Surface microbial dynamics and residual diversity in patient rooms with wooden and painted walls.

Acute respiratory distress syndrome (ARDS) is a life-threatening clinical condition characterized by acute hypoxemic respiratory failure (AHRF) and diffuse pulmonary inflammation that occurs independently of cardiogenic pulmonary edema [–]. It can be triggered by a wide range of direct pulmonary injuries or indirect extrapulmonary [, , ] insults. Despite the implementation of effective comprehensive critical care interventions, including lung-protective ventilation, prone positioning, and individualized fluid management [–], ARDS remains a major global health challenge with persistently high morbidity and mortality. Currently, no pharmacological therapies are routinely effective in ARDS, and precision-targeted treatments tailored to individual patient characteristics remain elusive. This challenge stems partly from the marked clinical and biological heterogeneity of the syndrome; in addition, potentially reversible causes, particularly the causative pathogens, are often difficult to identify in a timely manner [], which hinders early initiation of etiology-directed therapy. The molecular and cellular mechanisms underlying ARDS are complex and dynamically evolving, shaped by multiple factors including etiology, disease stage, host status, and immune compartmentalization. More importantly, clinically relevant biomarkers, genetic features, or phenotypic characteristics that are identifiable, measurable, and targetable remain lacking. As a result, most interventions continue to rely on average treatment effects rather than enabling precise selection of patients most likely to benefit. Meanwhile, conventional clinical trial designs are limited by rigid enrollment criteria, suboptimal timing of intervention, and insensitive endpoint selection, further reducing the ability to detect potentially meaningful therapeutic signals. Accordingly, meaningful advances in ARDS treatment will depend not only on the development of new drugs, but also on the coordinated progress in rapid etiological identification, mechanism-guided stratification, and innovative trial design.