REVIEW

CURRENT
OPINION Current incidence and outcome of the acute
respiratory distress syndrome
Jesús Villar a,b,c, Jesús Blanco a,d, and Robert M. Kacmarek e,f

Purpose of review
This article discusses recently published articles reporting the incidence and outcome of patients with the
acute respiratory distress syndrome (ARDS). This is a difficult task since there is a marked variability
regarding the methodology of the few, large epidemiological, and observational studies on ARDS.
Recent findings
The review will mainly focus on publications from the past 18 months. We have reviewed new
epidemiological studies reporting population-based incidence of ARDS. Also, we have reviewed the data
on survival reported in observational and randomized controlled trials, discussed how the current ARDS
definition modifies the true incidence of ARDS, and briefly mentioned recent approaches that appear to
improve ARDS outcome.
Summary
On the basis of current evidence, it seems that the incidence and overall hospital mortality of ARDS has not
changed substantially in the last decade. Independent of the definition used for identification of ARDS
patients, reported population-based incidence of ARDS is an order of magnitude lower in Europe than in
the USA. Current hospital mortality of combined moderate and severe ARDS reported in observational
studies is greater than 40%.
Keywords
acute respiratory distress syndrome, incidence, outcome, protective ventilation

INTRODUCTION are not clear. Independent of the clinical disorders

Acute respiratory distress syndrome (ARDS) is an
inflammatory process of the lungs that develops in
response to pulmonary and extrapulmonary insults
to the alveolar–capillary membrane, resulting in
increased permeability and subsequent interstitial
and alveolar edema. Clinically, ARDS is characterized
by acute hypoxemic respiratory failure, reduced lung
compliance, and bilateral radiographic infiltrates
with no clinical evidence of cardiogenic pulmonary
edema [1–3]. ARDS usually occurs in previously
healthy patients. Typically, there is a latent period
between the insult and the development of the
clinical syndrome, which usually is 18–36 h in
duration. After this interval, signs and symptoms
of acute respiratory failure are observed. Detailed
assessment of abnormalities in lung mechanics
and oxygenation are usually not assessed until the
patient is intubated and mechanically ventilated.
Although this condition has been recognized for
more than a century, it was not until the landmark
study by Ashbaugh et al. [4] that clinical interest
in ARDS began to emerge. The mechanisms of
how a wide variety of risk factors can lead to ARDS
associated with development of ARDS, it is useful to
think of the pathogenesis of ARDS as a result of
two different pathways: a direct insult to lung cells
and an indirect insult as result of an acute systemic
inflammatory response. Despite ongoing clarifica-
tion of the role of cellular and humoral components
of the inflammatory responses in the development
a
CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III,
Madrid, bMultidisciplinary Organ Dysfunction Evaluation Research Net-
work (MODERN), Research Unit, Hospital Universitario Dr Negrin, Las
Palmas de Gran Canaria, Spain, cKeenan Research Center for Biomed-
ical Science at the Li Ka Shing Knowledge Institute, St. Michael’s
Hospital, Toronto, Canada, dIntensive Care Unit, Hospital Universitario
Rı́o Hortega, Valladolid, Spain, eDepartment of Respiratory Care, Mas-
sachusetts General Hospital and fDepartment of Anesthesia and Critical
Care Medicine, Harvard Medical School, Boston, Massachusetts, USA
Correspondence to Jesús Villar, MD, PhD, FCCM, Multidisciplinary
Organ Dysfunction Evaluation Research Network, Hospital Universitario
Dr Negrı́n Barranco de la Ballena, s/n – 4th floor, south wing, 35019 Las
Palmas de Gran Canaria, Spain. Tel: +34 928 449413; fax: +34 928
449813; e-mail: jesus.villar54@gmail.com
Curr Opin Crit Care 2016, 22:1–6
DOI:10.1097/MCC.0000000000000266

