**Abstract**

The state of knowledge regarding the adverse effects of mechanical ventilation in severe acute respiratory distress syndrome (ARDS) will be reviewed along with the benefits and limitations of lung protective ventilation strategies such as low tidal volume ventilation, prone positioning, and neuromuscular blockade. The potential for the use of ECMO as an ARDS-specific lung protective strategy, particularly as technology and experience at major medical centers advances, will be discussed. Experiences with the use of ECMO for ARDS during the COVID pandemic will be highlighted. Current accepted indications for ECMO in ARDS, based on published guidelines and trial data, will be examined. Finally, predictions about future directions for research in this area will be offered.

**Keywords:** acute respiratory distress syndrome, refractory hypoxemia, hypoxia, respiratory failure, hypoxic respiratory failure, extracorporeal membrane oxygenation, mechanical ventilation
