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In ARDS, lung-protective ventilation prioritizes low tidal volumes (≈6 mL/kg PBW) and limits plateau pressure ≤30 cm H₂O. Persistent hypoxemia despite FiO₂ 0.60 and PEEP 12 suggests need for a higher PEEP strategy to recruit alveoli and improve V/Q matching. Incremental PEEP increases (e.g., by 2 cm H₂O) with close monitoring of plateau pressure, driving pressure (plateau − PEEP), and blood pressure are appropriate. Raising VT (A) risks volutrauma and increased plateau pressure. Decreasing RR (C) would likely worsen oxygenation and hypercapnia. Jumping to 100% FiO₂ (D) can be temporarily used for severe desaturation, but prolonged high FiO₂ increases oxygen toxicity risk and does not address low end-expiratory alveolar recruitment. Also consider prone positioning at the receiving facility, ensure adequate sedation, and evaluate for neuromuscular blockade if indicated by protocol and consulting team guidance.