This article reviews adult respiratory distress syndrome as it is associated with multiple organ dysfunction and systemic inflammatory response. The pathophysiology of adult respiratory distress syndrome is discussed and related to the clinical presentation. Included in the clinical presentation is a discussion of respiratory and hemodynamic alterations, lung mechanics, and oxygen delivery and consumption alterations. Conventional therapeutic modalities for treatment of adult respiratory distress syndrome are reviewed in addition to new ventilatory approaches. New approaches to ventilation and oxygenation included in this article are pressure control ventilation, inverse ratio ventilation, permissive hypercapnia, and extracorporeal therapy. New pharmacologic therapy for the treatment of adult respiratory distress syndrome is also reviewed in this article.