‘Lung-protective’ ventilation in acute respiratory distress syndrome: still a challenge?

The acute respiratory distress syndrome (ARDS) is a major cause of morbidity and mortality in the intensive care unit (ICU) (1). It is a life-threating condition characterized by widespread inflammation of the lungs, leading to diffuse injury to alveolar cells, surfactant dysfunction, abnormal coagulation and activation of the immune response (2). Clinically, ARDS presents as a respiratory failure with bilateral opacities on chest imaging, hypoxemia and absence of signs of heart failure or volume overload (3). Usually, patients presenting to the ICU with ARDS are treated with mechanical ventilation and supportive therapies, since ARDS is not a particular disease, rather it is a clinical phenotype which may be triggered by various pathologies.