ARDS management beyond the guidelines: a practical physiology-based approach to individualized care

Practice guidelines for acute respiratory distress syndrome (ARDS) have established lung-protective ventilation as the standard of care, but optimized management requires further individualization to each patient's specific physiological characteristics and response to treatment. Beyond guidelines-level targets, clinicians must answer numerous practical bedside questions from how to start ventilating a newly intubated patient, to what to do when the driving pressure target is not met, and how to assess recruitability and set positive end expiratory pressure (PEEP). Integrating ventilator management with gas exchange and hemodynamic targets requires further careful consideration. Managing sedation to the patient's respiratory drive and effort, and its crucial role during the transition from controlled to assisted ventilation, poses additional complexity. This narrative review addresses these questions through recent physiological advances and translates them into practical strategies that inform decisions at bedside.