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This article describes modern strategies for treating acute respiratory distress syndrome (ARDS), with a focus on extracorporeal gas exchange procedures, weaning concepts, and new phenotype-based therapeutic approaches. It highlights key aspects of ARDS treatment based on current recommendations, in particular the new German S3 guideline "Invasive ventilation and use of extracorporeal gas exchange procedures in acute respiratory failure", the American Thoracic Society (ATS) and the European Society of Intensive Care Medicine (ESICM). Venovenous extracorporeal membrane oxygenation (vvECMO) is discussed as a key option for severe ARDS, including indications, complications, technical requirements, and prognostic factors. In addition, the role of ECCO₂R in severe hypercapnia is explained. The second part focuses on a structured weaning process from invasive ventilation, including prerequisites, spontaneous breathing trials, and the management of prolonged weaning. Finally, new developments in the individualization of ARDS therapy are discussed, as biological and radiological subphenotypes demonstrating different responses to therapies may enable future personalized treatment concepts.