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Acute respiratory distress syndrome

Definition
ARDS is an acute inflammatory disease of the lungs that develops secondary to pulmonary or extrapulmonary damage to the alveolar-capillary membrane, leading to interstitial and alveolar edema. Clinically, ARDS is characterized by acute hypoxemic respiratory failure, decreased lung compliance, and bilateral radiographic infiltrates in the absence of cardiogenic pulmonary edema.
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Pathophysiology
An acute injury to the lungs (direct or indirect) is the most common cause of ARDS, with pneumonia, aspiration of gastric contents, and sepsis accounting for > 85% of all cases.
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Epidemiology
In the US, the incidence of ARDS is estimated at 64.2-78.9 cases per 100,000 person-years.
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Disease course
Classically, an initial exudative phase with interstitial and alveolar edema is followed by a proliferative phase, which may further progress to a fibrotic phase. The latter is associated with collagen deposition, along with interstitial and alveolar fibrosis, causing decreased lung compliance, respiratory dysfunction, multisystem organ failure, and death.
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Prognosis and risk of recurrence
ARDS is associated with an in-hospital mortality of 27%, 32%, and 45% for mild, moderate, and severe disease, respectively.
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Key sources
The following summarized guidelines for the evaluation and management of acute respiratory distress syndrome are prepared by our editorial team based on guidelines from the American Thoracic Society (ATS 2024), the Society of Critical Care Medicine (SCCM 2024; 2016), the European Society of Intensive Care Medicine (ESICM 2023), the Japanese Society of Respiratory Care Medicine (JSRCM/JSICM 2022), the Surviving Sepsis Campaign (SSC 2021; 2017), the British Thoracic Society (BTS 2019), the European Society of Intensive Care Medicine (ESICM/SCCM 2017), the European Respiratory Society (ERS 2017), and the European Society of Intensive Care Medicine (ESICM/SCCM/ATS 2017).
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Guidelines

1.Screening and diagnosis

Diagnosis: suspect ARDS in patients with acute respiratory failure.
B
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2.Classification and risk stratification

Prognosis: avoid using lung pathology, chest CT, or PaO2/FiO2 ratio only for predicting the prognosis in patients with ARDS.
D

3.Diagnostic investigations

Cardiac biomarkers: consider measuring BNP or NT-proBNP levels to identify cardiogenic pulmonary edema in patients with acute respiratory failure.
C

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  • Infectious workup

4.Respiratory support

High-flow nasal oxygen therapy
As per ESICM 2023 guidelines:
Initiate high-flow nasal oxygen therapy over conventional oxygen therapy to reduce the risk of intubation in non-mechanically ventilated patients with acute hypoxemic respiratory failure (including patients with COVID-19) not due to cardiogenic pulmonary edema or acute exacerbation of COPD.
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Insufficient evidence to recommend for or against the use of high-flow nasal oxygen compared to CPAP/noninvasive ventilation to reduce intubation
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or mortality in unselected patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema or acute exacerbation of COPD.
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  • Noninvasive ventilation

  • Mechanical ventilation (early tracheostomy)

  • Mechanical ventilation (tidal volume targets)

  • Mechanical ventilation (plateau pressure targets)

  • Mechanical ventilation (PEEP targets)

  • Mechanical ventilation (recruitment maneuvers)

  • Mechanical ventilation (prone positioning)

  • Mechanical ventilation (high-frequency oscillatory ventilation)

  • Mechanical ventilation (oxygen targets)

  • Mechanical ventilation (weaning)

5.Medical management

Fluid management: consider using restrictive strategies for fluid management in adult patients with ARDS.
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  • Sedation

  • Corticosteroids

  • Neuromuscular blockade

  • Inhaled nitric oxide

  • Thrombomodulin

  • Sivelestat

6.Nonpharmacologic interventions

Enteral nutrition: consider administering enteral nutrition with high omega-3 fatty acid content in patients with ARDS.
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7.Therapeutic procedures

Pulmonary artery catheterization: do not perform pulmonary artery catheterization routinely in patients with sepsis-induced ARDS.
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  • ECMO

  • Extracorporeal CO2 removal

8.Follow-up and surveillance

Rehabilitation: consider initiating early (within 72 hours) rehabilitation in adult patients with ARDS.
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