Revisiting Acute Respiratory Distress Syndrome ventilation management: Time for a paradigm shift focusing on tidal volume

Acute Respiratory Distress Syndrome (ARDS) remains a critical challenge in intensive care medicine, with persistently high mortality despite decades of research and advancements in supportive therapies. Mechanical ventilation, particularly low tidal volume (VT) strategies, has become the cornerstone of ARDS management; however, emerging evidence suggests that a uniform application of these approaches may not be universally beneficial. This viewpoint critically examines the evolution of ARDS ventilation strategies, from high VT methods to protective ventilation protocols centered on reduced VT and plateau pressures. It explores the limitations of current guidelines, highlighting how global parameters such as VT and driving pressure (ΔP) may inadequately capture the complex and heterogeneous pathophysiology of ARDS. Concepts like mechanical power, compliance-based ventilation, and transpulmonary pressure offer promising avenues for more personalized care but remain underutilized in clinical practice. Additionally, this viewpoint underscores the significance of heart-lung interactions and the impact of ventilator settings on cardiovascular function, further complicating one-size-fits-all approaches. Ultimately, this work calls for a reassessment of existing paradigms, advocating for individualized, physiology-driven strategies that move beyond population-based protocols to better address the nuanced needs of ARDS patients.