Objective: To review the principles of extracorporeal membrane oxygenation (ECMO) and to describe the recent advancements in ECMO technology that permit use of this rescue therapy for severe lung injury in combat casualties. Methods/Results: Lung protective ventilation has defined the state-of-the-art treatment for acute lung injury for more than a decade. Despite the benefits provided by a low tidal volume strategy, lung injury patients may experience deterioration in gas exchange to the point that other rescue interventions are needed or the patient succumbs to progressive respiratory failure. When this occurs in combat casualties, management of the patient in an austere environment and movement to definitive care become problematic. Recent advances in ECMO technology permit long-range transport of these critically ill casualties with greater physiologic reserve and potentially less mortality. Conclusions: Advances in ECMO technology now enable the stabilization and aeromedical evacuation of even the most critically ill combat casualties with severe lung injury.