Acute Respiratory Distress Syndrome (ARDS) Diagnosis, Treatment & Cost

✅Acute Respiratory Distress Syndrome Stages

ARDS is often described in three pathological stages based on changes seen in lung tissue and clinical progression. 3 stages have been described in standard critical care and pathology studies.

• Exudative (Early) Stage: This stage often develops between the first 1-7 days after the initial injury. Severe inflammation breaks down the alveolar-capillary barrier, allowing protein-rich fluid to enter the alveoli. As a result, the lungs grow heavier and less pliable, causing acute and severe hypoxia. Most people are diagnosed at this point and often require mechanical ventilator support. 
• Proliferative (Intermediate) Stage: This stage normally occurs 7-21 days following the beginning. Inflammation begins to subside, and the body starts to heal damaged lung tissue. Healing cells multiply, and some fluid from the air gaps is reabsorbed. Oxygen levels may gradually improve during this stage if recovery continues. 
• Fibrotic (Late) Stage: In some ARDS cases—especially when severe or prolonged—a fibrotic phase may develop after about three weeks. Scar tissue forms in the lungs, making them stiff and harder to ventilate. However, many patients recover before this stage occurs.
  

✅ARDS Differential Diagnosis

✅Goals of Treatment in ARDS

The management of acute respiratory distress syndrome (ARDS) aims to support breathing, protect the lungs from further damage, and address the underlying cause while preserving overall organ function. Key goals include:

• To improve oxygenation via adequate respiratory support, such as supplemental oxygen or mechanical ventilation, to maintain acceptable blood oxygen levels.
• To reduce further lung injury through lung-protective ventilation strategies, including low tidal volumes and controlled airway pressures.
• To treat the underlying cause by promptly managing conditions such as infection, sepsis, aspiration, or trauma that triggered ARDS.
• To maintain hemodynamic stability by carefully managing fluids and medications to ensure adequate blood flow to vital organs without worsening lung edema.
• To prevent complications by reducing the risk of ventilator-associated pneumonia, blood clots, pressure injuries, and long-term lung damage.

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Severe hypoxemia (low oxygen) and decreased lung compliance due to diffuse alveolar damage are characteristic symptoms of acute respiratory distress syndrome, a potentially fatal condition. The primary goals of supportive care are to increase oxygenation and stop additional lung damage.

The following are the treatment options for ARDS:

Management of the Underlying Cause

• Early broad-spectrum antibiotics for suspected sepsis or pneumonia
• Antiviral or antifungal therapy when indicated
• Source control (e.g., drainage of abscess, control of bleeding, surgery for trauma)
• Discontinuation of offending drugs
• Hemodynamic stabilization with intravenous fluids and vasopressors
• Blood transfusion if clinically indicated

Early correction of the triggering event prevents further lung injury.

Respiratory Support (Core of ARDS Treatment)

• Oxygen Therapy for mild ARDS
• Nasal cannula
• Face mask
• High-flow nasal oxygen (HFNO)

Used when oxygen levels are low but the patient can breathe independently.

• Non-Invasive Ventilation for Selected Cases
• CPAP (Continuous Positive Airway Pressure)
• BiPAP (Bilevel Positive Airway Pressure)

Used cautiously in mild ARDS with close monitoring.

• Invasive Mechanical Ventilation for Moderate–Severe ARDS
• Endotracheal intubation
• Lung-protective ventilation strategy:
• Low tidal volume (6 mL/kg predicted body weight)
• Plateau pressure ≤ 30 cm H₂O
• Appropriate PEEP titration
• Driving pressure monitoring
• Permissive hypercapnia (pH ≥ 7.20 if tolerated)
• Target SpO₂ 88–95%

Mechanical ventilation is the main life-saving therapy in ARDS.

• Advanced Ventilatory Strategies for Severe ARDS
• Prone positioning ≥16 hours/day (PaO₂/FiO₂ <150)
• Short-term neuromuscular blockade for ventilator synchrony
• Recruitment maneuvers (selected cases)
• Airway pressure release ventilation (selected centers)
  
  
• Extracorporeal Support for Rescue Therapy
• Venovenous Extracorporeal Membrane Oxygenation (ECMO)
• Extracorporeal CO₂ removal (in specialized centers)

Used when oxygenation fails despite optimal ventilation.

