Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has become an integral part in the rescue therapy of severe acute respiratory distress syndrome (ARDS) and may be lifesaving in patients with refractory hypoxemia [1]. Ventilator-induced lung injury, ventilatoracquired pneumonia and ventilator-induced diaphragm dysfunction are severe side effects of invasive ventilation and may contribute to the complex pathophysiology of multi-organ failure and death in ARDS [2]. The use of ECMO in patients who are awake and spontaneously breathing (termed awake ECMO) might avoid side effects and complications associated with sedation, intubation and invasive mechanical ventilation [3]. Our group reported the first successful use of awake ECMO in six ARDS patients several years ago [4]. We then concluded that the concept of an awake ECMO strategy as a potential alternative to intubation deserves further evaluation especially in patients with higher mortality following traditional invasive ventilation and ECMO support.