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Low tidal volume ventilation (LTVV) reduces mortality in acute respiratory distress syndrome (ARDS) patients. Understanding local barriers to LTVV use at a former ARDS Network hospital may provide new insight to improve LTVV implementation.A cohort of 214 randomly selected adults met the Berlin definition of ARDS at Harborview Medical Center between 2008 and 2012. The primary outcome was the receipt of LTVV (tidal volume of ≤6.5 mL/kg predicted body weight) within 48 h of ARDS onset. We constructed a multivariable logistic regression model to identify factors associated with the outcome.Only 27% of patients received tidal volumes of ≤6.5 mL/kg PBW within 48 h of ARDS onset. Increasing plateau pressure (OR 1.11; 95% CI 1.03 to 1.19; p-value < 0.01) was positively associated with LTVV use while increasing PaO2:FIO2 ratio was negatively associated (OR 0.75; 95% CI 0.57 to 0.98; p-value 0.03). Physicians documented an ARDS diagnosis in only 21% of the cohort. Neither patient height nor gender was associated with LTVV use.Most ARDS patients did not receive LTVV despite implementation of a protocol. ARDS was also recognized in a minority of patients, suggesting an opportunity for improvement of care.