Pharmacological Therapy

Adjunctive ARDS Therapy

• Corticosteroids in selected moderate–severe cases
• Short-term neuromuscular blocking agents
• Inhaled pulmonary vasodilators (e.g., nitric oxide) as rescue therapy

Hemodynamic & Organ Support

• Vasopressors (e.g., norepinephrine) for shock
• Sedatives and analgesics for ventilated patients
• Diuretics in fluid-overloaded patients

Not routinely recommended:

• High-frequency oscillatory ventilation (HFOV)
• Routine surfactant therapy in adults
• Routine beta-agonists

Procedural & Long-Term Support

• Central venous and arterial line placement for monitoring
• Tracheostomy (for prolonged ventilation)
• Dialysis (if acute kidney injury develops)
• Nutritional tube placement (if prolonged feeding required)

Supportive ICU Care

• Conservative fluid strategy after stabilization of shock
• Early enteral nutrition (within 24–48 hours if feasible)
• Glycemic control
• Deep vein thrombosis (DVT) prophylaxis
• Stress ulcer prophylaxis (when indicated)
• Ventilator-associated pneumonia (VAP) care bundle
• Pressure area care
• Early physiotherapy and mobilization
  
  

Management of the Underlying Cause

Management of acute respiratory distress syndrome (ARDS) requires prompt identification and treatment of its underlying cause. Commonly include:

• Early broad-spectrum antibiotics (suspected sepsis/pneumonia): These are given early because infection is one of the most common ARDS triggers, and rapid control of the infection helps limit ongoing lung inflammation and organ failure. 
• Antiviral or antifungal therapy: It is indicated only when a particular viral/fungal cause is confirmed, and treating the real pathogen helps in reducing the inflammatory drive that worsens lung injury. 
• Source control (drain abscess/control bleeding/surgery for trauma): It is important to remove or correct the source of infection or injury, as ARDS often persists if the trigger persists. 
• Discontinue offending drugs: If ARDS/ acute lung injury is drug-related, stopping the causative agent prevents continued toxic/inflammatory lung damage and supports recovery with supportive care. 
• Hemodynamic stabilization (IV fluids + vasopressors): It ensures adequate organ perfusion; after initial resuscitation, avoiding excess fluids helps prevent worsening lung edema. 
• Blood transfusion (if clinically indicated): It is used when low haemoglobin/major bleeding compromises oxygen delivery; transfuse only when needed, balancing benefits vs transfusion-related complications.
  
  

Respiratory Support (Core of ARDS Treatment)

Oxygen Therapy (Mild ARDS)

• Nasal cannula / Face mask: These are simple ways to deliver extra oxygen when a person is still able to breathe on their own. They can raise blood oxygen levels, reduce breathlessness, and may be enough in milder cases if oxygen improves and breathing effort stays stable. 
  
• High-flow nasal oxygen (HFNO): HFNO delivers warm, humidified oxygen at higher flow rates than standard oxygen. It can make breathing easier, improve oxygen levels, and help some patients avoid intubation—provided they are monitored closely so that worsening is not missed.

Non-Invasive Ventilation (Selected Cases)

• Continuous Positive Airway Pressure (CPAP): It maintains steady pressure to keep the air sacs open. It can enhance oxygenation in specifically selected moderate cases, but it must be used with caution because some patients can suddenly deteriorate and require emergency intubation. 
• Bilevel Positive Airway Pressure (BiPAP): It gives additional support during inhalation, minimising the amount of time spent inhaling. It may benefit some patients early on, but if oxygen levels remain low or breathing becomes labored, doctors usually switch to invasive ventilation rather than prolonging non-invasive assistance for too long.

Invasive Mechanical Ventilation (Moderate–Severe ARDS)

• Endotracheal Intubation: In patients with moderate to severe ARDS, a breathing tube is inserted into the trachea to allow the ventilator to assist or control breathing. This step is considered when oxygen levels remain low despite oxygen therapy, breathing difficulty increases, or the patient is unable to maintain airway protection.
• Lung-Protective Ventilation Strategy: Mechanical ventilation is necessary for many ARDS patients, although high pressures and huge air volumes can exacerbate lung injury. As a result, a lung-protective technique is used to prevent additional damage while ensuring proper gas exchange.
• Low Tidal Volume (around 6 mL/kg predicted body weight): Smaller breath volumes are used to avoid overstretching of wounded lung tissue. This method has been found to improve survival across bigger breath volumes.
  
