Firmer footing for ventilating and monitoring the injured lung

The acute respiratory distress syndrome (ARDS) is widely considered the signature problem of critical care. From the outset, it was understood not to be a lung disease but rather, a life-threatening clinical condition provoked by diverse stimuli (1). The description of this problem as a syndrome was justified by the assumption that these diverse etiologies could be managed clinically by a unified approach. To this point, that na？ve assumption has proven flawed. Critical care investigators and physicians have learned from laboratory experimentation and clinical observation that the pathobiology of ARDS changes rapidly over hours and days and varies significantly in its nature (2,3) as well as severity from individual to individual. Furthermore, patients with ARDS often have multiple concomitant medically and surgically related disorders that further complicate treatment selection and often confound the interpretation of effects from ARDS-specific interventions. Soon after its initial description it also became clear that the disease course is influenced not only by such idiosyncratic disease co-factors but also by the life support measures we apply (4). It follows that wise selection and application of treatment requires consideration of the timing and intensity of any proposed intervention, such as mechanical ventilation