Nosocomial infections are common in patients receiving extracorporeal membrane oxygenation (ECMO), with ECMO cannula-site infections (ECMO-CSI) being the most frequent infections directly related to the ECMO run. These infections can significantly impact patient outcomes. Currently, no adult guidelines exist for the prevention, diagnosis, and/or treatment of peripheral ECMO-CSI, resulting in heterogeneity in both clinical practice and research findings. We conducted a Delphi study involving 39 international experts in ECMO management. The experts participated in four Delphi rounds to reach consensus on various aspects of ECMO-CSI complicating peripheral ECMO (central ECMO excluded), including definition, clinical suspicion, diagnostic methods, preventive measures, and treatment. Consensus was defined as ≥ 70

Functional chest imaging using electrical impedance tomography (EIT) has experienced an impressive technological development since its invention in the early eighties of the last century. The number of experimental and clinical studies using this technology is continuously rising, and the increasing availability of devices approved for clinical use accelerates and diversifies its applications in patients. EIT is predominantly used in intensive care units but its utilisation in operating theatres, delivery rooms, pulmonary function laboratories and even remote outpatient settings is growing. Chest EIT is mainly applied to determine the regional distribution of pulmonary ventilation, aeration changes, and respiratory system mechanics both during mechanical ventilation and spontaneous breathing, but an increase in the use of chest EIT for imaging lung perfusion and cardiac action has recently been noted. The ongoing innovation of both EIT hardware and software, the new application fields, and the rising number of users of this technology require consensus on EIT terminology and definitions. This secures a common framework for conducting EIT studies, patient examinations and guarantees unified analysis of EIT data, documentation, reporting and comparability of findings. Our article provides a comprehensive consensus document on EIT terminology and definitions generated by EIT experts of the international TRanslational EIT development stuDy group in cooperation with the producers of EIT technology. It not only updates and extends the first consensus EIT terminology published in 2017, but also offers a new taxonomy of EIT measures, systematically based on the quantification of ventilation-related, heartbeat-related, and contrast-enhanced EIT signals. Thanks to its clear structure with tabulated recommended EIT terms, abbreviations, comprehensible explanations, notes, extensive literature sources and parameter calculations, EIT researchers, clinical users and manufacturers may use this document as a reference source of information relevant for chest EIT.

Background/Objectives: Respiratory failure in late pregnancy represents a complex and high-risk clinical scenario due to physiological adaptations during pregnancy that reduce maternal respiratory reserve, with tightly coupled maternal and foetal outcomes. This review aims to synthesise current evidence on epidemiology, maternal-foetal physiology, and management strategies for respiratory failure in late gestation. Methods: This narrative review integrates contemporary literature, national surveillance data, physiological principles, and expert consensus to summarise the causes, clinical implications, and management of respiratory failure in pregnancy. Results: Respiratory failure in pregnancy arises from diverse obstetric and non-obstetric conditions, including pneumonia, asthma, pulmonary embolism, cardiogenic pulmonary oedema, and ARDS. Maternal hypoxaemia is strongly associated with foetal compromise. Management requires pregnancy-specific ventilatory targets, avoidance of permissive hypercapnia, cautious use of non-invasive and invasive ventilation, and safe implementation of prone or semi-prone positioning. ECMO use has expanded, with maternal survival improving to approximately 75%, although optimal anticoagulation and timing of delivery remain uncertain. Conclusions: Effective management of respiratory failure in late pregnancy requires early recognition, multidisciplinary coordination, and adaptation of respiratory support to maternal-foetal physiology. Despite improvements in critical care and ECMO outcomes, key evidence gaps persist, underscoring the need for integrated maternal critical care pathways and further research to optimise outcomes for both mother and baby.

