Aims : To describe invasive mechanical respiratory support, including mechanical ventilation and/or extracorporeal life support (ECLS), that has become common practice in patients with acute cardiopulmonary failure or for bridging to lung transplantation; to describe technical and ethical challenges associated with ECLS; to evaluate technical expertise, knowledge of candidate selection, transplant referral guidelines and organ allocation systems crucial to achieve acceptable results in patients on ECLS; and to describe the aims, indications, contra-indications, principles and complications of ECLS.