This study was designed to determine if clinical features apparent after seven days of mechanical ventilation predict long-term intubation beyond 14 days and subsequent need for tracheotomy in patients with ARDS. Twenty-four patients were entered into the study. Group 1 patients were successfully extubated in less than or equal to 14 days after onset of ARDS and group 2 patients remained intubated greater than 14 days. On day 7 of ARDS, group 1 had a higher PaO2/PAO2 ratio, a lower PEEP requirement, less severe chest radiographic abnormalities and a greater likelihood of an improved radiograph from the baseline study. None of group 1 and 11 group 2 patients eventually underwent tracheotomy. Clinical features apparent after seven days of mechanical ventilation in patients with ARDS suggest the likelihood of prolonged intubation beyond 14 days and eventual tracheotomy. Recognition of these features may allow more timely conversion of endotracheal intubation to tracheotomy.