PURPOSE OF REVIEW: To describe the most recent advances and clinical applications of adjunctive techniques in mechanical ventilation, focusing on their overall impact on mortality and their potential indications in critically ill patients. RECENT FINDINGS: The modern variants of extracorporeal membrane oxygenation are not only rescue alternatives but also therapeutic options for patients with severe but potentially reversible acute respiratory distress syndrome. Prone positioning returns as a desirable therapeutic option for patients with severe acute respiratory distress syndrome. Recent reports suggest that permissive hypercapnia, therapeutic paralysis, sedation, and controlled hypothermia could potentially improve important clinical outcomes. Although more clinical trials are clearly needed to support the use of inhaled prostacyclins in severe respiratory failure, encouraging results have been described in recent publications. SUMMARY: Giving the complexity and dynamism of acute lung injury, timing, severity, and pathophysiologic pertinence are mandatory components of decision-making when considering the application of adjunctive measures to support mechanical ventilation.