Lung protection in acute respiratory distress syndrome: moving from protective ventilation to precision respiratory support

PURPOSE OF REVIEW: Lung-protective ventilation focuses on limiting tidal volume and airway pressure to prevent ventilator-induced lung injury (VILI) in acute respiratory distress syndrome (ARDS). Nevertheless, patients exposed to similar ventilatory strategies often develop markedly different degrees of lung injury, indicating that conventional ventilatory targets alone do not fully account for VILI development. This review examines the evolving concept of lung protection, emphasizing load distribution, regional lung mechanics, respiratory effort, and host susceptibility. RECENT FINDINGS: Mechanical ventilation delivers energy to a structurally heterogeneous lung, where the biological consequences of a given mechanical load depend not only on its magnitude but also on its regional distribution, patient-generated respiratory effort, and host susceptibility. Recent advances in physiological monitoring, bedside imaging, and computational modelling now allow these interactions to be assessed directly at the bedside, enabling physiology-guided ventilatory strategies. SUMMARY: Conventional protective ventilatory targets remain the foundation of lung protection but do not fully explain why some lungs tolerate mechanical ventilation better than others. Effective ventilatory support requires ongoing adaptation to the evolving mechanical, physiological, and biological characteristics of the injured lung.