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Acute Respiratory Distress Syndrome: Differential Diagnoses & Workup

Author: Eloise M Harman, MD, Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida College of Medicine
Contributor Information and Disclosures

Updated: Nov 4, 2009

Differential Diagnoses

Goodpasture Syndrome
Septic Shock
Hypersensitivity Pneumonitis
Shock, Hemorrhagic
Multisystem Organ Failure of Sepsis
Toxic Shock Syndrome
Nosocomial Pneumonia
Toxicity, Heroin
Perioperative Pulmonary Management
Toxicity, Salicylate
Pneumocystis Carinii Pneumonia
Transfusion Reactions
Pneumonia, Aspiration
Tumor Lysis Syndrome
Pneumonia, Bacterial
Ventilation, Mechanical
Pneumonia, Viral
Ventilation, Noninvasive
Pulmonary Eosinophilia
Ventilator-Associated Pneumonia
Respiratory Failure
Sepsis, Bacterial

Other Problems to Be Considered

Pulmonary hemorrhage
Near drowning
Drug reaction
Noncardiogenic pulmonary edema
Hamman-Rich syndrome
Retinoic acid syndrome
Acute hypersensitivity pneumonitis
Transfusion-related acute lung injury (TRALI)
Acute eosinophilic pneumonia
Reperfusion injury
Leukemic infiltration
Fat embolism syndrome

Workup

Laboratory Studies

  • In addition to hypoxemia, arterial blood gases often initially show a respiratory alkalosis. However, in acute respiratory distress syndrome (ARDS) occurring in the context of sepsis, a metabolic acidosis with or without respiratory compensation may be present. As the condition progresses and the work of breathing increases, the partial pressure of carbon dioxide (PCO2) begins to rise and respiratory alkalosis gives way to respiratory acidosis. Patients on mechanical ventilation for ARDS may be allowed to remain hypercapnic (permissive hypercapnia) to achieve the goals of low tidal volume and limited plateau pressure ventilator strategies aimed at limiting ventilator-associated lung injury.
  • ARDS is a clinical diagnosis, and no specific laboratory abnormalities are noted beyond the expected disturbances in gas exchange and radiographic findings. ARDS is defined by a PaO2/FiO2 ratio of less than 200 and ALI by a ratio of less than 300. Other abnormalities observed depend on the underlying cause or associated complications and may include the following:
    • Hematologic: In septic patients, leukopenia or leukocytosis may be noted. Thrombocytopenia may be observed in septic patients in the presence of disseminated intravascular coagulation (DIC). Von Willebrand factor (VWF) may be elevated in patients at risk for ARDS and may be a marker of endothelial injury.
    • Renal: Acute tubular necrosis (ATN) often ensues in the course of ARDS, probably from ischemia to the kidneys. Renal function should be closely monitored.
    • Hepatic: Liver function abnormalities may be noted in either a pattern of hepatocellular injury or cholestasis.
    • Cytokines: Multiple cytokines, such as IL-1, IL-6, and IL-8, are elevated in the serum of patients at risk for ARDS.

Imaging Studies

  • Radiographic manifestations
    • Acute respiratory distress syndrome (ARDS) is defined by the presence of bilateral pulmonary infiltrates. The infiltrates may be diffuse and symmetric or asymmetric, especially if superimposed upon preexisting lung disease or if the insult causing ARDS was a pulmonary process, such as aspiration or lung contusion.
    • The pulmonary infiltrates usually evolve rapidly, with maximal severity within the first 3 days. Infiltrates can be noted on chest radiograph almost immediately after the onset of gas exchange abnormalities. Infiltrates may be interstitial, characterized by alveolar filling, or both.
    • Initially, the infiltrates may have a patchy peripheral distribution but soon progress to diffuse bilateral involvement with ground glass changes or frank alveolar infiltrates.
    • The correlation between radiographic findings and severity of hypoxemia is highly variable. Also, diuresis tends to improve infiltrates and volume overload tends to worsen them, irrespective of improvement or worsening in underlying ARDS.
    • For patients who begin to improve and show signs of resolution, improvement in radiographic abnormalities generally occurs over 10-14 days, but more protracted courses are common.
  • CT scans
    • In general, clinical evaluation and routine chest radiography are sufficient in patients with ARDS. However, a CT scan may be indicated in some situations.
    • The CT scan is more sensitive than plain chest radiography in detecting pulmonary interstitial emphysema, pneumothoraces and pneumomediastinum, pleural effusions, cavitation, and mediastinal lymphadenopathy.
    • In some instances, the discovery of unexpected pulmonary pathology, such as a pneumothorax, may be lifesaving. However, this potential benefit must be weighed against the risk associated with transporting a critically ill patient on high-intensity mechanical ventilation out of the intensive care unit to the CT scan equipment.
    • The heterogeneity of alveolar involvement is often apparent on CT scan even in the presence of diffuse homogeneous infiltrates on routine chest radiograph.

