Ventilatory management of patients with acute respiratory distress syndrome and optimization of lung mechanics.

Acute respiratory distress syndrome (ARDS) is a form of acute lung injury characterized by increased alveolar-capillary permeability and non-cardiogenic pulmonary edema. Mechanical ventilation remains the cornerstone of supportive care, but ventilatory support itself can worsen lung injury. Current guidelines recommend focusing on minimizing ventilator-induced lung injury through volume and pressure limitation (lung-protective ventilation). In selected patients, noninvasive strategies such as high-flow nasal cannula and noninvasive ventilation may prevent intubation. For patients requiring invasive ventilation, lung-protective ventilation (low tidal volume, limitation of plateau and driving pressures, positive end-expiratory pressure titration), prone position, and judicious use of neuromuscular blockade improves outcomes in moderate and severe ARDS. Advanced bedside monitoring tools, including esophageal pressure manometry, electrical impedance tomography, computed tomography, and lung ultrasound, have been proposed in the literature to monitor respiratory mechanics, regional ventilation, and recruitability, enabling clinicians to tailor ventilatory strategies to individual physiology.