NIV has some theoretical advantages in IPF patients and has been used extensively in cases of acute respiratory failure to avoid intubation. Unfortunately, the studies about its use have the same methodological problems as those for the invasive ventilation studies mentioned previously, and no fi rm conclusions can be drawn. Th ere are two things that make NIV more 'attractive' in this setting: the almost absolute mortality that invasive mechanical ventilation carries and the avoidance of intubation and ventilation risks (aspiration, ventilator-associated pneumonia, and ventilatorassociated injury). Th e problem is that in most cases the excessive work of breathing associated with IPF exacerbation cannot be managed eff ectively by NIV. Extracorporeal membrane oxygenation could represent a valuable adjunct to conventional treatment for selected cases of IPF. Limited availability, high cost, complicated technology, and increased rates of complications have been the most important factors limiting its use so far [71] [72] [73] . In the setting of IPF therapeutics, it has been used mainly as a bridge to transplantation [74] . Transplantation represents the fi nal line of defense for the IPF patient and is the only therapy with a proven survival benefi t. Early referral (even at the time of diagnosis) to a lung transplant center is mandatory [75] because of the prolonged waiting-list time, which sometimes exceeds the patient's life expectancy.