The role of extracorporeal membrane oxygenation (ECMO) in the management of severe acute respiratory failure, including the acute respiratory distress syndrome, has become better defined in recent years in light of emerging high-quality evidence and technological advances. Utilization of ECMO has consequently increased throughout many parts of the world. The coronavirus disease 2019 (COVID-19) pandemic, however, has highlighted deficiencies in organizational capacity, research capability, knowledge sharing and resource utilization. While governments, medical societies, hospital systems and clinicians were collectively unprepared for the scope of this pandemic, the use of ECMO – a highly resource-intensive and specialized form of life support – presented specific logistical and ethical challenges. As the pandemic has evolved, there has been greater collaboration in the use of ECMO across centers and regions, along with more robust data-reporting through international registries and observational studies. Nevertheless, centralization of ECMO capacity is lacking in many regions of the world and equitable use of ECMO resources remains uneven. There are no widely available mechanisms to conduct large-scale, rigorous clinical trials in real-time. In this Critical Care Perspective, we outline lessons learned during COVID-19 and prior respiratory pandemics in which ECMO was used, and how we might apply these lessons going forward both during the ongoing COVID-19 pandemic as well as in the future.