Background: Acute respiratory distress syndrome [ARDS] is usually associated with significant morbidities, and may need admission to intensive care unit [ICU]. Mechanical ventilation when indicated needs continuous monitoring. Aim of the work: To assess clinical value of ultrasonic monitoring in pulmonary recruitment and optimal positive end-expiratory pressure [PEEP] in cases of ARD. Methods: It included thirty patients with ARDS. All were subjected to clinical evaluation, X-ray chest, lung ultrasound and laboratory investigations. All patients underwent mechanical ventilation by increasing PEEP, starting at 5 mmHg then [6, 9, 12, and 15 mmHg] according to patient response with documentation of good response. At each PEEP, chest ultrasound was completed and results were correlated with respiratory functions. Results: Hypertension, diabetes, COPD and hypothyroidism were reported in 63.3%, 66.7%, 16.7% and 40.0% respectively. The rate of primary weaning success was 36.7%, and 30.0% achieved weaning success in the third trail; tracheostomy indicated for 13.3%, pneumothorax 10.0%, pleural effusion 6.7% and mortality rate was 33.3%. Increased PEEP was concomitant by progressive improvement of respiratory functions. In addition, there was progressive significant decrease of B-lines at different areas from right and left lungs. All effects were significant at PEEP 9. Conclusions: Gradual increments of PEEP helps to tailor the patient response on an individual basis. The use of readily available, portable ultrasound, permits the daily monitoring and could guide the treatment protocol.