BACKGROUND:Acute respiratory distress syndrome (ARDS) is a clinically defined, biologically heterogeneous condition with no proven disease-modifying therapies. Retrospective analyses have identified two biologically distinct subphenotypes (hyperinflammatory and hypoinflammatory) of ARDS, with differing outcomes and responses to therapy. Rapid identification of these subphenotypes in an actionable timeframe has previously not been possible. The PHIND study aimed to prospectively identify these subphenotypes and to demonstrate differing 60-day mortality. METHODS:The PHIND study was a prospective, multicentre, observational cohort study conducted in intensive care units (ICUs) within the National Health Service in the UK and the Health Service Executive in Ireland. Adult patients aged 18 years and older with ARDS or acute hypoxaemic respiratory failure (AHRF) were enrolled within 72 h of onset of the syndrome. Eligible patients were required to be receiving invasive mechanical ventilation, non-invasive ventilation, or high-flow nasal oxygen. Plasma interleukin (IL-6) and soluble TNF receptor-1 (TNFR1) were quantified at enrolment using a near-patient benchtop immunoanalyser (Randox multiSTAT) with a run time of approximately 1 h. Together with plasma bicarbonate measured from an arterial blood sample, these values were used to prospectively determine subphenotypes on an individual patient basis using a validated parsimonious logistic regression model. The primary outcome was 60-day mortality. The study was registered on ClinicalTrials.gov, NCT04009330. FINDINGS:Between Nov 22, 2019, and Sept 28, 2023, 1853 patients from 30 centres were screened for eligibility. Of these, 1328 were excluded and 525 were recruited into the study, with 512 individuals included. 308 (60%) patients were male, 204 (40%) were female, and mean age was 57·0 years (SD 15·1). 443 (87%) patients were white, 18 (4%) were Black, and 16 (3%) were Asian. 490 were subphenotyped using the near-patient assay: 89 (18%) were classified as hyperinflammatory and 401 (82%) as hypoinflammatory. The primary outcome of 60-day mortality was measured in 486 patients after four patients withdrew consent for confirmation of vital status. 60-day mortality was significantly higher in the hyperinflammatory group (45 [51%] of 88) than in the hypoinflammatory group (111 [28%] of 398; risk ratio 1·8 [95% CI 1·4-2·4], p<0·0001). After adjustment, hyperinflammatory patients had increased odds of 60-day mortality (adjusted odds ratio 2·7 [95% CI 1·6-4·4], p=0·0002). INTERPRETATION:Rapid identification of ARDS inflammatory subphenotypes using a near-patient assay was feasible and associated with many clinical characteristics and outcomes consistent with those described in earlier retrospective studies, including mortality, prevalence of sepsis, and incidence of metabolic acidosis. These findings support the implementation of precision medicine approaches in ARDS and the urgent need for prospective, subphenotype-stratified interventional trials. FUNDING:Innovate UK, Randox Laboratories, and Belfast Health & Social Care Trust.

Extracorporeal life support provides temporary cardiorespiratory support for patients with severe, potentially reversible cardiac and/or respiratory failure refractory to conventional measures. Its application has broadened across a wide spectrum of critical illness, yet the mechanistic basis of its physiologic benefit remains incompletely defined. This review explores the mechanisms through which extracorporeal life support may confer benefit in respiratory and cardiac failure. These include restoration of gas exchange, optimization of circulatory dynamics, and mitigation of secondary organ injuries, creating conditions that facilitate tissue repair, enable adjunctive therapies, and, in selected cases, provide a bridge to transplantation. In isolated respiratory failure, respiratory extracorporeal life support stabilizes gas exchange and modulates respiratory drive, enabling lung-protective ventilation and potentially attenuating ventilator- and patient self-inflicted lung injury. In cardiogenic shock, cardiac extracorporeal life support restores systemic perfusion and may reduce myocardial oxygen demand, while during cardiac arrest, it may confer neuroprotective effects. In combined cardiorespiratory failure, advanced extracorporeal support modalities may augment both systemic and pulmonary circulation, supporting gas exchange and maintaining end-organ perfusion. Mechanistically, these interventions interrupt the cascade of hypoxemia- and/or hypercapnia- induced pulmonary vasoconstriction, right ventricular overload, and systemic hypoperfusion, facilitating multiorgan recovery. Optimizing patient selection, timing for extracorporeal life support initiation, and use of adjunctive therapies require a nuanced understanding of the interplay between these physiologic pathways alongside careful considerations of key limitations, including device-related complications, hematologic and inflammatory perturbations, and physiologic trade-offs. This State-of-the-Art review synthesizes the current literature on the mechanistic basis of extracorporeal life support in adults.

