An expert panel compiled recommendations for the setting and modification of airway positive pressure ventilation (APRV) in adult patients with acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). Initial settings include upper airway pressure (PHigh) at plateau or peak inspiratory pressure from previous ventilation, PHigh duration (THigh) according to current respiratory rate on conventional ventilation, lower pressure (PLow) at 0 cmH2O, and PLow duration (TLow) calculated as peak expiratory flow times 75%. Recommendations are based on roundtable discussions, a nominal group consensus technique, clinical experience, and evidence from the pulmonary physiology literature. Settings are titrated according to changes in lung physiology and deleterious settings that impair gas exchange or cause lung instability are identified. The protocol optimizes lung protection in APRV for patients with ALI, ARDS, or elastance disorders.