A history of alcohol abuse is very common and many times unrecognized in critically ill patients. The consequences of alcohol abuse are multifactorial, and it is associated with excessive morbidity and increased mortality. Alcohol causes acute and chronic dysfunction in multiple organ systems, and the underlying mechanisms responsible for organ injury are complex. In adults with septic shock, a history of alcohol abuse is associated with an increased incidence of Acute Respiratory Distress Syndrome (ARDS) and the development of more severe organ dysfunction. This increased susceptibility to developing acute lung injury has been evaluated by many investigators, and the common variable appears to be oxidative stress. In this article, we review the epidemiology of alcohol abuse and its association with ARDS. In addition, we provide an overview of the mechanisms thought to contribute to ARDS and multiple organ dysfunction.