OBJECTIVE To examine the role of extracorporeal membrane oxygenation (ECMO) as potential therapeutic option for severe cases of acute respiratory distress syndrome (ARDS). RESULTS The use of ECMO to treat acute respiratory failure dramatically increased. Factors that may explain this increase in the use of ECMO are H1N1 pandemic influenza, results of recent clinical trials and not lastly the technological development and consequently the commercial pressure of the industry. Under these circumstances, clinicians urgently need clinical trials and formal indication, contraindication and rules for implementation to provide reproducible results. CONCLUSIONS Guidelines from the Extracorporeal Life Support Organization still indicate ECMO for acute severe pulmonary failure potentially reversible and unresponsive to conventional management. The new definition of ARDS (Berlin definition) addresses clinicians to the best treatment options in respect of the severity of illness and allocates ECMO as a potential therapeutic option for patients with severe ARDS and a P/F ratio lower than 100 and proposed that the indication of ECMO may be shifted from the treatment of choice for refractory hypoxemia to the treatment of choice to minimize ventilator-induced lung injury.