ARDA is a common clinical problem resulting in acute respiratory failure in many and death in the majority of patients with a wide variety of direct and indirect pulmonary insults. ARDS is widely recognized and appropriately treated by empiric supportive care. Pharmacologic approaches to support the circulation are established. The use of corticosteroids remains controversial. The future depends upon unraveling the biologic mysteries which lead to the cascade of events which result in ARDA. This will establish a basis for further improvements in management.