Acute respiratory distress syndrome: Clinical features and diagnosis in adults
- Mark D Siegel, MD
Mark D Siegel, MD
- Professor of Medicine
- Yale University School of Medicine
A distinct type of hypoxemic respiratory failure characterized by acute abnormality of both lungs was first recognized during the 1960s. Military clinicians working in surgical hospitals in Vietnam called it shock lung, while civilian clinicians referred to it as adult respiratory distress syndrome . Subsequent recognition that individuals of any age could be afflicted led to the current term, acute respiratory distress syndrome (ARDS).
ARDS is an acute, diffuse, inflammatory lung injury that leads to increased pulmonary vascular permeability, increased lung weight, and a loss of aerated tissue . Clinical hallmarks of ARDS are hypoxemia and bilateral radiographic opacities, while the pathological hallmark is diffuse alveolar damage (ie, alveolar edema with or without focal hemorrhage, acute inflammation of the alveolar walls, and hyaline membranes).
ARDS is associated with a variety of risk factors and etiologies. These conditions are grouped together under the term ARDS because the clinical, physiological features, pathological features, and management are similar regardless of the inciting event.
The clinical presentation, course, diagnostic evaluation, and diagnostic criteria of ARDS are reviewed here. The epidemiology, pathogenesis, etiology, and management of ARDS are discussed separately. (See "Acute respiratory distress syndrome: Epidemiology, pathophysiology, pathology, and etiology in adults" and "Acute respiratory distress syndrome: Prognosis and outcomes in adults" and "Mechanical ventilation of adults in acute respiratory distress syndrome" and "Acute respiratory distress syndrome: Supportive care and oxygenation in adults" and "Acute respiratory distress syndrome: Investigational or ineffective pharmacotherapy in adults".)
Clinical presentation — The clinical features of ARDS usually appear within 6 to 72 hours of an inciting event and worsen rapidly . Patients typically present with dyspnea, cyanosis (ie, hypoxemia), and diffuse crackles. Respiratory distress is usually evident, including tachypnea, tachycardia, diaphoresis, and use of accessory muscles of respiration. A cough and chest pain may also exist.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet 1967; 2:319.
- The ARDS Definition Task Force. Acute Respiratory Distress Syndrome: The Berlin Definition. JAMA 2012; May 21, 2012:Epub ahead of print.
- Hudson LD, Milberg JA, Anardi D, Maunder RJ. Clinical risks for development of the acute respiratory distress syndrome. Am J Respir Crit Care Med 1995; 151:293.
- Goodman LR. Congestive heart failure and adult respiratory distress syndrome. New insights using computed tomography. Radiol Clin North Am 1996; 34:33.
- Gattinoni L, Presenti A, Torresin A, et al. Adult respiratory distress syndrome profiles by computed tomography. J Thorac Imaging 1986; 1:25.
- Pelosi P, Crotti S, Brazzi L, Gattinoni L. Computed tomography in adult respiratory distress syndrome: what has it taught us? Eur Respir J 1996; 9:1055.
- Rubenfeld GD, Caldwell E, Granton J, et al. Interobserver variability in applying a radiographic definition for ARDS. Chest 1999; 116:1347.
- Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293.
- Mikkelsen ME, Christie JD, Lanken PN, et al. The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury. Am J Respir Crit Care Med 2012; 185:1307.
- Gammon RB, Shin MS, Buchalter SE. Pulmonary barotrauma in mechanical ventilation. Patterns and risk factors. Chest 1992; 102:568.
- Gammon RB, Shin MS, Groves RH Jr, et al. Clinical risk factors for pulmonary barotrauma: a multivariate analysis. Am J Respir Crit Care Med 1995; 152:1235.
- Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342:1301.
- Boussarsar M, Thierry G, Jaber S, et al. Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome. Intensive Care Med 2002; 28:406.
- Schnapp LM, Chin DP, Szaflarski N, Matthay MA. Frequency and importance of barotrauma in 100 patients with acute lung injury. Crit Care Med 1995; 23:272.
- Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29:1370.
- Artigas A, Bernard GR, Carlet J, et al. The American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome. Am J Respir Crit Care Med 1998; 157:1332.
- Bercker S, Weber-Carstens S, Deja M, et al. Critical illness polyneuropathy and myopathy in patients with acute respiratory distress syndrome. Crit Care Med 2005; 33:711.