Other Tests

  • Acute respiratory distress syndrome (ARDS) is defined by the acute onset of bilateral pulmonary infiltrates and severe hypoxemia in the absence of evidence of cardiogenic pulmonary edema.
  • In ARDS, if the PaO2 is divided by the FIO2, the result is 200 or less. For patients breathing 100% oxygen, this means that the PaO2 is less than 200.

Procedures

  • Hemodynamic monitoring with central venous or pulmonary artery (Swan-Ganz) catheter
    • Because the differential diagnosis of acute respiratory distress syndrome (ARDS) includes cardiogenic pulmonary edema, hemodynamic monitoring with the Swan-Ganz catheter may be helpful in selected cases in separating cardiogenic from noncardiogenic pulmonary edema. The pulmonary artery catheter is floated through an introducer that is placed in a central vein, usually the right internal jugular or subclavian vein. With the balloon inflated, the catheter is advanced with continuous pressure monitoring. This allows measurement of right atrial pressure, right ventricular pressure, pulmonary artery pressure, and pulmonary capillary wedge pressure (PCWP).
    • With the catheter properly positioned, the PCWP reflects filling pressures on the left side of the heart and, indirectly, intravascular volume status. A PCWP of less than 18 mm Hg is usually consistent with noncardiogenic pulmonary edema, although other factors, such as a low plasma oncotic pressure, may allow cardiogenic pulmonary edema to occur at lower pressures.
    • The pulmonary artery catheter also provides other information that may be helpful in both the differential diagnosis and the treatment of these patients. For example, the calculation of systemic vascular resistance based upon thermodilution cardiac output, right atrial pressure, and mean arterial pressure may provide support for the clinical suspicion of sepsis. The use of mixed venous oxygen saturation to allow the calculation of shunt and oxygen delivery is used by some to adjust ventilator parameters and vasoactive support. Mixed venous oxygen saturation is also used in goal-directed therapy for sepsis.
    • Because avoiding fluid-overload may be beneficial in the management of ARDS, the use of a central venous catheter or pulmonary artery (Swan-Ganz) catheter may facilitate appropriate fluid management in these patients in whom judging intravascular volume status on clinical grounds may be difficult or impossible. This may be especially helpful in patients who are hypotensive or those with associated renal failure.
    • Although Swan-Ganz catheters provide considerable information, their use is not without controversy
      • The ARDS Clinical Trials Network studied whether a difference in mortality could be found in patients with ARDS whose fluid management was guided by pulmonary artery catheter versus central venous catheter after initial resuscitation had been completed.7 The study found no difference in mortality, ventilator days, ICU days, need for pressors or dialysis. The pulmonary artery group had twice as many catheter related complications, primarily arrhythmias.
      • Another large retrospective study of critically ill patients monitored with pulmonary artery catheters in the first 24 hours of intensive care admission showed that patients with PA catheters had an increased mortality rate, hospital cost, and length of stay compared with a retrospectively developed matched patient group managed without them.8 Thus, no survival benefit and possibly an adverse effect on survival is associated with the use of the pulmonary artery catheter past the time of initial resuscitation. In addition, accurate measurement of hemodynamic parameters with the Swan-Ganz catheter requires skill and care. This is especially difficult in patients either on mechanical ventilation or with forced spontaneous inspirations because the pressure tracing is affected by intrathoracic pressure. PCWP should be measured at end expiration and from the tracing rather than from digital displays on the bedside monitor.
  • Bronchoscopy with BAL or protected specimen brush culture
    • Bronchoscopy may be considered to evaluate the possibility of infection in patients acutely ill with bilateral pulmonary infiltrates. Culture material may be obtained by wedging the bronchoscope in a subsegmental bronchus and collecting the fluid suctioned after instilling large volumes of nonbacteriostatic saline (BAL). The fluid is analyzed for cell differential, cytology, silver stain, and Gram stain and is quantitatively cultured.
    • Ten thousand organisms per milliliter is generally considered significant in a patient not previously treated with antibiotics. The presence of neutrophils in the lavage with intracellular organisms in these cells is also consistent with infection.
    • As noted above, early ARDS is characterized by the presence of neutrophils in the BAL fluid, so the presence of intracellular organisms and the use of quantitative culture are important in establishing infection. An alternative means of obtaining a culture is by means of a protected specimen brush, which is passed through the bronchoscope into a segmental bronchus. Subsequently, the brush is cut off into 1 mL of sterile nonbacteriostatic saline. Culture of 1000 organisms is considered significant.
    • Analysis of the types of cells present in the BAL fluid may be helpful in the differential diagnosis of patients with ARDS. For example, the finding of a high percentage of eosinophils (>20%) in the BAL fluid is consistent with the diagnosis of acute eosinophilic pneumonia. The use of high-dose corticosteroids in these patients may be lifesaving. A high proportion of lymphocytes may be observed in acute hypersensitivity pneumonitis, sarcoidosis, or bronchiolitis obliterans-organizing pneumonia (BOOP). Red cells and hemosiderin-laden macrophages may be observed in pulmonary hemorrhage. Lipid laden macrophages are suggestive of aspiration or lipoid pneumonia.
    • Cytologic evaluation of the BAL fluid may also be helpful in the differential diagnosis of ARDS. This may reveal viral cytopathic changes for example. Silver stain may be helpful in diagnosing an infection, such as Pneumocystis.

