In The Lancet Respiratory Medicine, Kollengode Ramanathan and colleagues provide excellent recommendations for the use of extracorporeal membrane oxygenation (ECMO) for patients with respiratory failure from acute respiratory distress syndrome (ARDS) 2ary to coronavirus disease 2019 (COVID-19). The authors describe pragmatic approaches to the challenges of delivering ECMO to patients with COVID-19, including training health-care personnel, resolving equipment and facilities issues, implementing systems for infection control and personal protection, providing overall support for health-care staff, and mitigating ethical issues. They also address some of the anticipated challenges with local and regional surges in COVID-19 ARDS cases; although there has been an increase in hospitals with the capacity to provide ECMO, the potential demand might exceed the available resources. Furthermore, some health-care systems offer advanced therapies such as ECMO but lack a coordinated local, regional, or national referral protocol.

Given the practical constraints on substantially increasing the global availability of ECMO services in the next few months, it is important to emphasise the other evidence-based treatment options that can be provided for patients with severe ARDS from COVID-19. Before endotracheal intubation, it is important to consider a trial of high-flow nasal oxygen for patients with moderately severe hypoxemia. This procedure might avoid the need for intubation and mechanical ventilation because it provides high concentrations of humidified oxygen, low levels of positive end-expiratory pressure, and can facilitate the elimination of carbon dioxide. WHO guidelines support the use of high-flow nasal oxygen in some patients, but they urge close monitoring for clinical deterioration that could result in the need for emergent intubations because such procedures might increase the risk of infection to health-care workers.

Since treatment of severe ARDS from COVID-19 is an ongoing challenge, it is important to learn from the patients who have been treated to gain an understanding of the disease's epidemiology, biological mechanisms, and the effects of new pharmacological interventions. Currently, there are some research groups working to coordinate and disseminate key information, including information on patients who have been treated with ECMO for COVID-19, although an accurate estimate of the number of such patients is not currently available. The Extracorporeal Life Support Organization is an international non-profit consortium that plans to maintain a registry of patients to facilitate an improved understanding of how ECMO is being used for patients with COVID-19.