Background: Acute respiratory distress syndrome (ARDS) is a common diagnosis among children admitted to pediatric intensive care units. This heterogeneous disorder has numerous pulmonary and non-pulmonary causes and is associated with a significant risk of mortality. Many supportive therapies exist for ARDS. Search: Literature search was performed by using the key words ARDS and related topics on the Pubmed search engine maintained by the National Heart, Lung, Blood Institute. Pediatric randomized controlled trials that have been published in the last 10 years were included. Emphasis was placed on pediatric literature, although sentinel adult studies have been included. Most of the evidence presented is of levels I and II. Results: Low tidal volume is the only strategy that has consistently improved outcome in ARDS. A tidal volume of ≤6mL/kg predicted body weight should be used. Ventilator induced lung injury may result in systemic effects with multi-system organ failure, and all efforts should be made to minimize this. Positive end-expiratory pressure should be used to judiciously maintain lung recruitment. There is insufficient evidence to routinely use high frequency ventilation, prone positioning, or inhaled nitric oxide. Calfactant therapy is promising and may be considered in children with direct lung injury and ARDS. Current literature does not support routine use of corticosteroids for non-resolving ARDS.