Beginning August 2009, the Italian Ministry of Health and the Tuscany Ministry of Health issued instructions to identify and establish referral centers able to care for the more severely ill influenza patients. Therefore, several referral centers were identified throughout the national territory among the hospitals already experienced in extracorporeal respiratory support techniques. The referral ECMO centres, in addition to being capable of guaranteeing the most advanced treatment in influenza related respiratory failure, were also entrusted with providing support to the nearby hospitals and assuring safe transportation.