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
If left untreated, 70% of patients with ARDS may progress to mortality. Common complications to ARDS include weakness, impaired lung function, and brain death. Prognosis for patients with ARDS is generally poor and varies based on the severity of illness, the precipitating insult, and medical comorbidities.
Natural History
The natural history of ARDS is hallmarked by three histopathological phases—exudative, proliferative, and fibrotic phase—each correlated to distinctive clinical manifestations.[1]
Exudative Phase
The exudative phase typically encompasses the first 5 to 7 days of illness after exposure to one or more precipitation factors. Histopathologically, loss of integrity of the alveolar barrier results in influx of proteinaceous fluid into the air place and formation of hyaline membrane. Pulmonary edema and atelectasis with reduced pulmonary compliance ensue, leading to the development of pulmonary shunt and hypoxemia. In this phase, patients experience respiratory symptoms including dyspnea, tachypnea, and increased work of breathing that eventually result in respiratory failure requiring ventilator support. If left untreated, approximately 70% of patients with ARDS may progress to mortality.[2] Among non-survivors, approximately 50% patients die within a week of the onset with exudative change as the predominant histopathological feature.[3]
Proliferative Phase
The proliferative phase generally lasts from day 7 to day 21. Histopathologically, reparative processes take place in the injured alveoli, including organization of exudates, a shift to lymphocyte-predominant infiltrates, and proliferation of type II pneumocytes. In this phase, patients may recover from acute respiratory distress despite the persistence of residual symptoms. Patients who do not recover during this phase develop progressive lung injury and early changes of fibrosis.
Fibrotic Phase
The fibrotic phase occurs 3 to 4 weeks following the initial pulmonary insult. Histopathologically, extensive fibrosis is prominent in the alveolar interstitium and duct, with disruption of acinar architecture and emphysema-like changes. The evidence for pulmonary fibrosis on biopsy is associated with increased mortality.
Complications
Complications of ARDS are more likely to develop among patients who do not receive early or adequate treatment.
Common complications include:
- ARDS is complicated by VAP in approximately 37% to 60% of cases.[4][5][6][7]
- VAP usually develops 5 to 7 days after the initial exposure to the precipitating factor.[8]
- The most likely microorganisms of VAP include non-fermenting Gram-negative bacilli, methicillin-resistant Staphylococcus aureus, and Enterobacteriaceae.[9]
- Barotrauma (e.g., pneumothorax, pneumomediastinum, and subcutaneous emphysema)
- Barotrauma occurs as a consequence of inappropriate positive airway pressure in regions with reduced pulmonary compliance and may complicate ARDS in approximately 10% of cases.[10][11][12]
Other complications include:
- Significant weakness due to critical illness myoneuropathy and muscle atrophy as a result of long-term immobilization
- 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, including post-traumatic stress disorder (PTSD), anxiety, and depression
- Impaired cognition
- Persistent vegetative state or brain death due to prolonged hypoxemia
Complications associated with a prolonged ICU stay include:
- 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 is generally poor and varies based on the severity of illness, the precipitating insult, and medical comorbidities:[13][14][15][16][17][18]
- The 90-day morality rates for mild, moderate, and severe ARDS are 27%, 32%, and 45%, respectively.
- The 1-year mortality rate for patients with ARDS who survive to hospital discharge varies widely and is estimated at 11% to over 40%.
- Between 1992 and 1995, in-hospital mortality rate ranges from 36% to 52%.
- ARDS among trauma patients have a lower mortality as compared with sepsis patients.
References
- ↑ Ware, Lorraine B. “Autopsy in ARDS: Insights into Natural History.” The Lancet. Respiratory Medicine 1, no. 5 (July 2013): 352–54. doi:10.1016/S2213-2600(13)70093-6.
- ↑ National Heart and Lung Institute. Task Force on Research in Respiratory Diseases, and National Heart and Lung Institute. Lung Program. Respiratory Diseases; Task Force Report on Problems, Research Approaches, Needs. The Lung Program, National Heart and Lung Institute. [Bethesda, Md., U.S. Dept. of Health, Education, and Welfare, National Institutes of Health] for sale by the Supt. of Docs., U.S. Govt. Print. Off., Washington, 1972. http://archive.org/details/respiratorydisea00nati.