• Plateau Pressure ≤ 30 cm H₂O: It reflects the pressure applied to the lungs during ventilation. Keeping it within safe limits reduces the risk of pressure-related lung injury.
• Appropriate PEEP Adjustment: It helps keep air sacs open at the end of exhalation. This improves oxygenation and reduces repeated collapse and reopening of lung units.
• Driving Pressure Monitoring: It represents the pressure difference needed to deliver each breath. Lower driving pressures are associated with better outcomes, so adjustments are made to keep this value controlled.
• Permissive Hypercapnia: To avoid using high ventilator pressures, slightly elevated carbon dioxide levels may be accepted, provided blood pH remains within a tolerable range.
• Target Oxygen Saturation (SpO₂ 88–95%): Oxygen levels are maintained within a safe range rather than pushed to very high values, as excessive oxygen can also cause harm.
  
  

Advanced Ventilatory Strategies (Severe ARDS)

• Prone Positioning (usually for long sessions in severe cases): In severe acute respiratory distress syndrome (ARDS), if oxygen levels remain low despite regular ventilator settings, the patient may be reversed onto his stomach. This position can boost oxygen levels by changing how air flows through the lungs. It is frequently done for an extended amount of time in the ICU to ensure close monitoring.
• Short-Term Neuromuscular Blockade: Some patients do not breathe in coordination with the ventilator. In such cases, short-term muscle relaxants may be given so the ventilator can deliver set breaths properly. This is generally limited to selected patients and for a short duration.
• Recruitment Maneuvers: It involves briefly increasing airway pressure to open collapsed parts of the lung. The effect on oxygen may be temporary. Because this method can affect blood pressure, it is not used routinely and is applied only when considered necessary.
• Airway Pressure Release Ventilation (APRV): It is a ventilation mode used in some ICUs. It maintains higher airway pressure for longer periods while allowing spontaneous breathing. It is not standard for all ARDS patients and is used based on clinician judgment and local practice.

Extracorporeal Support (Rescue Therapy)

• Venovenous extracorporeal membrane oxygenation (VV-ECMO): ECMO is a machine that supplies oxygen to the blood and removes carbon dioxide from the body, enabling the lungs to rest while maintaining protective ventilation. Trials in very severe ARDS back up their use as a rescue option in carefully selected patients at specialized hospitals. 
• Extracorporeal CO₂ removal (specialized centers): This approach mainly removes carbon dioxide and may help reduce ventilator stress in very specific situations. Because it requires expertise and is not widely available, it is typically limited to specialized centers and selected cases.
  
  

Pharmacological Therapy in ARDS

Adjunctive ARDS Therapy

• Corticosteroids (moderate to severe cases): These can help certain ARDS patients by alleviating inflammation of the lung and shortening severe illness. However, they are not suitable for all individuals. Their use depends on the severity of the condition, duration of treatment, risk factors of infection, and the doctor's judgment.
• Short-term neuromuscular blocking agents: In early, severe ARDS, short-term muscle relaxants may be used to improve ventilator synchrony and allow lung-protective ventilation to be delivered properly. Evidence is not uniform across trials, so they are usually reserved for selected patients and have a limited duration. 
• Inhaled pulmonary vasodilators — rescue treatment: These may temporarily improve oxygenation in some patients by improving blood flow to better-ventilated lung areas. However, studies show no consistent survival benefit, so it is not a routine treatment and is mainly used as a short “rescue” measure in refractory hypoxemia.
  
  

Hemodynamic & Organ Support

• Vasopressors for shock: If blood pressure drops to dangerously low levels, as commonly seen in sepsis, vasopressor medications are administered to maintain adequate blood flow to vital organs. These agents help raise blood pressure effectively and are selected based on their safety profile and the patient’s overall condition.
• Sedatives and analgesics for ventilated patients: Pain relief and sedation are used to reduce distress, help tolerate the breathing tube, and allow safe ventilation (especially during proning). ICU guidance generally supports using the lowest sedation needed and aiming for lighter sedation, when possible, to reduce delirium and weakness. 
• Diuretics in fluid-overloaded patients: After shock is stabilized, excess fluid can worsen lung swelling. Diuretics are used to remove extra fluid and support a "dry weight" strategy, which has been shown to improve lung function and reduce time on the ventilator in acute lung injury/ARDS.

Procedural & Long-Term Support

Some procedures are needed in ARDS to monitor unstable patients, deliver medicines, and support organs while the lungs recover. This includes:

• Central venous and arterial line placement for monitoring: Vasopressors can be safely delivered through central lines, which also make it easy to get emergency care. Arterial lines allow for constant monitoring of blood pressure (BP) and frequent blood sampling, which is often needed in people with severe ARDS and shock. 
• Tracheostomy: If ventilation is expected to be prolonged, tracheostomy may be considered to improve comfort, reduce sedation needs in some cases, and support long-term weaning. Timing is individualized; early tracheostomy has not consistently shown survival benefit. 
• Dialysis (if acute kidney injury develops): Kidney injury commonly occurs in critical illness and ARDS. Renal replacement therapy is indicated for fluid overload, uremia, electrolyte/acid-base disturbances, or toxin removal.
• Nutritional tube placement (if prolonged feeding required): When patients cannot eat safely (common with ventilation), enteral feeding is used to provide the calories and protein needed for healing and to decrease muscle loss.
  
