**Abstract**

Extracorporeal membrane oxygenation (ECMO) has clear benefits in patients with acute cardiopulmonary failure. However, selecting patients who will benefit from extracorporeal membrane oxygenation can be a challenge and remains a hurdle for clinicians today. An increased concern when considering ECMO therapy is whether the patient will recover enough function and be able to be weaned from ECMO support and survive to discharge or undergo lung transplantation and specially on whether to extend extracorporeal membrane oxygenation as a bridge to recovery in those with concerns of a meaningful recovery or as a bridge-to-decision (BTD) for patients whose criteria for lung transplantation are unknown. In addition, ECMO is a resource-intensive form of lung support that requires significant institutional commitment and a well-trained team to ensure good outcomes. The critical factors in the decision-making process when there are concerns regarding the initiation, continuation, or withdrawal of ECMO include early transfer to a specialized lung transplant center and a multidisciplinary consensus among lung transplant pulmonologists, lung transplant surgeons, and ECMO critical care intensivists to expedited transplant evaluation and to clearly defined the goals of care and selecting the appropriate candidates who will benefit from ECMO as a BTD for patients not listed yet for lung transplantation.

**Keywords:** ECMO, lung transplantation, indications, timing, patient selection, outcomes
