question: Coronavirus disease 2019 (COVID-19) was identified as causing an unusual pneumonia in Wuhan in late 2019 and rapidly evolved to a pandemic We present a case of an otherwise well 55-year-old female patient who had seemingly mild symptoms when she presented to the emergency department, and then rapidly deteriorated with progressive ventilatory deficit requiring intubation, ventilation, and extracorporeal membrane oxygenation (ECMO) We present the surprise finding of haemorrhagic endobronchial casts in the airways causing a complete ventilatory failure, managed by cryobiopsy and argon plasma coagulation (APC) leading to improved ventilation To our knowledge, this is the only patient placed on ECMO for COVID-19 infection in Australia and we would like to highlight the complications and challenges when trying to manage pulmonary haemorrhagic casts whilst on ECMO