Lung-morphology-guided mechanical ventilation in ARDS patients

PURPOSE OF REVIEW: This review aims to provide an overview of lung morphology classification in acute respiratory distress syndrome (ARDS) and morphology-guided mechanical ventilation. It discusses the distinct morphological subphenotypes, focal and nonfocal, and how they affect the selection and effectiveness of ventilation strategies. RECENT FINDINGS: Computed tomography (CT) imaging has traditionally been used to differentiate ARDS morphologies, revealing that focal and nonfocal patterns respond differently to ventilation strategies such as positive end-expiratory pressure (PEEP) titration, recruitment maneuvers, and prone positioning. The Lung Imaging for Ventilator Setting (LIVE) trial highlighted the importance of correct morphology classification, showing that misclassification can obscure survival benefits from personalized ventilation. Lung ultrasound (LUS) has recently emerged as a viable, noninvasive tool for identifying morphological subtypes, with multiple classification methods demonstrating high accuracy. An ongoing trial is now evaluating LUS-based morphology classification to guide personalized mechanical ventilation. SUMMARY: Accurate assessment of lung morphology is critical for morphology-guided mechanical ventilation in ARDS. LUS represents a promising tool to implement morphology-guided strategies at the bedside, but further validation is needed to ensure clinical benefit.