Recent advances in mechanical ventilation, accompanied with a better understanding of the pathophysiology of ARDS, have resulted in a brighter outlook for the child who acquires this still dreaded disease. A greater understanding of the pathophysiology of ARDS has led to a heightened awareness that the care of these patients should be more than just supportive. The potential for exacerbation of lung injury by mechanical ventilation is real. Many new therapies are being evaluated for the treatment of ARDS; all are intended to reduce ventilator-induced injury. With the recognition of "volutrauma" as a serious complication of mechanical ventilation in ARDS, the mode of ventilation used should minimize the potential for this complication in a child with signs of progressive lung disease requiring mechanical ventilation. Optimal integration of the many new techniques into the treatment of pediatric ARDS will require more research and experience. Surfactant replacement in ARDS as an adjunct to the basic care of these patients may be beneficial. Liquid ventilation is another exciting new ventilation technique that has a significant protective effect in animal models of ARDS. Other therapies, such as tracheal gas insufflation, or other new modes of ventilation may also improve outcome. Techniques of high-frequency ventilation and ECMO in the treatment of children already show potential for improved outcome. The decision between using ECMO or "nonconventional" forms of mechanical ventilation should be considered carefully, after the morbidity of the procedures, the duration of therapy, and the cost have been weighed. Centers with experience using ECMO in the setting of pediatric ARDS have better results than those where ECMO is infrequently used for this purpose. It is imperative that future studies of both mechanical ventilation and ECMO describe ventilation strategy and prospectively identify protocols or algorithms for ventilator management. Coupled with severity scores, ventilator techniques and ECMO can then be systematically compared in children with ARDS.