OBJECTIVES: To present the clinical outcome of a newborn with severe respiratory distress secondary to meconium aspiration syndrome and treated by extracorporeal membrane oxygenation (ECMO); and to present the effect of the use of exogenous surfactant in this case and the cost of the procedure. METHODS: Case report of a newborn with meconium aspiration syndrome and treated at the neonatal ICU of the Instituto da Criança Prof. Pedro de Alcantara, Hospital das Clínicas of the Universidade de São Paulo. RRESULTS: ECMO was carried out for 5 days with no clinical or mechanical complications. On the 4th day of ECMO, we administered porcine exogenous surfactant; a significant improvement in lung compliance was observed and the newborn was decannulated shortly after that. Treatment costs were compatible with the situation of healthcare in Brazil for treatment of critically ill newborn patients. CONCLUSIONS: ECMO is indicated in cases of neonatal respiratory distress not responding to other treatments. The technique should be made available in neonatal Intensive Care Units (ICUs) of tertiary hospitals according to well-established protocols. The use of exogenous surfactant apparently allowed for earlier decannulation of the patient and should be considered in similar cases. The treatment costs do justify the organizing of ECMO teams in this type of ICUs.