1070-5295 Copyright ! 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Respiratory system
KEY POINTS
" The global impact of ARDS is difficult to estimate:
demographic, cultural, economical, and healthcare
system differences among developed, developing, and
underdeveloped countries may account for differences
in the incidence of ARDS.
" Mortality continues to be the most important outcome in
ARDS clinical trials: current hospital mortality of
combined moderate and severe ARDS in observational
studies is greater than 40%.
" Accurate risk stratification of patients with ARDS will be
important to the success of future clinical trials.
and progression of the acute injury to the lung, the
precise sequence of events is still unknown. The risk
for developing ARDS depends not only on the pre-
disposing clinical condition but also increases with
the number of predisposing factors. Sepsis, bacterial
pneumonia, multiple trauma, and aspiration pneu-
monia are the most common predisposing factors,
accounting together for more than 70% of cases [5].
As diagnosis of ARDS is based on a combination
of clinical, oxygenation, hemodynamic, and radio-
graphic criteria, these criteria allow the inclusion of
a highly heterogeneous group of patients because
various types of lung injury can lead to a similar
pulmonary response. Differences among the ARDS
definition used is apparent in the majority of obser-
vational studies and clinical trials [6 ]. Despite a
&
general agreement on the overall criteria on which
to base a definition of ARDS, the specific values of
these variables and the necessary conditions of
measurements have varied greatly since the original
report [4]. A precise definition is necessary since the
effects on outcome of certain ventilatory and
adjunctive techniques may vary depending on the
degree of lung injury. In terms of prognosis, a uni-
versal definition of ARDS is necessary for comparing
data among studies and institutions [7 ].
&&
POPULATION-BASED INCIDENCE OF THE
ACUTE RESPIRATORY DISTRESS
SYNDROME
Owing to the problems inherent to changes in the
definition for ARDS, there has been a wide disparity
in the literature on the incidence of ARDS. In 1994,
an American–European Consensus Conference
(AECC) defined ARDS as follows [2]: acute and sud-
den onset of severe respiratory distress, bilateral
infiltrates on frontal chest radiograph, the absence
of left atrial hypertension (a pulmonary capillary
wedge pressure <18 mmHg) or no clinical signs of
2 www.co-criticalcare.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
left ventricular failure, and severe hypoxemia
(assessed by a PaO2/FiO2 ! 200 mmHg) regardless
of the level of positive end-expiratory pressure
(PEEP) and FiO2. According to these guidelines,
patients with a PaO2/FiO2 greater than 200 (but
!300 mmHg) were classified as having acute lung
injury (ALI). Recently, an update of this definition
(Berlin definition) [3] made ALI no longer a
category, and severity of ARDS is stratified by
PaO2/FiO2 ratio (!300 mmHg for mild, !200 for
moderate, and !100 for severe) with a minimum
level of 5 cmH2O of PEEP. The Berlin panel made this
addition without testing the effects of various PEEP
levels. However, both definitions have serious
limitations [7 ,8 ]. As the Berlin criteria, similar
&& &&
to the AECC criteria, did not mandate the assess-
ment of hypoxemia under standardized ventilatory
conditions, the values of PaO2/FiO2 recorded at the
time of ARDS diagnosis do not provide accurate
assessment of ARDS severity and outcome [8 ].
&&
The global impact of ARDS is difficult to
estimate. Almost nothing is known about the epi-
demiology of ARDS in the underdeveloped and
developing world, in part because of the lack of
resources and actual development of critical care
across those countries, such as sufficient mechanical
ventilators and other critical care equipment, avail-
ability of arterial blood gases analysis, limited
capacity for chest radiography, lack of well trained
critical care physicians, and available beds. A recent
study reporting the global disease incidences and
causes of death in 187 countries, offered little
insights into the epidemiology of ARDS [9]. Popu-
lation structure, burden of disease, and risk factors
for ARDS might differ between the developed and
developing countries. Singh et al. [10] performed a
prospective observational study to examine the
prevalence of ARDS, as defined by the AECC criteria,
in patients admitted during a 12-month period in
a surgical ICU of a large tertiary care hospital in
India. From a total of 902 admissions, they identi-
fied 67 (7.4%) patients meeting the AECC criteria
for ARDS. Sepsis was the most common risk factor
and the overall hospital mortality was 41.8%,
similar to what is reported in studies from developed
countries.
Reported data in the USA suggest an ARDS
occurrence rate greatly in excess of that expected
from current clinical experience in Europe. The
most common figure cited for the annual incidence
of ARDS is 75 cases/100 000 population, based on an
internal report of the National Heart and Lung
Institute dated in 1972 [11]. Demographic, cultural,
economical, and healthcare system differences
between the USA and Europe may account for the
order of magnitude differences. Li et al. [12] from the
Volume 22 " Number 1 " February 2016
 Incidence and outcome of ARDS Villar et al.

