Rozencwajg S, Guihot A, Franchineau G, et al. - In view of the current arbitrarily set ventilator settings for patients with severe acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation, researchers undertook this randomized clinical trial to determine the influence on serum and pulmonary biotrauma markers of the transition to ultra-protective ventilation settings after extracorporeal membrane oxygenation implantation, as well as various mechanical ventilation strategies while on extracorporeal membrane oxygenation. They found that ECMO enabled ultra- protective ventilation, which integrates significantly lower plateau pressure, tidal volume, and driving pressure. A significant limitation of pulmonary biotrauma was achieved with this ventilation strategy, ultimately attenuating ventilator-induced lung injury. However, they could not determine the optimal ultra-protective ventilation strategy once ECMO is started.