Clinical management of AHRF is essentially supportive and includes control of underlying infections, fluid balance and hemodynamic status, nutritional support, and optimized protective mechanical ventilation4,5,6. Ventilatory strategies should be directed at minimizing ventilator-induced lung injury (VILI), eliminating oxygen toxicity, and controlling lung inflammation. Also, when hypoxemia persists, additional treatments may be implemented, such as inhaled nitric oxide (iNO)and high-frequency oscillatory ventilation (HFOV).