Extracorporeal membrane oxygenation (ECMO) is a recognized and accepted therapeutic option in the treatment of neonatal and pediatric respiratory failure. However, early studies in adults did not demonstrate a survival benefit associated with the utilization of ECMO for severe acute respiratory failure. Despite this historical lack of benefit, use of ECMO in adult patients has seen a recent resurgence. Local successes and a recently published randomized trial have both demonstrated promising results in an adult population with high baseline mortality and limited therapeutic options. This article will review the history of ECMO use for respiratory failure; investigate the driving forces behind the latest surge in interest in ECMO for adults with refractory severe acute respiratory failure; and describe potential applications of ECMO that will likely increase in the near future.