Based on current evidence, patients with ARDS due to severe RVI should be managed with lung-protective strategy with low tidal volumes (6 ml/kg predicted body weight) and plateau pressures < 30 to 35 cmH2O. In adults with acute lung injury or ARDS due to various causes, an individual patient data meta-analysis of 2299 patients from three trials (50% with pneumonia) found that higher positive end-expiratory pressure (PEEP) levels were associated with improved survival among the subgroup of patients with ARDS (defined by PaO2/FiO2 ≤ 200 mmHg) [51]. A recent RCT of over 1000 patients with moderate-to-severe ARDS (55% with pneumonia) demonstrated that prolonged and high-pressure recruitment maneuvers was associated with increased 28-day mortality [52]. Titration of PEEP to achieve optimal oxygenation, perhaps without aggressive recruitment maneuvers, remains a reasonable strategy for most patients.