Background Successful non-invasive ventilation (NIV) reduces ICU length of stay, the need for intubation and the risk of death. However, patients who fail NIV and require intubation have a higher risk of death. We developed NIVPredict, an easy-to-use web-based AI tool to predict NIV outcome within two hours of initiation in patients with acute respiratory failure (ARF) from diverse aetiologies and tested its useability in a hospital setting. Methods This study included data from immunocompromised and immunocompetent patients with hypoxemic ARF due to pneumonia, sepsis or COVID-19, and hypercapnic ARF due to acute exacerbation of chronic obstructive pulmonary disease or obesity hypoventilation syndrome. The tool uses the recently proposed Tabular Prior-Data Fitted Network (TabPFN) machine learning model and was trained using a dataset of routinely collected measurements taken within one hour after NIV initiation in 665 ARF patients from the recent RENOVATE trial in Brazil. Initial external validation of the model was conducted on a dataset of 422 ARF patients from Italy, Spain, and the USA. Subsequently, the useability of a web-based tool based on the model was tested by clinicians at the University Hospitals of North Midlands NHS Trust in the UK between December 2024 and November 2025, who applied it to data collected from 57 eligible ARF patients. Results The AI tool provided accurate and robust prediction of NIV outcomes and consistently outperformed conventional clinical indices across all validation settings. In internal repeated cross-validation, external validation, and in-hospital testing, the tool achieved AUCs of 0.793, 0.772, and 0.858, vs. 0.717, 0.709, and 0.693 for the best clinical index (Updated HACOR score), and balanced accuracies of 78.9%, 74.5%, and 85.0%, vs. 68.7%, 63.7%, and 67.6% for the best clinical index (HACOR or Updated HACOR score), respectively. Conclusions This study demonstrates superior predictive performance, compared to current clinical indices, of an AI-based tool for NIV outcome prediction on a cohort of patients with overt-acute and acute-on-chronic respiratory failure. Clinical useability of the tool was confirmed via testing by clinicians in a hospital setting, motivating its future evaluation in prospective multi-centre studies.

The rationale of albumin use lies in its potential to increase oncotic pressure and optimize tissue perfusion. Randomized trials have not demonstrated a survival benefit, and the effects of albumin on volemia remain unclear. This study investigates, in healthy pigs, the effects of a 48-h albumin infusion on intravascular fluid volume, albumin kinetics, and its impact on respiratory function. Thirty-nine healthy female pigs ventilated for 48 h were grouped according to mechanical power (high 18 J/min vs. low 6 J/min) and type of fluid (5

