The increase in short-term survival of near-drowning victims after an acute submersion episode has respiratory distress syndrome and persistent hypoxic-ischemic central nervous system injury. A 43-year-old male patient was presented with acute respiratory distress syndrome after near drowning. He was severely hypothermic and hypotensive when he arrived to emergency department. His body temperature was 24℃. There was no pulse and no spontaneous respiration. He was treated with advanced life support measure. He was intubated and vasoactive drugs such as epinephrine and norepinephrine were used. On ICU admission, his blood pressure and pulse rate were 80/40 mmHg, 170 beats/min respectively. His oxygen saturation was 40~60% with 100% oxygen. We applied 16~30 cmH_2O of PEEP with low tidal volume for recruitment. Patient was flipped over to prone position. Solu-medrol 1.0g was infused. The blood pressure restored to 140/50 mmHg, and the pulse rate was normalized to 100 beats/min. The dose of vasopressors and inotropes were reduced and stopped 5 hour after the arrival. When the oxygenation has improved, the position was changed to supine and PEEP was lowered. Eventually weaning was successful. Brain MRI and EEG showed global atrophy of cerebral cortex and moderate diffuse brain dysfunction respectively. He received tracheostomy since he was semi-comatose. He was transferred to general ward on 39th ICU day.