Table 1. Characteristics of main prospective epidemiological studies, published since 2011, reporting the population-based
incidence of the acute respiratory distress syndrome in adults
Villar et al. [5] Hernu et al. [16 ] Caser et al. [17 ]
& &&

Country Spain France Brazil

Study period 1 year November 2008– 6 months March– 15 months October 2006–
October 2009 September 2012 December 2007
Study design Prospective Prospective Prospective
Single/multicenter Multicenter 10 ICUs affiliated Multicenter
with one hospital
Catchment’s population area 3 546 629 1 500 000 1 454 000
ARDSa cases 255 198 81
ARDSa cases/100 000 population 7.2 26.3 6.3
Tidal volume (ml/kg PBW) 7.2 # 1.1 7 (6–8) 9.0 # 2.0
PEEP (cmH2O, at baseline) 9.3 # 2.4 9 (5–10) 10.8 # 3.0
Mortality (%)
ICU 42.7 Not reported Not reported
In hospital 47.8 Not reported 55.5
28 day – 35.6 43.2

ARDS, acute respiratory distress syndrome; PBW, predicted body weight; PEEP, positive end-expiratory pressure.
a
As defined by American–European Consensus Conference criteria or as moderate/severe by Berlin criteria.

Mayo Clinic performed a retrospective analysis of identified 240 patients who met the Berlin criteria
patients admitted over an 8-year period (2001– for ARDS; 197 of them had moderate or severe
2008) in two hospitals serving a US county and ARDS. Caser et al. [17 ] performed a prospective
&&

identified 42 ARDS patients in 2008, representing
an incidence of 33.8/100 000. However, the demo-
graphics of that county are not representative of the
USA. ICUs in the USA admit many more patients
than European and Canadian ICUs [13]. According
to a retrospective analysis from hospitals in six US
states, one in five (22.4%) US citizens died in the
ICU [14], a figure that is greatly in excess of that in
Europe. Most epidemiological studies from Europe
published in the last decade reported an ARDS inci-
dence ranging from five to eight cases/100 000
inhabitants [15 ].
&&
observational study in 14 ICUs in one region of
Brazil during a 15-month period. From a cohort
of more than 7000 ICU admissions, they identified
130 patients meeting the AECC definitions for ALI
(49 patients) and ARDS (81 patients), representing
an overall annual incidence of 10.1 cases/100 000
population when considering all patients, and an
incidence of 6.3 cases/100 000 population when
considering only the 81 patients meeting the AECC
ARDS criteria.

There are only three main prospective studies SURVIVING ACUTE RESPIRATORY
on ARDS incidence in adults [5,16 ,17 ] published
& &&
DISTRESS SYNDROME
in the last 5 years, two from Europe and one from In-hospital mortality of ARDS has been high since
Brazil (Table 1). One of them [5] used the AECC the syndrome was first described. Current hospital
definition and two used the Berlin criteria mortality is in the range of 40–50% in major obser-
[16 ,17 ]. Two of those studies [5,17 ] reported a vational studies [5,15 ,17 ,18]. Most common
& && && && &&