Acute respiratory distress syndrome (ARDS) remains a significant clinical challenge, with high morbidity and mortality rates despite advances in supportive care. Mechanical ventilation is central to the management of this condition, yet sex-related differences have been largely overlooked in research and clinical practice. Female patients have smaller lung volumes, different chest wall mechanics, and hormonal modifications that affect inflammation, vascular tone, respiratory compliance, and respiratory drive. These have an impact on treatment and care. This narrative review synthesises current evidence on sex-specific physiological differences affecting ARDS management. It evaluates the impact of physiological differences on lung volumes, chest wall mechanics, and pharmacokinetics and emphasises the importance of personalised ventilation and sedation strategies. Female patients exhibit greater susceptibility to ventilator-induced lung injury. Recent physiological studies show that, despite lower absolute mechanical power, each 1 J min-1 increase in mechanical power is associated with a 52.8% higher mortality risk in female patients compared with males, with an excess mortality of 8.2% above a threshold of 17 J min-1. Sex-related sensitivity to sedatives and neuromuscular blocking agents has also been described, with females requiring 20-30% lower opioid doses, 30% increased propofol doses, and a 30% greater sensitivity to neuromuscular blockers. Addressing sex-based differences is crucial for personalised ARDS management. Strategies including normalisation of mechanical power to lung volume and sex-specific analgo-sedation protocols are needed. Equitable access to advanced therapies is essential for all patients. Future research must systematically integrate sex-specific analyses (e.g. the Sex And Gender Equity in Research (SAGER) guidelines) to improve understanding of reported outcomes for critically ill patients.

Background Despite decades of research and advances in critical care, mortality of the Acute Respiratory Distress Syndrome (ARDS) remains high, ranging from 30 to 45% in high-income countries and markedly higher in low-resource settings (LRS), where management guidelines implementation is constrained. An international consensus aimed to provide statements for ARDS management tailored to LRS. Methods Since management of critically ill patients is a major public health problem in LRS, the Bosnia and Herzegovina Society of Intensive Care Medicine convened an international, multidisciplinary Steering Committee with expertise in ARDS management. The committee appointed an international panel of clinicians and investigators specialized in the field of ARDS. Through an iterative Delphi process, a panel of 52 experts developed several consensus statements. Results After three Delphi rounds, consensus was reached on 44 out of 56 of statements (79%). The survey covered eight domains related to ARDS management in LRS related to: critical care infrastructure, diagnostic tools, respiratory support, other supportive therapies, sedation strategies, weaning, nutrition, and management of complications. Statements were compared with recent ESICM guidelines, highlighting specific LRS considerations. Conclusion Using the Delphi method, international experts developed clinical practice statements guiding clinicians on ARDS management in LRS. These statements complemented existing guidelines by addressing areas where evidence is limited, and highlight aspects of ARDS management pertinent for LRS not covered by current international recommendations. Future studies are needed to evaluate the adherence and impact of these statements and to address remaining uncertainties.

Positive end-expiratory pressure (PEEP) remains a cornerstone of acute respiratory distress syndrome management. However, randomized trials of PEEP strategies have yielded conflicting results, reflecting inter-individual heterogeneity. PEEP-induced alveolar recruitment enhances lung protection by redistributing tidal volume over a larger functional lung and reducing atelectrauma and bronchiolotrauma. Conversely, in poorly recruitable lungs, PEEP predominantly increases stress in already aerated regions, potentially exacerbating ventilator-induced lung injury and cardiovascular compromise. The net effect of PEEP reflects a patient-specific balance between recruitment and overdistension, shaped by hemodynamic tolerance. Clinical markers traditionally used for assessing PEEP response (gas exchange, compliance, and driving pressure), while informative at a population level, remain unreliable for clinical decision-making at the individual level. With the exception of specific subgroups (e.g., obesity), patients with PaO2/FiO2 > 200 mmHg are unlikely to have substantial alveolar collapse amenable to recruitment and can be managed with lower PEEP (e.g., 5–8 cmH2O) facilitating transition to assisted ventilation. In contrast, higher PEEP is more likely to benefit patients with PaO2/FiO2 ≤ 200 mmHg, in whom a physiologically grounded framework should begin with assessment of lung recruitability (e.g., computed tomography, gas recruitment indices). This should account for airway closure, since PEEP below the airway opening pressure does not modify lung volume and may confound respiratory mechanics interpretation. In patients with significant recruitability, PEEP titration should integrate global measures (plateau pressure, stress index) with regional monitoring (electrical impedance tomography, transpulmonary pressure) when available. Conversely, poorly recruitable patients are unlikely to benefit from higher PEEP and can be managed with lower levels.

