service delivery.