similar population-based incidence ranging from
6.3 to 7.2 new ARDS cases/100 000 population/year,
when using the AECC criteria for ARDS or the Berlin
criteria for moderate/severe ARDS. Villar et al. [5]
found that the incidence of ARDS in Spain was in
the range of estimates provided by previous
European epidemiological studies [15 ]. This figure
&&
predictors of survival include age, type of the under-
lying medical condition, the severity of lung dam-
age, the presence of extrapulmonary organ
dysfunction, and ongoing sepsis. Survival to home
discharge is lowest in patients with severe sepsis and
pneumonia and highest in patients with trauma.
Approximately 80% of all deaths occur within

is markedly lower than the 26.3/100 000/year esti- 2–3 weeks after the onset of ARDS [5] and only a
mated by Hernu et al. [16 ] in a 6-month prospective small portion of ARDS patients die from hypoxemia.
&

study conducted in 10 ICUs affiliated with the When ARDS develops in cancer patients, the hospi-
Public University Hospital in Lyon where they tal mortality is above 50%, as reported by Azoulay

1070-5295 Copyright ! 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com 3

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Respiratory system
et al. [19 ] in a recent cohort of 1004 cancer-
&
associated ARDS patients admitted to 14 ICUs
between 1990 and 2011 in France.
Although mechanical ventilation is the most
important life support technique for patients
with ARDS, the most important advance in ARDS
research has been the recognition that mechanical
ventilation can itself aggravate or cause lung
damage through a variety of mechanisms collec-
tively referred to as ventilator-induced lung injury
(VILI) [20,21 ]. The improved understanding of the
&
relationship between ARDS and VILI has been
important in designing lung protective mechanical
ventilation strategies to attenuate VILI and improve
ARDS survival. Limiting the tidal volume to
4–8 ml/kg predicted body weight (PBW), applying
moderate to high levels of PEEP and plateau press-
ures to less than 29 cmH2O, and maintaining the
driving pressure (plateau pressure minus PEEP)
below 15 cmH2O [22 ] represents the current
&&
standard for mechanical ventilation in patients
with and without acute lung injury [23]. The infor-
mation that ‘normal’ tidal volume in humans is in
the range of 6–7 ml/kg body weight [21 ] never
&
found a place in clinical practice until the publi-
cation of the ARDS Network trial [23]. There is now a
plethora of experimental and clinical data support-
ing the concept that any tidal volume, regardless of
how small, has the potential to damage the pre-
injured lung. A systematic review and meta-analysis
of lung protective ventilation for ARDS [24] showed
that 28-day and hospital mortality is reduced by
using a lung protective ventilation strategy with
lower tidal volume, whereas ventilation with a
higher tidal volume or higher plateau pressure is
associated with increased risk of death, although the
independent contributions of these two variables
cannot be identified. In the short term, the authors
confirmed that the application of protective mech-
anical ventilation decreased the number of deaths
by 26% on average. Needham et al. [25 ] examined
&&
prospectively the tidal volume over time in 482
ARDS patients meeting the Berlin criteria admitted
into 13 ICUs in Baltimore from 2004 to 2007.
Although they did not report the number of patients
