Acute respiratory distress syndrome (ARDS) is a critical condition affecting 10% to -15% of ICU patients, with mortality rates varying according to severity. Mechanical ventilation is essential but requires strategies to prevent ventilator-induced lung injury (VILI) and comfort the patient. Sedation and analgesia improve tolerance to ventilation, but excessive deep sedation can be harmful. Guidelines recommend light sedation with daily interruptions or dose titration, though severe ARDS cases may require neuromuscular blockade and, consequently, deep sedation. Specific ventilation and sedation strategies, to modulate respiratory drive and allow spontaneous breathing without vigorous efforts, are necessary to optimize care and improve survival in patients with severe ARDS.