  

Supportive ICU Care

Alongside oxygen/ventilator care, ICU measures focus on preventing complications such as clots, infections, bleeding, weakness, and pressure sores.

• Conservative fluid strategy after hemodynamic stabilization: Once blood pressure and circulation are stabilized, a conservative fluid management approach is recommended. This strategy helps reduce pulmonary edema and may decrease the duration of mechanical ventilation and intensive care unit (ICU) stay.
• Enteral nutrition early (within 24 to 48 hours, if possible): Starting enteral feeding early, when it is clinically safe to do so, helps the gut system work well and makes sure that the patient stays healthy. The current guidelines for the ICU usually recommend early enteral nutrition for the right patients. 
• Glycemic control: Extremely tight glucose control has been associated with increased mortality in critically ill patients. Therefore, current practice favors maintaining blood glucose within a moderate and safer target range rather than pursuing strict normalization.
• Deep vein thrombosis (DVT) prophylaxis: Critically ill and immobile patients are at increased risk of venous thromboembolism. Pharmacologic prophylaxis or mechanical methods, when bleeding risk is elevated, are used to reduce the risk of DVT and pulmonary embolism.
• Stress Ulcer Prophylaxis (When Indicated): Selected ICU patients at increased risk of gastrointestinal bleeding may receive acid-suppressive therapy. Prophylaxis is typically targeted to high-risk individuals rather than administered routinely to all patients.
• Ventilator-associated pneumonia (VAP) prevention bundle: Implementation of evidence-based prevention bundles—such as head-of-bed elevation, regular oral care, appropriate sedation management, and adherence to unit protocols—has been shown to reduce VAP incidence and may shorten the duration of mechanical ventilation.
• Pressure injury prevention: Regular repositioning, routine skin assessment, and the use of pressure-relieving surfaces help minimize the risk of pressure injuries during prolonged ICU stays.
• Early physiotherapy and mobilization: When clinically appropriate, early and structured mobilization reduces ICU-acquired weakness and improves functional recovery, particularly when combined with optimized sedation practices.

✅Acute Respiratory Distress Syndrome Prognosis

Acute respiratory distress syndrome (ARDS) used to carry a very high risk of mortality, with studies from the 1980s and 1990s reporting mortality rates between 40% -70%. Survival has improved over the last 20 years because of advances in intensive care, but death rates are still significant—about 35%-45% overall, and more than 40% in severe cases. Improvements in outcome are mainly related to low-tidal-volume ventilation, earlier and better treatment of sepsis, careful fluid management, timely antibiotics, and practices such as prone positioning. Even so, outcomes remain worse in older adults and in patients with comorbidities. In most cases, patients die from sepsis and multiple organ failure rather than from respiratory failure alone.

Acute Respiratory Distress Syndrome (ARDS) Treatment Cost in Hyderabad, India

Frequently Asked Questions (FAQs) on Acute Respiratory Distress Syndrome (ARDS)

How is ARDS diagnosed?

ARDS is diagnosed based on the symptoms within one week following a recognized clinical insult, such as pneumonia, sepsis, or trauma. Patients show hypoxemia (lower PaO₂/FiO₂ ratio) and bilateral lung infiltrates on chest imaging (X-ray or CT), which cannot be attributed to heart failure or fluid overload. Physical examination and, in many cases, echocardiography are used to rule out cardiogenic pulmonary edema. Arterial blood gas analysis is used to determine the severity of oxygenation impairment, dividing ARDS into mild, moderate, and severe groups.

What is the cause of death in ARDS?

In Acute Respiratory Distress Syndrome (ARDS), the main cause of death is generally multi-organ failure resulting from severe sepsis, rather than the lung injury alone. While the lungs are severely affected, most deaths occurring after the first 72 hours are because of secondary infections or new organ dysfunction. The leading causes such as sepsis, multi-organ dysfunction syndrome (MODS), and, less commonly, refractory hypoxemia. Ongoing systemic inflammation and the overall stress of critical illness worsen organ function, making early recognition and comprehensive ICU care essential for survival.

Is ARDS terminal?

