This annual review summarizes major advances in respiratory medicine in the intensive care unit (ICU) published in 2025, focusing on high-impact clinical and translational studies most likely to influence current practice and future research. Across the field, 2025 strengthened the evidence base for key physiological concepts while more clearly defining where physiological strategies translate into clinical benefit and where broadly applied interventions remain insufficient, reflecting an increasing shift toward precision-based respiratory care. Precision medicine advanced through open-source inflammatory acute respiratory distress syndrome (ARDS) subphenotype classifiers and trajectory-based physiological phenotypes that outperform static definitions and support time-dependent treatment strategies. Evidence for non-invasive respiratory support expanded in obesity, immunocompromised patients, and procedure-related hypoxemia, emphasizing that implementation factors such as duration, staffing, and positive end-expiratory pressure (PEEP) strategy strongly influence success. Prospective multicenter cohorts reinforced the prognostic relevance of driving pressure (DP) and mechanical power, whereas randomized trials indicated that DP-guided PEEP titration and advanced ventilator modes do not reliably improve patient-centered outcomes when broadly applied under lung-protective targets. A major 2025 development was the operationalization of spontaneous breathing risk, and bedside indices of inspiratory efforts (Pocc and P0.1) were linked to pendelluft and outcomes, with oxygenation severity modifying harm versus benefit, supporting an effort-guided framework for preventing patient self-inflicted lung injury. In ARDS, prolonged inhaled volatile sedation failed to improve outcomes and was associated with possible harm compared with intravenous sedation. The largest 2025 oxygen trial showed no mortality benefit for broadly conservative targets, while subgroup analyses suggested heterogeneity of treatment effect. Electrical impedance tomography advanced toward bedside stratification and individualized titration, including emerging three-dimensional approaches. Finally, 2025 strengthened long-term outcome data for extracorporeal membrane oxygenation (ECMO) and ICU survivorship, reinforcing recovery as a core component of respiratory critical care.
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