Acute respiratory distress syndrome natural history, complications, and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Brian Shaller, M.D. [2]
Overview
ARDS usually develops within 24 to 48 hours of the initial injury or illness and typically progresses over the course of 1 to 2 weeks (refer to [[Acute respiratory distress syndrome pathophysiology|Pathophysiology of ARDS]). Failure to diagnose and treat ARDS early on is associated with a high mortality rate and may result in lifelong complications among survivors.
Natural History
The first signs of ARDS typically present within 24 to 48 hours of the precipitating illness or injury and progress over the course of 1 to 2 weeks. The early clinical features of ARDS include:
- Hypoxemia (a declining peripheral blood oxygen saturation [SpO2] on pulse oximetry or a declining partial pressure of oxygen [PaO2] on arterial blood gas analysis) requiring high concentrations of supplemental oxygen (i.e., a higher fraction of inspired oxygen [FIO2]) or positive pressure ventilation (i.e., a higher continuous positive airway pressure [CPAP] or a higher positive end-expiratory pressure [PEEP]) in order to maintain acceptable blood oxygenation
- Tachypnea and labored breathing
- Tachycardia
- Signs or symptoms that suggest worsening of the underlying illness
Left untreated, the mortality rate from ARDS is estimated to be upwards of 70%.[1]
Complications
Long-term sequelae of ARDS are common, however, they are more likely to develop among those who do not receive early or adequate treatment. They include:
- Significant weakness due to critical illness myoneuropathy and muscle atrophy as a result of long-term immobilization, sometimes resulting in lifelong physical disability
- Impaired lung function
- Chronic ventilator dependency due to advanced weakness and atrophy of the muscles of respiration
- Pulmonary fibrosis and restrictive lung disease
- Psychiatric illness (e.g., post-traumatic stress disorder [PTSD], anxiety, depression)
- Impaired cognition
- Persistent vegetative state or brain death due to prolonged hypoxemia
The most common complications of ARDS are those associated with a prolonged ICU stay:
- Secondary or nosocomial infections (e.g., ventilator-associated pneumonia [VAP] or central line-associated blood stream infection [CLABSI])
- Venous thromboembolic events (e.g., deep vein thrombosis [DVT] or pulmonary embolism [PE])
- Gastrointestinal bleeding (often secondary to stress ulcers)
- Pressure ulcers and poor wound healing
- Muscle wasting and atrophy
Prognosis
Prognosis for patients with ARDS varies based on the severity of illness, the [[Acute respiratory distress syndrome causes|precipitating insult}}, and medical comorbidities:
- The ARDS Definition Task Force calculated 90-day morality rates for mild, moderate, and severe ARDS as 27%, 32%, and 45%, respectively[2]
- The 1-year mortality rate for patients with ARDS who survive to hospital discharge varies widely between different studies and is estimated to be anywhere from 11% to over 40%[3][4][5]
- One study of patients diagnosed with ARDS in Maryland, United States, from 1992 through 1995 calculated an in-hospital mortality rate of 36% to 52%[1]
- The mortality rate among patients with ARDS due to trauma appears to be lower than among patients with ARDS due to sepsis[6]
References
- ↑ 1.0 1.1 Reynolds HN, McCunn M, Borg U, Habashi N, Cottingham C, Bar-Lavi Y (1998). "Acute respiratory distress syndrome: estimated incidence and mortality rate in a 5 million-person population base". Crit Care. 2 (1): 29–34. doi:10.1186/cc121. PMC 28999. PMID 11056707.
- ↑ ARDS Definition Task Force. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E; et al. (2012). "Acute respiratory distress syndrome: the Berlin Definition". JAMA. 307 (23): 2526–33. doi:10.1001/jama.2012.5669. PMID 22797452.
- ↑ Herridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Granados N, Al-Saidi F; et al. (2003). "One-year outcomes in survivors of the acute respiratory distress syndrome". N Engl J Med. 348 (8): 683–93. doi:10.1056/NEJMoa022450. PMID 12594312.
- ↑ Linko R, Suojaranta-Ylinen R, Karlsson S, Ruokonen E, Varpula T, Pettilä V; et al. (2010). "One-year mortality, quality of life and predicted life-time cost-utility in critically ill patients with acute respiratory failure". Crit Care. 14 (2): R60. doi:10.1186/cc8957. PMC 2887181. PMID 20384998.
- ↑ Wang CY, Calfee CS, Paul DW, Janz DR, May AK, Zhuo H; et al. (2014). "One-year mortality and predictors of death among hospital survivors of acute respiratory distress syndrome". Intensive Care Med. 40 (3): 388–96. doi:10.1007/s00134-013-3186-3. PMC 3943651. PMID 24435201.
- ↑ Sheu CC, Gong MN, Zhai R, Chen F, Bajwa EK, Clardy PF; et al. (2010). "Clinical characteristics and outcomes of sepsis-related vs non-sepsis-related ARDS". Chest. 138 (3): 559–67. doi:10.1378/chest.09-2933. PMC 2940067. PMID 20507948.