In some cases of severe acute respiratory distress syndrome, hypoxemia occurs despite optimized conservative therapy; however, extracorporeal membrane oxygenation (ECMO) can assure sufficient gas exchange. To increase safety and reliability of devices, the oxygenator design was optimized integrating new plasma-resistant composite membranes and new blood pumps are used with longer durability and reduced blood cell damage. Another approach is the use of an arterio-venous pumpless extracorporeal lung assist (pECLA) using an oxygenator with reduced pressure drop to simplify management and to avoid pump-related complications. First attempts were made to integrate basic control and safety concepts in ECMO circuits, but this does not seem to be sufficient to overcome the specific problems of ECMO (long-term use and limited supervision of the intensive care unit). The integration of sophisticated automated control and safety concepts in combination with revised ECMO circuits could allow a more reliable application of ECMO of the intensive care unit without continuous observation by a perfusionist. Easier intra- and interhospital transfer of patients with running ECMO would be another advantage.