In acute exacerbations of COPD with acute hypercapnic respiratory failure and a pH 7.25 - 7.35, the initiation of non-invasive ventilation is the gold standard. However, absolute and relative contraindications have to be taken into account. The implementation of non-invasive ventilation in case of a severe respiratory acidosis necessitates a skilled therapeutic team and a close monitoring in order to avoid or perceive a NIV failure in time. In this case, the intubation and invasive mechanical ventilation is recommended. Ventilator settings have to aim at the prevention of an overinflation and increase of intrinsic PEEP. If severe hypercapnia and respiratory acidosis cannot be managed by mechanical ventilation, extracorporeal CO2 removal (ECCO2R) is a new treatment option. There are some reports about its use in awake patients in order to avoid an intubation. However, its general and primary use without optimizing medical therapy and mechanical ventilation is not indicated. ECCO2R is an experimental therapy in COPD with acute hypercapnic respiratory failure, its significance is still ambiguous. Therefore, it should only be applied in individual situations by a specialist team trained in its use.