Histologic Findings

The histologic changes in acute respiratory distress syndrome (ARDS) are those of diffuse alveolar damage. An exudative phase occurs in the first several days and is characterized by interstitial edema, alveolar hemorrhage and edema, alveolar collapse, pulmonary capillary congestion, and hyaline membrane formation. These histologic changes are nonspecific and do not provide information that would allow the pathologist to determine the cause of the ARDS. A biopsy performed after several days shows the beginning of organization of the intra-alveolar exudate and repair, the proliferative phase of ARDS, which is characterized by the growth of type 2 pneumocytes in the alveolar walls and the appearance fibroblasts, myofibroblasts, and collagen deposition in the interstitium. The final phase of ARDS is fibrotic. Alveolar walls are thickened by connective tissue rather than edema or cellular infiltrate.

Staging

In the 1980s, Murray and coworkers (1988) developed a lung injury scoring system.9 This system was based on 4 parameters, as follows: severity of consolidation based on chest radiograph findings, severity of hypoxemia based on the PaO2/FIO2 ratio, lung compliance, and level of PEEP required. This scoring system has proven helpful in clinical research in ARDS.

More on Acute Respiratory Distress Syndrome

Overview: Acute Respiratory Distress Syndrome
Differential Diagnoses & Workup: Acute Respiratory Distress Syndrome
Treatment & Medication: Acute Respiratory Distress Syndrome
Follow-up: Acute Respiratory Distress Syndrome
Multimedia: Acute Respiratory Distress Syndrome
References
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Further Reading

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Keywords

acute respiratory distress syndrome, ARDS, adult respiratory distress syndrome, acute lung injury, ALI, diffuse alveolar damage, noncardiogenic pulmonary edema, diffuse alveolar injury, bilateral pulmonary infiltrates

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Contributor Information and Disclosures

Author

Eloise M Harman, MD, Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida College of Medicine
Eloise M Harman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American Medical Women's Association, American Thoracic Society, Phi Beta Kappa, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Cory Franklin, MD, Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science; Director, Division of Critical Care Medicine, Cook County Hospital
Cory Franklin, MD is a member of the following medical societies: New York Academy of Sciences and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair, Academic Affairs, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

 
 
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