Acute respiratory distress syndrome is a common cause of morbidity and
mortality in intensive care units. For the most part, the mortality o
f this syndrome has arguably not decreased since the syndrome was orig
inally described. One of the major reasons for this lack of reduction
in mortality may be related to adherence to more traditional ventilato
ry strategies that have the potential to cause ventilator-induced lung
injury. Ventilator strategies that attempt to limit ventilator-induce
d lung injury and accept permissive hypercapnia have successfully demo
nstrated a marked reduction in mortality in uncontrolled settings. So
encouraging are these reductions that there has been a subtle shift in
philosophy of mechanical ventilation toward using lung-protective ven
tilatory strategies at all times. With broad acceptance of this shift
in philosophy, and the use of recently standardized clinical definitio
ns for controlled studies, we optimistically anticipate improved morta
lity rates for acute respiratory distress syndrome.