BackgroundWe conducted a roundtable discussion and provided evidence-based guidance on the setting and adjustment of Airway Pressure Release Ventilation (APRV) in adult patients with acute respiratory distress syndrome (ARDS).MethodsA panel of clinicians and basic scientists with extensive experience in lung physiology and using APRV was assembled to provide expert consensus guidance. The panel first established and agreed upon guiding principles for optimal APRV settings. To support consensus discussions, we then reviewed the literature on the physiological basis of APRV as a lung-protective ventilation strategy, as well as published APRV research. Finally, we held a one-day meeting and conducted robust, iterative consensus discussions using the Nominal Group Technique to reach agreement on the optimal APRV settings. This work represents an Expert Recommendation and Position Statement rather than a formal consensus guideline. The recommendations were developed through iterative expert discussions that integrated extensive clinical experience with supporting basic science evidence on time-controlled ventilation and alveolar mechanics. Recommendations were based on expert experience with APRV in the intensive care unit and supported by published animal and clinical studies.ResultsConsensus on initial APRV settings for acute lung injury (ALI) such as ARDS or disorders of normal or increased elstance was as follows: set the upper airway pressure (PHigh) to either plateau or peak inspiratory pressure when transitioning from volume control or pressure control/dual control, respectively; set the duration of PHigh (THigh) to match the current respiratory rate on conventional ventilation; set lower airway pressure (PLow) to 0 cmH2O; and calculate duration of PLow (TLow) using the equation Peak Expiratory Flow x 75% = Termination of Expiratory Flow. Other recommendations included titrating these settings in response to changes in lung physiology and reaching consensus on injurious APRV settings that could impair gas exchange or cause lung instability.ConclusionThe panel developed a protocol for adjusting the four APRV settings based on expert experience and solid clinical and scientific evidence for patients with ALI and ARDS, or disorders of normal or increased elastance. Optimizing the lung-protective settings in APRV mode can improve patient outcomes.

BACKGROUND:Mucoactive agents are widely used in patients with acute respiratory failure despite limited evidence of their effectiveness or safety. METHODS:We conducted a multicenter, open-label, randomized trial with a 2-by-2 factorial design that involved critically ill, mechanically ventilated participants 16 years of age or older with acute respiratory failure and difficult-to-clear secretions. All participants received usual care along with carbocisteine (750 mg three times daily enterally), 6% or 7% nebulized hypertonic saline (HTS) (4 ml four times daily), both interventions, or usual care alone for up to 28 days. The primary outcome was duration of mechanical ventilation (from randomization to first successful unassisted breathing). The primary comparisons were between any carbocisteine and no carbocisteine and between any HTS and no HTS, with each comparison comprising two treatment groups. RESULTS:A total of 1956 participants underwent randomization: 486 were assigned to carbocisteine, 485 to HTS, 492 to both treatments, and 493 to usual care alone (472, 474, 479, and 478, respectively, were included in the primary analysis). No evidence of treatment interaction was found (hazard ratio, 1.01, 95% confidence interval [CI], 0.83 to 1.22; P = 0.91). The median duration of mechanical ventilation was 186.1 hours (95% CI, 168.3 to 196.6) with carbocisteine and 172.7 hours (95% CI, 165.2 to 190.4) with no carbocisteine (adjusted hazard ratio, 0.96; 95% CI, 0.87 to 1.05; P = 0.34) and 184.5 hours (95% CI, 165.6 to 194.1) with HTS and 174.3 hours (95% CI, 166.9 to 192.7) with no HTS (adjusted hazard ratio, 1.00; 95% CI, 0.91 to 1.10; P = 0.98). Clinically important upper gastrointestinal bleeding occurred significantly more often with carbocisteine than with no carbocisteine (13 of 965 [1.4%] vs. 2 of 966 [0.2%]; risk ratio, 6.51; 95% CI, 1.47 to 28.76; P = 0.01). Bronchoconstriction leading to bronchodilator use occurred significantly more often with HTS than with no HTS (23 of 967 [2.4%] vs. 4 of 964 [0.4%]; risk ratio, 5.73; 95% CI, 1.99 to 16.52; P = 0.001), as did hypoxemia during nebulization (40 of 967 [4.1%] vs. 3 of 964 [0.3%]; risk ratio, 13.29; 95% CI, 4.12 to 42.83; P<0.001). One serious adverse reaction was reported in the combination group. CONCLUSIONS:Among critically ill patients with acute respiratory failure, neither carbocisteine nor HTS significantly reduced the duration of mechanical ventilation, and each was associated with harm. (Funded by the NIHR Health Technology Assessment Programme and the Belfast Health and Social Care Trust Charitable Trust Fund; MARCH ISRCTN Registry number, ISRCTN17683568.).

