Diffuse alveolar damage (DAD) describes the pathological features of ARDS. The clinical significance and limitation of high-resolution CT (HRCT) findings in ARDS were reviewed. The HRCT findings correlate well with the pathological phases (exudative, proliferative, and fibrotic) of DAD, though it cannot detect an early exudative phase. Traction bronchiolectasis or bronchiectasis within areas of increased attenuation on HRCT is a sign of progression of these DAD phases, from exudative to the proliferative and fibrotic. Extensive HRCT abnormalities indicative of fibroproliferative changes were independently predictive of poor prognosis in patients with clinically early ARDS. Such findings were also associated with ventilator dependency and its associated complications (ventilator-associated pneumonia, ventilator-associated lung injury, and barotraumas) in patients with ARDS. Pulmonary fibroproliferation assessed by HRCT in patients with early ARDS predicts increased mortality with an increased susceptibility to multiple organ failure, including ventilator dependency and its associated outcomes.