Survivors of acute respiratory distress syndrome (ARDS) frequently experience cognitive impairment, psychological symptoms, and reduced health-related quality of life after intensive care. Immersive virtual reality (VR) may provide an engaging, multimodal adjunct to conventional rehabilitation, but evidence in the ARDS recovery population remains limited.

In this single-center, parallel-group randomized controlled trial, 88 ARDS patients in the rehabilitation phase were randomized 1:1 to a 4-week augmented rehabilitation package incorporating immersive VR in addition to usual care (n = 44) or usual care alone (n = 44). One control participant was lost to follow-up, and 87 participants were included in the available-case analysis. The primary outcome was change in Montreal Cognitive Assessment (MoCA) score from baseline to 4 weeks. Secondary outcomes included the 36-Item Short Form Health Survey (SF-36) and Hospital Anxiety and Depression Scale (HADS) scores. The main between-group analysis used analysis of covariance (ANCOVA), with follow-up score as the dependent variable and baseline score as the covariate.

Baseline imbalances were observed for age, MoCA, SF-36, and HADS-A scores. After adjustment for corresponding baseline scores, the VR group showed greater improvement in MoCA score than the control group (adjusted between-group effect: 1.42, 95% CI 0.86–1.98; p <  0.001). The VR group also showed higher SF-36 scores (adjusted effect: 13.20, 95% CI 11.85–14.54; p <  0.001) and lower HADS-A scores (adjusted effect: −2.55, 95% CI −3.23 to −1.88; p <  0.001). In the VR group, 29 of 44 participants (65.9%) reported being very satisfied or satisfied with the intervention.

An augmented rehabilitation package incorporating immersive VR was associated with short-term improvements in cognition, health-related quality of life, and anxiety symptoms during early ARDS recovery. Because the package also entailed additional structured rehabilitation exposure, staff attention, interaction, repeated activity, feedback, and treatment time, and because the control condition was not time- or attention-matched, the observed differences cannot be attributed specifically to VR. These single-center, short-term, hypothesis-generating findings require confirmation in larger studies with time- and attention-matched controls. Trial registration: Chinese Clinical Trial Registry, ChiCTR2600122078; retrospectively registered on 8 April 2026, after completion of participant recruitment.