• Spontaneous breathing within 12 h after admission • Positive end-expiratory pressure (PEEP) primary 12-15 mbar • Ppeak (peak pressure) < 30 mbar • Pmean < 20 mbar • FiO 2 , work pressure, and frequency of jet, ASB in adaption to blood gas analyses; goal: oxygen delivery (DO 2 ) normal, lactate normal, pH 7.3-7.45 • Supine position 135°up to 12-14 h as long as oxygenation benefits • ECMO (QUADROX PLS and ROTAFLOW RF 32, MAQUET GmbH &Co. KG, Rastatt, Germany) Interventional Lung Assist (ILA Membranventilator ® , Novalung GmbH, Talheim, Germany) when CO 2 > 50 mmHg, pH < 7.3 and no progress by conservative ventilation and sedation management