Approximately 2-5% of admissions to pediatric intensive care units are due to diseases which develop into the adult respiratory distress syndrome (ARDS). About 8% of intensive care patient days are involved in treating patients with ARDS. ARDS is associated with approximately a third of deaths in the pediatric intensive care unit. Overall mortality is 50-70%. Frustratingly, little improvement in outcome has occurred over the past decade. The outcome predictors which have been developed to date have been unreliable for individual patients who may have been treated with alternative respiratory support modalities. The following is a review of current ventilatory management of ARDS, including the promising new modality of high-frequency oscillatory ventilation.