Advances in Imaging and Physiology-Guided Personalized Care in Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is a heterogeneous inflammatory lung injury marked by increased alveolar–capillary permeability, reduced respiratory system compliance, and impaired gas exchange. Despite advances in supportive care, ARDS remains associated with high mortality. Lung-protective ventilation with low tidal volumes and prone positioning is the cornerstone of treatment. However, these strategies do not fully account for patient-specific physiological variability. Recent guidelines emphasize a more individualized approach to respiratory support. Key elements include limitation of driving pressure, optimized use of high-flow nasal oxygen, and application of bedside tools such as the SpO2/FiO2 ratio and lung ultrasound. These measures improve diagnosis, monitoring, and physiological assessment at the bedside. This narrative review summarizes current evidence supporting contemporary ventilatory and non-invasive strategies in ARDS. It also examines emerging diagnostic and therapeutic approaches that integrate respiratory physiology into clinical decision-making. Finally, we discuss future directions focused on personalized, physiology-guided management to improve outcomes in patients with ARDS.