in each category of lung injury severity, and since
the overall ICU mortality of the cohort (combined
mild, moderate, and severe ARDS) was 35%, it is
plausible that the hospital mortality for the sub-
group of moderate/severe ARDS was above 40%.
Median and interquartile range for tidal volume
in their series was 6.6 (5.9–8.0) ml/kg PBW,
suggesting that an important portion of patients
were ventilated with tidal volume more than
8 ml/kg PBW. In fact, almost half of their patients
never received tidal volume 6.5 ml/kg or less PBW.
4 www.co-criticalcare.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Their analyses revealed that patients who were
ventilated with tidal volume more than 6.5 ml/kg
PBW had a higher ICU mortality, and each increase
in initial tidal volume of 1 ml/kg PBW was associated
with a 23% increase in ICU mortality.
Mortality continues to be the most important
outcome in ARDS clinical trials [26]. In addition to
low tidal volume ventilation, some interventions
have demonstrated survival benefits including:
higher levels of PEEP [27], early and short-term
use of neuromuscular blockade [28], and prone
ventilation [29]. In a recent retrospective analysis
by Amato et al. [22 ], decreases in driving pressure
&&
were associated with increased rates of survival.
However, a prospective, randomized, controlled
trial is necessary to test the hypothesis that the
targeting of driving pressure below 15 cmH2O is
better than the current standard of care. It is import-
ant to note that the reported mortality rates for
ARDS in randomized controlled trials do not
represent true disease mortality. Regardless of the
number of ARDS patients enrolled in clinical trials,
enrolled patients represent only a small portion of
patients requiring treatment. The strict inclusion
and exclusion criteria eliminate patients with the
highest probability of death, the bulk of patients
that clinicians are obliged to treat [30]. When assess-
ing prognosis, it is essential to enroll patients that
will most likely benefit or respond to the interven-
tion. Because severe hypoxemia is the hallmark of
ARDS, it should be crucial for the assessment and
stratification of ARDS severity, for assessing the
prognosis, and for assessing the response to treat-
ment. Significant heterogeneity within the syn-
drome exists, and this will continue to challenge
accurate risk stratification and associated outcomes.
Clearly, the selection of therapy for an individual
patient with ARDS involves both assessment of the
degree of respiratory dysfunction, as measured by
PaO2/FiO2 after 24 h of routine clinical care, and
evaluation of the response to PEEP therapy. Villar
et al. [31 ] classified 300 patients with moderate/
&&
severe ARDS into four clinical subsets based on a
threshold value of 150 mmHg for PaO2/FiO2 and of
10 cmH2O for PEEP. Although patients had a wide
degree of variability in lung injury severity, the
subsets identified by these two parameters showed
a direct relation to hospital mortality, independent
of age, sex, underlying disease, or specific therapy.
The investigators found that each subset was
associated with a concrete overall mortality, which
increased with advancing lung dysfunction. Thus,
ventilatory management should be focused on
moving patients into a subset with a better survival.
As established pharmacologic treatments for ARDS
do not currently exist, accurate risk stratification
Volume 22 " Number 1 " February 2016