BACKGROUND: Adult patients receiving extracorporeal membrane oxygenation (ECMO) for acute respiratory failure generally are younger and have fewer comorbidities before ICU admission than other critically ill patients. These factors might be associated with less morbidity after hospital discharge. However, few studies have compared patient-reported outcomes of ECMO survivors with those of the general ICU population. RESEARCH QUESTION: What are the psychological, health-related quality of life, sleep, swallowing, nutrition, airway, and voice outcomes measured 3 months after hospital discharge, comparing those reported by ICU survivors receiving ECMO with those receiving invasive mechanical ventilation (IMV; $ 3 days)? STUDY DESIGN AND METHODS: In this prospective observational longitudinal cohort (2015-2023), patients attending a post-ICU recovery clinic were recruited, including those admitted to an 11-bed ECMO service. Data included demographic and clinical characteristics and self-reported outcomes. We compared outcomes using linear and logistic regression modelling. RESULTS: We received patient-reported outcomes from 841 of 1,848 post-ICU recovery clinic attendees (46%; 54% attended but did not complete questionnaires). Of these, 289 patients (34%) received ECMO, were 13 years younger on average (P < .001), and more often were White (81% vs 61%; P = .03). Compared with general patients in the ICU, patients receiving ECMO showed similar admission illness severity (median Acute Physiology and Chronic Health Evaluation [APACHE] II score of 16 in both groups), but a longer IMV duration (median, 15 days [interquartile range (IQR), 10-25 days] vs 8 days [IQR, 4-16 days]; P < .001) and higher delirium prevalence (75% vs 54%; P < .001). We found no difference in psychological morbidity prevalence and no association of ECMO with suspected posttraumatic stress disorder (adjusted OR, 0.86; 95% CI, 0.59-1.24), controlling for age, sex, and APACHE II score. Fewer patients receiving ECMO had mobility issues (EuroQol 5-Dimension 5-Level questionnaire [EQ-5D-5L] mobility, 29% vs 47%; P < .001). We found no differences in other physical morbidity outcomes and no association of ECMO with EQ-5D-5L visual analog scale score (adjusted estimate, 2.4; 95% CI, -3.9 to 10.8). INTERPRETATION: Our results show that except for better mobility, patients who received ECMO achieved similar outcomes after hospital discharge as patients requiring IMV for a minimum of 3 days.

