In the following days, gas exchange deteriorated and PEEP levels rose to 17cmH 2 O. Recruitment manoeuvres, prone positioning, and high doses of inhaled nitric oxide (NOi) were necessary to maintain viable gas exchange. Endotracheal instillation of porcine surfactant and a trial with High Frequency Oscillation were ineffective. On day 10, owing to the refractory hypoxia, worsening hypercapnia, and chest X-ray evidence of a pneumomediastinum, the patient was placed on venous-venous extracorporeal membrane oxygenation (ECMO) (Figure 3) . A double lumen 15 french catheter (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) was inserted into the right internal jugular vein. The ECMO circuit consisted of a polymethylpentene membrane oxygenator, permanent life support and a centrifugal Rotaflow pump (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany). ECMO was started with a blood flow of 0.8 to 0.9 L/minute and gas flow of 1 L/minute of 100% oxygen. Following the institution of ECMO, respiratory rate decreased from 45 to 10 breaths/minute, and it was possible to stop NOi.