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Airway pressure release ventilation (APRV) is a new mode of ventilation. APRV is used in the acute respiratory distress syndrome when the low tidal volume strategy was not responding to assisted controlled mandatory ventilation (ACMV). Four cases of acute respiratory distress syndrome and severe life threatening hypoxia with ACMV whom were successfully managed with APRV are reported in this article. Although hypoxemia patients were treated by APRV method but eventually two patients died.