Acute Respiratory Distress Syndrome (ARDS) is not always terminal, but it is a life-threatening and serious condition. Large clinical studies show that mortality remains substantial, commonly in the 30–50% range, with higher rates in severe cases and in older or medically complex patients. Although a significant proportion of patients do survive with modern critical care, including lung protective ventilation and sepsis management, many survivors experience long-term complications, including persistent muscle weakness, reduced exercise tolerance, cognitive impairment, and impaired quality of life. Therefore, while ARDS can be Life-threatening, it is not universally terminal, and survival with meaningful recovery is possible with prompt and comprehensive ICU care.

What helps heal lungs faster?

The recovery of the lungs from ARDS is largely dependent on proper care of the underlying illness, careful use of ventilator support, and appropriate oxygenation. Supportive measures, including balanced nutrition, hydration regulation, and stopping smoking, all contribute to the healing process. Following hospital discharge, conducting breathing exercises and gradually increasing physical activity helps to rebuild lung strength and endurance. While most patients improve significantly over several months, the rate of recovery may vary based on the ARDS severity and the patient's overall health.

What foods should be avoided during a lung infection?

Food cannot directly worsen lung infections, but eating too much processed, fried, or sugary foods might cause inflammation and slow recovery. Excess salt consumption can contribute to fluid imbalance, which can lead to issues with respiratory disorders. Eating heavy, fatty foods may cause acid reflux, which can worsen coughing or shortness of breath. Alcohol consumption should be avoided because it can decrease immunity and cause recovery to take longer. Consuming a well-balanced diet rich in water, protein, and plant-based foods aids healing from lung infections.

How fast does ARDS progress?

ARDS usually develops quickly, often within a few hours to several days after a serious illness such as severe infection, pneumonia, trauma, or sepsis. According to established clinical criteria, symptoms must begin or worsen within one week of the triggering event. Patients often experience rapidly increasing shortness of breath and low oxygen levels that do not improve with regular oxygen therapy. In severe cases, breathing can worsen over 24–48 hours, requiring intensive care and mechanical ventilation support.

What is the death rate of ARDS?

The death rate of ARDS varies depending on how severe the condition is and the patient’s overall health. Large international studies using the Berlin definition have shown that overall hospital mortality for ARDS is approximately 30% to 40%. Mortality increases with severity: about 25%–30% in mild ARDS, around 30%–35% in moderate ARDS, and 40%–45% or higher in severe ARDS.

Outcomes are also worse in older patients and in people with sepsis, shock, or multi-organ failure. Despite improvements in intensive care and lung-protective ventilation, ARDS remains a serious condition with significant mortality, particularly in serious cases.

How long are ARDS patients on a ventilator?

The duration of mechanical ventilation in ARDS depends largely on how severe the lung injury is and the patient’s overall condition. In many cases, especially with moderate to severe ARDS, ventilator support is needed for roughly one to two weeks. Some patients recover soon and can be taken off the ventilator within a few days. However, patients with severe ARDS, ongoing sepsis, or multiple organ dysfunction may necessarily breathing support for several weeks before they can be gradually taken off the ventilator

Clinical trials evaluating lung-protective ventilation strategies have shown that recovery time may vary widely, and prolonged ventilation is more common in severe ARDS patients. Early improvement in oxygen levels and stabilization of the underlying cause usually determine a shorter ventilator course.

Does ARDS cause brain damage?

Yes, ARDS can contribute to brain injury and lasting “brain-function” problems, but it’s not the same as a stroke in most cases.

In ARDS, the brain can be affected because oxygen levels may drop (hypoxemia), the body can have severe inflammation (especially with sepsis), and ICU complications like delirium can occur. Studies in ARDS survivors show that problems with memory, attention, processing speed, and executive function are common after discharge and may persist for months or longer in some people. 

Some research has also reported structural brain changes (e.g., brain atrophy) in certain ARDS survivors, suggesting that severe critical illness can have measurable effects on the brain. The risk is higher in people who have prolonged delirium, severe illness, prolonged ICU stay, or sepsis, delirium duration in ICU has been strongly linked with worse long-term cognitive outcomes.

Is ARDS a genetic condition?

ARDS is not a hereditary condition. It develops as a complication of serious illnesses or injuries such as severe pneumonia, sepsis, aspiration, major trauma, or pancreatitis. It does not pass from one generation to another and occurs only after a significant medical event triggers lung injury.

Research has shown that genetic differences may influence how a person’s immune system responds to severe infection or inflammation. These variations can influence the risk of developing ARDS or the severity of lung injury after a major trigger. However, genetics alone does not cause ARDS, it develops as a complication of serious underlying medical conditions.