# Beyond One-Size-Fits-All: Precision Mechanical Ventilation in ARDS

## TL;DR

This paper argues for a shift from standard mechanical ventilation to personalized, precision-based strategies for treating ARDS, considering individual lung mechanics and physiology.

## Contribution

The paper introduces a conceptual framework for precision mechanical ventilation in ARDS, emphasizing individualized physiological alignment over one-size-fits-all approaches.

## Key findings

- ARDS patients exhibit significant variability in lung mechanics and physiology, making uniform ventilation strategies imprecise.
- Precision ventilation strategies, such as subphenotyping and real-time monitoring, can improve safety and effectiveness in ARDS management.
- Tools like esophageal pressure monitoring and AI can support personalized ventilatory decisions without replacing clinical judgment.

## Abstract

Acute respiratory distress syndrome (ARDS) has traditionally been managed with population-based, protocolized mechanical ventilation strategies designed to limit ventilator-induced lung injury. While these approaches have improved outcomes, they fail to account for the pronounced biological, mechanical, radiological, and temporal heterogeneity that characterizes ARDS. Accumulating evidence shows that patients differ markedly in functional lung size, recruitability, chest wall mechanics, inflammatory burden, and tolerance to ventilatory stress, making uniform ventilatory targets physiologically imprecise and, at times, harmful. This narrative review examines the evolution from conventional lung-protective ventilation toward a precision-based paradigm that aligns ventilatory support with individual patient physiology. We conceptualize ARDS not as a static syndrome but as a dynamic spectrum, viewing the injured lung as a heterogeneous mechanical system susceptible to regionally amplified stress and strain. Within this framework, we discuss key principles underlying precision ventilation, including functional lung size (the “baby lung”), driving pressure, mechanical power, patient–ventilator interaction, spontaneous breathing-associated injury, and the time-dependent evolution of lung mechanics. We synthesize current evidence supporting mechanical, biological, and radiological subphenotyping as complementary strategies to individualize ventilatory management, while critically appraising their current limitations. This review also evaluates bedside tools that may operationalize precision ventilation in clinical practice, including esophageal pressure monitoring, lung ultrasound, and electrical impedance tomography, and examines the role of artificial intelligence as a clinician-directed decision-support aid rather than a prescriptive substitute for physiological reasoning. Implications for clinical trial design, ethical considerations, and future directions toward predictive and adaptive ventilation strategies are also addressed. Precision mechanical ventilation represents a shift from rigid thresholds toward proportional, physiology-guided intervention across the disease trajectory. By integrating evolving lung mechanics, ventilatory load, and patient effort over time, this approach provides a coherent framework for safer and more effective mechanical ventilation in ARDS while preserving the core principles of lung protection.