The chapter "Ventilator-Induced Lung Injury" by Shinya Tsuchida and Brian P. Kavanagh discusses the harmful effects of mechanical ventilation with large tidal volumes on the lungs. The authors highlight the importance of avoiding injurious ventilator strategies in treating acute respiratory distress syndrome (ARDS) patients, as studies have shown that the settings of mechanical ventilators directly impact patient mortality. The lung protective strategy, which includes low tidal volume, high positive end-expiratory pressure (PEEP), and recruitment maneuvers, has been shown to be superior in reducing mortality. The chapter also explores the mechanisms of ventilator-induced lung injury, emphasizing the need for a better understanding of the optimal levels of PEEP and tidal volume in individual patients. It reviews clinical trials and experimental studies to address these uncertainties. Key findings include the importance of preventing atelectasis and overinflation, and the complexity of applying a lung protective strategy in clinical practice, especially in pediatric intensive care units. The authors discuss the concept of volutrauma, where elevated tidal volume is more harmful than airway pressure alone, and the role of mean airway pressure in increasing pulmonary vascular permeability. They also address the issue of atelectasis, which can develop with low tidal volume ventilation, and the potential for low tidal volumes to be protective against atelectasis-associated lung injury. Finally, the chapter examines the "baby lung concept," which suggests that a given tidal volume may only ventilate the healthy portion of the injured lungs, leading to overdistention and injury in the remaining aerated areas. The ALVEOLI study, which compared higher and lower PEEP strategies, found no significant differences in clinical outcomes, further complicating the optimal ventilation strategy.The chapter "Ventilator-Induced Lung Injury" by Shinya Tsuchida and Brian P. Kavanagh discusses the harmful effects of mechanical ventilation with large tidal volumes on the lungs. The authors highlight the importance of avoiding injurious ventilator strategies in treating acute respiratory distress syndrome (ARDS) patients, as studies have shown that the settings of mechanical ventilators directly impact patient mortality. The lung protective strategy, which includes low tidal volume, high positive end-expiratory pressure (PEEP), and recruitment maneuvers, has been shown to be superior in reducing mortality. The chapter also explores the mechanisms of ventilator-induced lung injury, emphasizing the need for a better understanding of the optimal levels of PEEP and tidal volume in individual patients. It reviews clinical trials and experimental studies to address these uncertainties. Key findings include the importance of preventing atelectasis and overinflation, and the complexity of applying a lung protective strategy in clinical practice, especially in pediatric intensive care units. The authors discuss the concept of volutrauma, where elevated tidal volume is more harmful than airway pressure alone, and the role of mean airway pressure in increasing pulmonary vascular permeability. They also address the issue of atelectasis, which can develop with low tidal volume ventilation, and the potential for low tidal volumes to be protective against atelectasis-associated lung injury. Finally, the chapter examines the "baby lung concept," which suggests that a given tidal volume may only ventilate the healthy portion of the injured lungs, leading to overdistention and injury in the remaining aerated areas. The ALVEOLI study, which compared higher and lower PEEP strategies, found no significant differences in clinical outcomes, further complicating the optimal ventilation strategy.