Background: Human serum albumin (HSA), the most abundant plasma protein, is essential for oncotic pressure, endothelial protection, drug binding, and immune modulation. Despite its widespread clinical use since the 1940s, its therapeutic benefit in critically ill patients remains debated. This narrative review summarizes current evidence on HSA use in common intensive care scenarios. Clinical Applications: In hepatorenal syndrome (HRS), albumin combined with vasoconstrictors like terlipressin improves renal function and survival. In spontaneous bacterial peritonitis (SBP), albumin lowers the risk of acute kidney injury and mortality, particularly in high-risk cirrhotic patients. Post-paracentesis albumin reduces circulatory dysfunction and may enhance survival in cirrhosis. For septic shock, trials show no overall mortality benefit over crystalloids, though albumin may offer hemodynamic advantages in specific subgroups. In acute respiratory distress syndrome (ARDS), albumin improves oxygenation in hypoalbuminemic patients, without survival benefits. During major cardiac or abdominal surgery, albumin reduces fluid needs and postoperative complications, especially in hypoalbuminemic individuals. In acute brain injury, albumin’s role is controversial: it may aid recovery after cerebral hemorrhage, but can worsen outcomes in traumatic brain injury. In trauma and ECMO patients, albumin may stabilize hemodynamics and improve outcomes in selected cases. Conclusions: Inappropriate albumin use remains common, and evidence on its optimal concentration, dose, timing, and patient selection is limited. HSA is safe and beneficial in specific situations. Routine use should follow evidence-based guidelines. Future research must identify patients who are most likely to benefit and clarify optimal dosing strategies, concentrations, and therapeutic goals.

Patient-specific computational tools hold great promise for the development of more personalized treatment strategies for acute respiratory failure. Such tools span a continuum from data-driven predictors, to patient-specific mechanistic models, and ultimately to fully realized digital twins with continuous bidirectional model-patient interactions. Data-driven prediction models apply machine learning to large-scale patient datasets to develop tools that can help clinicians identify patients who are likely, or unlikely, to benefit from a particular course of treatment. By incorporating detailed computational representations of disease pathophysiology, patient-specific mechanistic models can provide insights into the effects of existing or novel treatment strategies, support patient stratification and treatment personalization, and enable the design of in silico clinical trials of new interventions. Finally, fully realized dynamic digital twins of patients could provide real-time decision support and ‘simulate-before-treat’ capabilities at the bedside, helping clinicians optimize treatment as the patient’s disease state evolves. This narrative review provides an overview of recent research applying these approaches in the context of acute respiratory failure, encompassing both respiratory and ventilatory support across neonatal, paediatric and adult populations, and pre-hospital, ward and intensive care environments.

Acute respiratory distress syndrome (ARDS) is a common and clinically significant complication in patients with acute brain injury (ABI), affecting up to one-third of critically ill individuals and contributing to increased mortality, prolonged mechanical ventilation, and worse neurological outcomes. The coexistence of ARDS and ABI creates a fundamental therapeutic dilemma: strategies that protect the lung may adversely affect cerebral physiology, whilst neuroprotective targets may compromise respiratory management. This narrative review examined the pathophysiological interactions between the injured lung and brain, highlighting the competing effects of key ventilatory variables. Lung-protective ventilation, including low tidal volume and higher positive end-expiratory pressure (PEEP), reduces ventilator-induced lung injury but may increase arterial carbon dioxide (PaCO2), resulting in intracranial hypertension and impaired cerebral perfusion. Conversely, strict control of PaCO₂ and optimisation of cerebral perfusion may necessitate deviations from conventional ARDS strategies. Oxygenation targets further illustrate this tension, as both hypoxaemia and hyperoxaemia can exacerbate secondary brain injury. We synthesised current evidence on respiratory support, including non-invasive strategies, invasive mechanical ventilation, rescue therapies such as prone positioning and extracorporeal support, and pharmacological interventions, with emphasis on their differential effects on pulmonary and cerebral physiology. Attention was also given to the role of multimodal neuromonitoring, including intracranial pressure and brain tissue oxygenation, as tools to individualise ventilatory management and reconcile competing organ priorities. Overall, available data support a shift from protocolised approaches towards physiology-driven, patient-specific strategies that integrate lung mechanics, gas exchange and cerebral haemodynamics in patients with concomitant ARDS and ABI. Future studies should incorporate combined lung and brain endpoints to define strategies that simultaneously minimise ventilator-induced lung injury and secondary brain injury.