The EOLIA trial compared early venovenous extracorporeal membrane oxygenation with conventional management in adults with very severe ARDS. Patients randomised to ECMO were transferred to experienced centres and received extracorporeal support when predefined criteria were met, while the control group received modern conventional therapy including lung-protective ventilation and, in most patients, prone positioning. The trial did not show a statistically significant reduction in 60-day mortality with ECMO. Nevertheless, crossover from the control group to ECMO occurred, and the mortality difference favoured ECMO, contributing to continued debate about its use as rescue therapy. The clinical lesson is that ECMO should not be viewed as a simple “next step” after conventional ventilation fails. Outcomes depend heavily on timing, patient selection, experienced teams and the quality of pre-ECMO management. EOLIA also underscores the importance of applying lung-protective ventilation and prone positioning before declaring conventional therapy unsuccessful. In selected patients with refractory, potentially reversible respiratory failure, ECMO remains a valuable rescue option, but the evidence does not support routine early use for every patient with severe ARDS. The trial therefore supports a centre-expertise and phenotype-based approach to ECMO referral rather than a single universal threshold.