Acute respiratory distress syndrome (ARDS) has been a great challenge in the field of pediatric critical care medicine. The clinical picture of children with ARDS in Taiwan has seldom been reported. The purpose of this study was to investigate the incidence, predisposing factors, clinical manifestations, strategies of ventilator support, adjuvant therapies, and prognosis of children with ARDS in a tertiary pediatric intensive care unit (PICU). A retrospective review of admissions to our PICU in the past 3 years showed that 16 cases met the criteria of pediatric ARDS. The incidence was 0.2% of all PICU admissions. The predisposing factors were varied, and pneumonia was the most common. The mean values of acute lung injury scores, ventilation indices and PaO2/FiO2 on admission were 3.6 +/- 0.5, 68.0 +/- 32.8 and 71.6 +/- 25.2, respectively. The averages of maximal peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP) were 40.3 +/- 9.8 and 14.0 +/- 4.6 cmH2O, respectively. Only three patients (19%) expired due to overwhelming systemic infection. Compared with our previous high mortality rate report, we emphasized gentle mechanical ventilation care, early employment of high PEEP and adjuvant therapy with sodium nitroprusside (SNP) nebulization and/or inhaled nitric oxide (iNO) to achieve an improved survival rate.