Age-specific respiratory support and monitoring for acute respiratory distress syndrome: a narrative review

INTRODUCTION: Acute respiratory distress syndrome (ARDS) causes inflammatory alveolar-capillary injury at different ages. Age-related differences in respiratory mechanics, airway anatomy, pulmonary vascular physiology, and disease etiology limit extrapolation of diagnostic and therapeutic strategies. This review compared respiratory monitoring and support strategies across adult, pediatric, and neonatal ARDS. AREAS COVERED: We searched PubMed for English-language human studies published from database inception through 14 August 2026 and reviewed major society guidelines. This review covers age-specific ARDS definitions, epidemiology, pathophysiology, respiratory support, adjunctive therapies, and liberation from mechanical ventilation. Adult-derived evidence supports low-tidal-volume ventilation, prolonged prone positioning for severe ARDS, selective higher positive end-expiratory pressure, and early extracorporeal membrane oxygenation for refractory disease. Recommendations for pediatric ARDS often rely on consensus or observational evidence. Neonatal ARDS management remains largely extrapolated from neonatal respiratory disorders and must account for gestational age, surfactant biology, pulmonary hypertension, and etiology. EXPERT OPINION: Respiratory support should be age-calibrated, phenotype-informed, and reassessed for gas exchange, respiratory effort, mechanics, hemodynamics, device performance, and clinical trajectory. Physiological improvements may not translate into positive outcomes. Noninvasive support should not delay intubation in cases of failure. Standardized interventions and prospective studies must be tailored to pediatric and neonatal populations.