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Severe persistent air leak is a recognised indication for veno-venous extracorporeal membrane oxygenation (VV ECMO). This case study reports on a toddler-aged girl who presented with respiratory failure, necessitating intubation. The patient subsequently developed bilateral pneumothoraces, pneumomediastinum and pneumoperitoneum, which severely compromised her ability to be oxygenated and ventilated. Despite timely interventions to drain these air leaks, the patient developed progressive subcutaneous emphysema and continued respiratory failure. This situation required the initiation of VV ECMO support via percutaneous cannulation and the cessation of positive pressure ventilation. Invasive mechanical ventilation was recommenced after 2 days, and the patient underwent successful decannulation and extubation on the 4th and 6th days, respectively. This case highlights the following: the beneficial role of early initiation of VV ECMO in cases of severe air leak, the time required for atraumatic air leaks to seal and the favourable prognosis for this demographic of young paediatric patients.