Practice Easily Missed?

Acute respiratory distress syndrome

BMJ 2017; 359 doi: (Published 16 November 2017) Cite this as: BMJ 2017;359:j5055
  1. John G Laffey, consultant anaesthetist and, professor of anaesthesia1 2 3,
  2. Cheryl Misak, professor of philosophy4,
  3. Brian P Kavanagh, clinician-scientist, intensive care medicine2 5
  1. 1Departments of Anesthesia and Critical Care Medicine, Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science, St Michael’s Hospital, Toronto, Canada
  2. 2Departments of Anesthesia, Physiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada
  3. 3Anaesthesia, School of Medicine, National University of Ireland, Galway, Ireland
  4. 4Department of Philosophy, University of Toronto, Canada
  5. 5Department of Critical Care Medicine and Anesthesia, Hospital for Sick Children, Toronto, Canada
  1. Correspondence to J G Laffey john.laffey{at}

What you need to know

  • Consider the possibility of acute respiratory distress syndrome (ARDS) in any sick patient with respiratory distress, especially in the presence of risk factors such as pneumonia, sepsis, trauma, or aspiration of gastric contents.

  • Perform a radiograph of the chest and arterial blood gas sampling for all patients with acute respiratory distress to aid early recognition of ARDS.

  • Timely diagnosis of ARDS facilitates implementation of simple measures that can reduce mortality, morbidity, and financial cost.

A 40 year old woman presented to the emergency department with fever, dyspnoea, and coughing purulent sputum. Chest radiograph revealed bilateral infiltrates, and peripheral capillary oxygen saturation (breathing 50% oxygen) was 92%. Antibiotics and a trial of non-invasive ventilation were commenced, and the patient was admitted to a medical ward.

Twenty four hours later she had worsening dyspnoea, fatigue, and hypotension, and was transferred to the intensive care unit for vasopressor infusion and invasive ventilation. The ventilation was weaned at 3 weeks, but rehabilitation was slow. Two months later, at hospital discharge, she had residual weakness and post-traumatic stress disorder, and her return to work seemed uncertain. Case review showed exemplary management of sepsis but noted a week’s delay in the diagnosis of acute respiratory distress syndrome (ARDS) because of incorrect initial interpretation of the chest radiograph—despite all criteria for ARDS being present in the emergency department. Furthermore, none of the proven strategies in ARDS were employed.

What is ARDS?

Acute respiratory distress syndrome was first described in 19671 and has become a defining condition in critical care. It is an acute inflammatory lung injury, often caused by infection, which increases lung microvascular permeability, resulting in hypoxaemic respiratory failure. It presents with dyspnoea, predominantly in the emergency department or hospital ward,23 and requires assisted ventilation. Around 40% of patients with ARDS will die,2 and survivors …

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