Extracorporeal Life Support (ECLS), including venovenous (VV) extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R) is a temporary support option for patients with severe respiratory failure. Current data and recent guidelines support the use of VV ECMO for select patients with very severe respiratory failure as this technique might improve survival in appropriately selected patients. Patient selection criteria, timing of ECMO initiation and optimal management of mechanical ventilation and anticoagulation, and other adjunctive treatment options are a matter of ongoing research.