Acute respiratory distress syndrome (ARDS) is a severe, acute and diffuse inflammatory lung injury arising from multiple etiologies, characterized by alveolar-capillary barrier disruption, pulmonary edema and hypoxemia, with mortality rates ranging from 35% to 50% among critically ill patients. Current management primarily relies on mechanical ventilation and supportive pharmacotherapy; however, there remains a lack of specific therapies for irreversible alveolar-capillary barrier damage, underscoring an urgent need for novel therapeutic strategies. Cellular therapy has emerged as a key focus in ARDS research owing to its multi-targeted actions: in terms of immunomodulation, mesenchymal stem cells (MSCs) and induced pluripotent stem cells (iPSCs) secrete anti-inflammatory factors such as prostaglandin E2 (PGE2) and interleukin (IL)-10, which inhibit the nuclear factor-κB (NF-κB) pathway, reduce levels of pro-inflammatory cytokines including tumor necrosis factor-α (TNF-α) and IL-6, and regulate immune cell homeostasis to mitigate excessive inflammatory responses; for antioxidative stress, MSCs and their exosomes restore mitochondrial function by activating the Nrf2-ARE pathway, diminish reactive oxygen species production and alleviate oxidative damage; regarding tissue repair, MSCs promote the proliferation and migration of alveolar epithelial cells and vascular endothelial cells via the Wnt/β-catenin pathway, while endothelial progenitor cells home to the injury site to repair the vascular endothelium and reduce vascular permeability; in relation to antifibrotic and anti-apoptotic effects, MSCs secrete hepatocyte growth factor to inhibit the TGF-β/Smad pathway and reduce myofibroblast activation, and exosomes deliver miRNAs to suppress alveolar epithelial pyroptosis and delay the fibrotic process. Clinical studies on corona virus disease 2019 (COVID-19)-associated ARDS have confirmed that MSCs, exosomes and regulatory T cells can effectively modulate inflammation and improve oxygenation, while umbilical cord blood, immunity-and-matrix regulatory cells and other cellular products, when combined with standard treatments, have demonstrated synergistic therapeutic potential. Nevertheless, cellular therapy for ARDS faces multiple challenges: therapeutic outcomes are influenced by cell source, dosage, timing of administration and patients’ baseline conditions, with limited long-term prognostic data available; safety concerns include microembolism, the tumorigenicity of iPSCs and immunogenicity issues; and standards for cell expansion, cryopreservation and quality control remain unstandardized, while the core mechanisms underlying therapeutic effects await further clarification. This article systematically reviews the pathogenesis of ARDS and advances in basic and clinical research on cellular therapy, aiming to provide new insights for future treatment strategies.