of patients with ARDS will be important to the
success of future clinical trials.
Very few studies have evaluated the long-term
outcome of ARDS patients. Patients who are treated
for this condition often face long-term physical and
psychological complications that result from their
prolonged hospitalization. Studies have considered
long-term outcomes in ARDS patients in terms of
respiratory function, loss of muscle mass, cognitive
effects, and death [32]. Wang et al. [33 ] identified
&&
predictors of 1-year mortality among 493 hospital
survivors of ALI/ARDS in several ICUs affiliated with
a hospital in the USA. They found that patients who
died after discharge were older and more likely to
have been discharged to a nursing home, another
hospital, or hospice, compared with those who sur-
vived to 1 year. Needham et al. [34] studied 2-year
survival rates in 485 patients with ALI/ARDS treated
in Baltimore from 2004 to 2007. They found that
64% died within 2 years, and the adherence to
protective ventilation while in the ICU showed a
linear correlation with 2-year survival.
CONCLUSION
On the basis of current evidence, the incidence
and overall hospital mortality of ARDS has not
changed substantially in the last decade. Independ-
ent of the definition used for identification of ARDS
patients, reported population-based incidence of
ARDS is an order of magnitude lower in Europe
than in the USA. Current hospital mortality of
combined moderate and severe ARDS in obser-
vational studies is greater than 40%. In patients
surviving hospitalization for ARDS, 1-year survival
after being discharged is essentially affected by non-
modifiable factors, such as age and premorbid
functional status.
Acknowledgements
This study is supported in part by Instituto de Salud
Carlos III, Spain (CB06/06/1088, PI10/0393, PI13/
0119), and Asociación Cientı´fica Pulmón y Ventilación
Mecánica.
Financial support and sponsorship
None.
Conflicts of interest
J.V. has received a research grant from Maquet. J.B. has
no conflicts of interest in relation to this manuscript.
R.M.K. is a consultant for Covidien, has received a
research grant from Venner Medical and Covidien.
The present manuscript has been developed, reviewed,
and approved by all contributing authors.
1070-5295 Copyright ! 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Incidence and outcome of ARDS Villar et al.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Villar J. What is the acute respiratory distress syndrome? Respir Care 2011;
56:1539–1545.
2. Bernard GR, Artigas A, Brigham KL, et al. The American-European Con-
sensus Conference on ARDS. Am J Respir Crit Care Med 1994; 149:818–
824.
3. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress
syndrome: the Berlin definition. JAMA 2012; 307:2526–2533.
4. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in
adults. Lancet 1967; 2:319–323.
5. Villar J, Blanco J, Añón JM, et al. The ALIEN Study: incidence and outcome of
acute respiratory distress syndrome in the era of lung protective ventilation.
Intensive Care Med 2011; 37:1932–1941.
6. Villar J, Kacmarek RM, Guerin C. Clinical trials in patients with the acute
respiratory distress syndrome: burn after reading. Intensive Care Med 2014;
&
40:900–902.
The editorial acknowledges that the two major factors which could explain the large
number of negative outcome studies in ARDS are excessive heterogeneity in study
populations and lack of standardization of outcome measures.
7. Villar J, Pérez-Méndez L, Blanco J, et al. A universal definition of ARDS: the
PaO2/FiO2 ratio under a standard ventilator setting: a prospective, multi-
&&
center, validation study. Intensive Care Med 2013; 39:583–592.
In this observational study, the use of a standardized ventilatory setting at 24 h of
ARDS onset allowed a more precise and clinically relevant stratification of ARDS
patients.
8. Villar J, Blanco J, del Campo R, et al. Assessment of PaO2/FiO2 for stratifica-
&& tion of patients with moderate and severe acute respiratory distress syn-
drome. BMJ Open 2015; 5:e006812.
The large, observational study demonstrated that risk stratification of ARDS
patients based on PaO2/FiO2 recorded at ARDS onset (baseline) or measured
without standardizing PEEP and FiO2 after 24 h of usual care, is not clinically
useful.
9. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235
causes of death for 20 age groups in 1990 and 2010: a systematic analysis
for the Global Burden of Disease Study 2010. Lancet 2012; 380:2095–
2128.
10. Singh G, Gladdy G, Chandy TT, Sen N. Incidence and outcome of acute lung
injury and acute respiratory distress syndrome in the surgical intensive care
unit. Indian J Crit Care 2014; 18:659–665.
11. National Heart and Lung Institutes. Respiratory diseases: task force on
problems, research approaches, needs. Washington, DC: US Government
Printing Office; DHEW Publication; 1972; NIH 74-432:167–180.
12. Li G, Malinchoc M, Cartin-Ceba R, et al. Eight-year trend of acute respiratory
distress syndrome. Am J Respir Crit Care Med 2011; 183:59–66.
13. Cavallazzi R, Marik PE, Hirani A, et al. Association between time of admission
