For patients with severe acute respiratory distress syndrome techniques of extracorporeal lung support have been established thirty years ago. In the beginning of such a strategy a roller-pump-driven veno-venous extracorporeal membrane oxygenation (ECMO) was used, which was characterized by high complication rate. Meanwhile the development of a miniaturized ECMO using centrifugal pumps might have improved the safety of use. Recently a pumpless arterio-venous interventional lung assist (iLA) was introduced. While ECMO enables a complete extrapulmonary gas exchange, iLA provides effective CO(2)-elimination. In this review, technical basements, results from clinical studies, incidence of complications and algorithms for clinical use of extracorporeal lung support systems are discussed.