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Acute respiratory distress syndrome

Nature Reviews Disease Primers volume 5, Article number: 18 (2019) Cite this article

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Abstract

The acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in critically ill patients and is defined by the acute onset of noncardiogenic pulmonary oedema, hypoxaemia and the need for mechanical ventilation. ARDS occurs most often in the setting of pneumonia, sepsis, aspiration of gastric contents or severe trauma and is present in ~10% of all patients in intensive care units worldwide. Despite some improvements, mortality remains high at 30–40% in most studies. Pathological specimens from patients with ARDS frequently reveal diffuse alveolar damage, and laboratory studies have demonstrated both alveolar epithelial and lung endothelial injury, resulting in accumulation of protein-rich inflammatory oedematous fluid in the alveolar space. Diagnosis is based on consensus syndromic criteria, with modifications for under-resourced settings and in paediatric patients. Treatment focuses on lung-protective ventilation; no specific pharmacotherapies have been identified. Long-term outcomes of patients with ARDS are increasingly recognized as important research targets, as many patients survive ARDS only to have ongoing functional and/or psychological sequelae. Future directions include efforts to facilitate earlier recognition of ARDS, identifying responsive subsets of patients and ongoing efforts to understand fundamental mechanisms of lung injury to design specific treatments.

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Fig. 1: The normal alveolus.
Fig. 2: Microscopic findings in lung tissue in patients with ARDS.
Fig. 3: The injured alveolus.
Fig. 4: Epithelial cell regeneration in ARDS.
Fig. 5: The repaired alveolus.
Fig. 6: Distinguishing ARDS on radiography.
Fig. 7: Common respiratory pathogens in ARDS and associated demographic features and comorbidities.
Fig. 8: Identifying patients with early acute lung injury before progression to ARDS by the Berlin criteria.

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Acknowledgements

The authors declare the following grant support: M.A.M. by the US National Health Lung and Blood Institute (NHLBI; HL140026 and HL134828); C.S.C. by NHLBI (HL140026); G.A.Z. by NHLBI (HL044525, HL077671 and HL130541); Y.M.A. by the Miracle Trial; J.R.B. by NHBLI (HL133489); R.L.Z. by NHLBI (HL131608); A.G.R. by the US National Institute of Child Health and Disease (HD095228); and M.H. by the Canadian Institute of Health. The authors thank S. Ke, University of California–San Francisco, for assistance with organizing the reference list for this article.

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Nature Reviews Disease Primers thanks O. Gajic, Y. Odeyemi, R. Rossaint, W. Seeger, J.-L. Vincent and the other anonymous reviewer(s), for their contribution to the peer review of this work.

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Authors and Affiliations

  1. Cardiovacular Research Institute, University of California–San Francisco, San Francisco, CA, USA

    Michael A. Matthay & Carolyn S. Calfee

  2. Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

    Rachel L. Zemans

  3. Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA

    Guy A. Zimmerman

  4. Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

    Yaseen M. Arabi

  5. Center for Acute Respiratory Failure and Department of Internal Medicine, Columbia University, New York, NY, USA

    Jeremy R. Beitler

  6. Department of Intensive Care, University of Angers, Angers, France

    Alain Mercat

  7. Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada

    Margaret Herridge

  8. Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA

    Adrienne G. Randolph

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  1. Michael A. Matthay
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Contributions

Introduction (M.A.M. and C.S.C.); Epidemiology (M.A.M., A.G.R. and C.S.C.); Mechanisms/pathophysiology (M.A.M., R.L.Z., G.A.Z. and C.S.C.); Diagnosis, screening and prevention (M.A.M., Y.M.A., A.G.R. and C.S.C.); Management (M.A.M., J.R.B., A.M. and C.S.C.); Quality of life (M.H.); Outlook (M.A.M. and C.S.C.); Overview of the Primer (M.A.M. and C.S.C.)

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Correspondence to Michael A. Matthay.

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Competing interests

M.A.M. declares grant support from Bayer (current), GlaxoSmithKline (prior) and Amgen (prior); has served as Data Safety and Monitoring Board chair for Roche-Genentech and has served as a consultant for GlaxoSmithKline, Bayer, Boehringer, CSL Berhring, Navigen, Quark and Cerus. G.A.Z. has served as a consultant for Navigen. Y.M.A. has served as a consultant for Gilead Sciences (past), Regeneron (past) and SAB Therapeutics (current). A.M. received fees for serving on a steering committee for Faron Pharmaceuticals, consulting fees from Air Liquide Medical Systems, grant support for research and lecture fees from Fisher & Paykel and Covidien, and lecture fees from Drager, Pfizer and ResMed. A.G.R. declares grant support from Roche-Genentech (current) and has served as a consultant for La Jolla Pharma and Bristol Meyer Squibb. C.S.C. declares grant support from Bayer (current) and GlaxoSmithKline (prior) and has served as a consultant for GlaxoSmithKline, Bayer, Boehringer, Prometic, Roche-Genentech, CSL Behring and Quark. The remaining authors declare no competing interests.

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Matthay, M.A., Zemans, R.L., Zimmerman, G.A. et al. Acute respiratory distress syndrome. Nat Rev Dis Primers 5, 18 (2019). https://doi.org/10.1038/s41572-019-0069-0

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