- van den Boogaard M, Schoonhoven L, Evers AW, et al. Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning. Crit Care Med 2012; 40:112.
- Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010; 363:1107.
- Seidenfeld JJ, Pohl DF, Bell RC, et al. Incidence, site, and outcome of infections in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1986; 134:12.
- Kollef MH, Silver P, Murphy DM, Trovillion E. The effect of late-onset ventilator-associated pneumonia in determining patient mortality. Chest 1995; 108:1655.
- Fagon JY, Chastre J, Vuagnat A, et al. Nosocomial pneumonia and mortality among patients in intensive care units. JAMA 1996; 275:866.
- Fagon JY, Chastre J, Hance AJ, et al. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 1993; 94:281.
- Sutherland KR, Steinberg KP, Maunder RJ, et al. Pulmonary infection during the acute respiratory distress syndrome. Am J Respir Crit Care Med 1995; 152:550.
- Andrews CP, Coalson JJ, Smith JD, Johanson WG Jr. Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. Chest 1981; 80:254.
- Chastre J, Trouillet JL, Vuagnat A, et al. Nosocomial pneumonia in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 1998; 157:1165.
- Levitt JE, Vinayak AG, Gehlbach BK, et al. Diagnostic utility of B-type natriuretic peptide in critically ill patients with pulmonary edema: a prospective cohort study. Crit Care 2008; 12:R3.
- Rudiger A, Gasser S, Fischler M, et al. Comparable increase of B-type natriuretic peptide and amino-terminal pro-B-type natriuretic peptide levels in patients with severe sepsis, septic shock, and acute heart failure. Crit Care Med 2006; 34:2140.
- Bouhemad B, Nicolas-Robin A, Arbelot C, et al. Acute left ventricular dilatation and shock-induced myocardial dysfunction. Crit Care Med 2009; 37:441.
- Landesberg G, Gilon D, Meroz Y, et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J 2012; 33:895.
- National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wheeler AP, Bernard GR, et al. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med 2006; 354:2213.
- Richard C, Warszawski J, Anguel N, et al. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003; 290:2713.
- Patel SR, Karmpaliotis D, Ayas NT, et al. The role of open-lung biopsy in ARDS. Chest 2004; 125:197.
- Papazian L, Thomas P, Bregeon F, et al. Open-lung biopsy in patients with acute respiratory distress syndrome. Anesthesiology 1998; 88:935.
- Guerin C, Bayle F, Leray V, et al. Open lung biopsy in nonresolving ARDS frequently identifies diffuse alveolar damage regardless of the severity stage and may have implications for patient management. Intensive Care Med 2015; 41:222.
- Ferguson ND, Fan E, Camporota L, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 2012; 38:1573.
- Rice TW, Wheeler AP, Bernard GR, et al. Comparison of the SpO2/FIO2 ratio and the PaO2/FIO2 ratio in patients with acute lung injury or ARDS. Chest 2007; 132:410.
- Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149:818.
- Bellani G, Laffey JG, Pham T, et al. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. JAMA 2016; 315:788.
- Thille AW, Esteban A, Fernández-Segoviano P, et al. Comparison of the Berlin definition for acute respiratory distress syndrome with autopsy. Am J Respir Crit Care Med 2013; 187:761.
- Schwarz MI, Albert RK. "Imitators" of the ARDS: implications for diagnosis and treatment. Chest 2004; 125:1530.
- Pope-Harman AL, Davis WB, Allen ED, et al. Acute eosinophilic pneumonia. A summary of 15 cases and review of the literature. Medicine (Baltimore) 1996; 75:334.
- Buchheit J, Eid N, Rodgers G Jr, et al. Acute eosinophilic pneumonia with respiratory failure: a new syndrome? Am Rev Respir Dis 1992; 145:716.
- Philit F, Etienne-Mastroïanni B, Parrot A, et al. Idiopathic acute eosinophilic pneumonia: a study of 22 patients. Am J Respir Crit Care Med 2002; 166:1235.
- CLINICAL FEATURES
- Clinical presentation
- Clinical course
- - Barotrauma
- - Delirium
- - Nosocomial infection
- - Other complications
- DIAGNOSTIC EVALUATION
- Excluding cardiogenic pulmonary edema
- Excluding other causes of hypoxemic respiratory failure
- DIAGNOSTIC CRITERIA
- Berlin definition
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS