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Over the past 30 years, significant progress has been made in the practice of mechanical ventilation. We have, however, not seen a marked decrease in mortality over the same period. These two divergent facts can be explained by a general lack of understanding of the physiology of artificial ventilation. We believe mortality can be affected through a basic understanding of how mechanical ventilation impacts the lung. We review the importance of pressure-controlled ventilation and how it affects alveolar lung units. The ability to modulate lung injury by proper ventilation is stressed. The “open lung concept” and its ability to improve both acute management and outcome are keys to proper ventilatory support. Opening pressures of 40 to 60 cm H2O are applied for 10 to 30 breaths, and then the open lung is splinted open by the use of static positive end-expiratory pressure so that cyclic alveolar collapse does not occur. The new form of pressure control, pressure-regulated volume control, with its inherent advantage of volume guarantee, may make pressure-controlled ventilation more user-friendly.