On admission the patient presented severe acute respiratory distress syndrome (ARDS) for which he required high MV parameters ( Figure 1 ). He presented serious refractory hypoxemia and remained 36 days on MV. Using a low tidal volume ventilation protocol we were not able to achieve an adequate minimal oxygenation. So, as we do not count on high frequency oscillatory ventilation (HFOV) because of certain socioeconomic limitations within our hospital, we resorted to standard modalities, reaching mean airway pressure (Paw) of 15. 2 Extubation failed by respiratory insufficiency in 2 opportunities requiring reintubation in the first 24 hours. In both opportunities the patient had passed a spontaneous breathing trial (SBT).