- ↑ Thille, Arnaud W., Andrés Esteban, Pilar Fernández-Segoviano, José-María Rodriguez, José-Antonio Aramburu, Patricio Vargas-Errázuriz, Ana Martín-Pellicer, José A. Lorente, and Fernando Frutos-Vivar. “Chronology of Histological Lesions in Acute Respiratory Distress Syndrome with Diffuse Alveolar Damage: A Prospective Cohort Study of Clinical Autopsies.” The Lancet. Respiratory Medicine 1, no. 5 (July 2013): 395–401. doi:10.1016/S2213-2600(13)70053-5.
- ↑ Delclaux, C., E. Roupie, F. Blot, L. Brochard, F. Lemaire, and C. Brun-Buisson. “Lower Respiratory Tract Colonization and Infection during Severe Acute Respiratory Distress Syndrome: Incidence and Diagnosis.” American Journal of Respiratory and Critical Care Medicine 156, no. 4 Pt 1 (October 1997): 1092–98. doi:10.1164/ajrccm.156.4.9701065.
- ↑ Markowicz, P., M. Wolff, K. Djedaïni, Y. Cohen, J. Chastre, C. Delclaux, J. Merrer, et al. “Multicenter Prospective Study of Ventilator-Associated Pneumonia during Acute Respiratory Distress Syndrome. Incidence, Prognosis, and Risk Factors. ARDS Study Group.” American Journal of Respiratory and Critical Care Medicine 161, no. 6 (June 2000): 1942–48. doi:10.1164/ajrccm.161.6.9909122.
- ↑ Meduri, G. U., R. C. Reddy, T. Stanley, and F. El-Zeky. “Pneumonia in Acute Respiratory Distress Syndrome. A Prospective Evaluation of Bilateral Bronchoscopic Sampling.” American Journal of Respiratory and Critical Care Medicine 158, no. 3 (September 1998): 870–75. doi:10.1164/ajrccm.158.3.9706112.
- ↑ Chastre, J., J. L. Trouillet, A. Vuagnat, M. L. Joly-Guillou, H. Clavier, M. C. Dombret, and C. Gibert. “Nosocomial Pneumonia in Patients with Acute Respiratory Distress Syndrome.” American Journal of Respiratory and Critical Care Medicine 157, no. 4 Pt 1 (April 1998): 1165–72. doi:10.1164/ajrccm.157.4.9708057.
- ↑ Delclaux, C., E. Roupie, F. Blot, L. Brochard, F. Lemaire, and C. Brun-Buisson. “Lower Respiratory Tract Colonization and Infection during Severe Acute Respiratory Distress Syndrome: Incidence and Diagnosis.” American Journal of Respiratory and Critical Care Medicine 156, no. 4 Pt 1 (October 1997): 1092–98. doi:10.1164/ajrccm.156.4.9701065.
- ↑ Chastre, J., J. L. Trouillet, A. Vuagnat, M. L. Joly-Guillou, H. Clavier, M. C. Dombret, and C. Gibert. “Nosocomial Pneumonia in Patients with Acute Respiratory Distress Syndrome.” American Journal of Respiratory and Critical Care Medicine 157, no. 4 Pt 1 (April 1998): 1165–72. doi:10.1164/ajrccm.157.4.9708057.
- ↑ “Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. The Acute Respiratory Distress Syndrome Network.” The New England Journal of Medicine 342, no. 18 (May 4, 2000): 1301–8. doi:10.1056/NEJM200005043421801.
- ↑ Weg, J. G., A. Anzueto, R. A. Balk, H. P. Wiedemann, E. N. Pattishall, M. A. Schork, and L. A. Wagner. “The Relation of Pneumothorax and Other Air Leaks to Mortality in the Acute Respiratory Distress Syndrome.” The New England Journal of Medicine 338, no. 6 (February 5, 1998): 341–46. doi:10.1056/NEJM199802053380601.
- ↑ Stewart, T. E., M. O. Meade, D. J. Cook, J. T. Granton, R. V. Hodder, S. E. Lapinsky, C. D. Mazer, et al. “Evaluation of a Ventilation Strategy to Prevent Barotrauma in Patients at High Risk for Acute Respiratory Distress Syndrome. Pressure- and Volume-Limited Ventilation Strategy Group.” The New England Journal of Medicine 338, no. 6 (February 5, 1998): 355–61. doi:10.1056/NEJM199802053380603.
- ↑ 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.