In this issue of the Journal, Barbaro and colleagues (pp. 1177- 1186) begin to shed more light on the role of ECMO in pediatric acute respiratory distress syndrome (ARDS) (6). Using existing data collected from the multicenter RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) randomized controlled trial (7), the authors examined the effect of ECMO on mortality, ventilator-free and hospital days, and cerebral functional status at hospital discharge. ECMO-supported patients who developed severe ARDS also had a higher admission risk of mortality, a higher number of organ system failures, and higher use of high-frequency oscillation ventilation than non-ECMO-supported patients who developed severe ARDS. ...with only 61 ECMO-supported patients, the study was not sufficiently powered to detect small differences in mortality that might be considered clinically significant. ...we agree with Barbaro and colleagues that a rigorously performed randomized controlled clinical trial of ECMO in severe pediatric ARDS should be performed, but the results they report suggest that such a trial is likely infeasible.