to the ICU and mortality: a systematic review and metaanalysis. Chest 2010;
138:68–75.
14. Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the
end of life in the United States: an epidemiologic study. Crit Care Med 2004;
32:638–643.
15. Villar J, Sulemanji D, Kacmarek RM. The acute respiratory distress syndrome:
&& incidence and mortality, has it changed? Curr Opin Crit Care 2014; 20:3–9.
An extensive review of epidemiological studies performed after the year 2000 with
a special focus on incidence and outcome of patients with ARDS managed with
protective mechanical ventilation.
16. Hernu R, Wallet F, Thiolliere F, et al. An attempt to validate the modification of
& the American-European consensus definition of acute lung injury/acute
respiratory distress syndrome by the Berlin definition in a university hospital.
Intensive Care Med 2013; 39:2161–2170.
A 6-month prospective observational study in 10 ICUs of public hospitals
covering a district of the city Lyon. The study did not validate the Berlin definition
of ARDS since the stratification by severity at study entry was not associated with
mortality.
17. Caser EB, Zandonade E, Pereira E, et al. Impact of distinct definitions of acute
&& lung injury on its incidence and outcomes in Brazilian ICUs: prospective
evaluation of 7133 patients. Crit Care Med 2014; 42:574–582.
In this population-based epidemiological study, no difference between AECC and
Berlin criteria was found in their ability to predict mortality. ARDS incidence was
similar to European figures.
18. Phua J, Badia JR, Adhikari NKJ, et al. Has mortality from acute respiratory
distress syndrome decreased over time? Am J Respir Crit Care Med 2009;
179:220–227.
19. Azoulay E, Lemiale V, Mokart D, et al. Acute respiratory distress syndrome in
& patients with malignancies. Intensive Care Med 2014; 40:1106–1114.
Outcomes of ARDS in patients with malignancies were studied in this cohort of
more than 1000 patients with mainly hematological malignancies and infection-
induced ARDS. The most important point was that survival improved over time.
www.co-criticalcare.com 5
Respiratory system
20. Fan E, Villar J, Slutsky AS. Novel approaches to minimize ventilator-induced
lung injury. BMC Medicine 2013; 11:85.
21. Villar J, Kacmarek RM. It does not matter whether you are an elephant or a
& shrew: all mammals’ tidal volumes are similarly scaled. Minerva Anestesiol
2014; 80:1149–1151.
An article focusing on the variability of what has been considered a normal tidal
volume in health and sickness over the last 50 years.
22. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in
&& the acute respiratory distress syndrome. N Engl J Med 2015; 372:747–
755.
A posthoc analysis with data from several randomized clinical trials testing various
ventilatory strategies. Driving pressure was the variable that best stratified patient
outcome.
23. The Acute Respiratory Distress Syndrome Network. Ventilation with lower
tidal volumes as compared with traditional tidal volumes for acute lung injury
and the acute respiratory distress syndrome. N Engl J Med 2000; 342:1301–
1308.
24. Petrucci N, De Feo C. Lung protective ventilation strategy for the acute
respiratory distress syndrome. Cochrane Database Syst Rev 2013;
2:CD003844.
25. Needham DL, Yang T, Dinglas VD, et al. Timing of low tidal volume ventilation
&& and Intensive Care Unit mortality in acute respiratory distress syndrome. Am J
Respir Crit Care Med 2015; 191:177–185.
The study was designed to evaluate the association of critical illness and ICU care,
in particular lung protective mechanical ventilation, on patients’ long-term mortality
and functional outcomes.
26. Moss M. Mortality is the only relevant outcome in ARDS: yes. Intensive Care
Med 2015; 41:141–143.
6 www.co-criticalcare.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
27. Briel M, Meade M, Mercat A, et al. Higher vs. lower positive end-expiratory
pressure in patients with acute lung injury and acute respiratory distress
syndrome: systematic review and meta-analysis. JAMA 2010; 303:865–873.
28. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute
respiratory distress syndrome. N Engl J Med 2010; 363:1107–1116.
29. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute
respiratory distress syndrome. N Engl J Med 2013; 368:2159–2168.
30. Villar J, Pérez-Méndez L, Aguirre-Jaime A, et al. Why are physicians so
skeptical about positive randomized controlled trials in critical care medicine?
Intensive Care Med 2005; 31:196–204.
31. Villar J, Fernández RL, Ambrós A, et al. A clinical classification of the acute
&& respiratory distress syndrome for predicting outcome and guiding medical
therapy. Crit Care Med 2015; 43:346–353.
The first study classifying ARDS patients into four clinical subsets based on PaO2/
FiO2 and PEEP values after 24 h of routine care that should be considered for
enrollment in clinical trials and for guiding therapy.
32. Mikkelsen ME, Christie JD, Lanken PN, et al. The adult respiratory distress syn-
drome cognitive outcomes study. Long-term neuropsychological function in
survivorsofacutelunginjury.AmJ RespirCritCareMed2012;185:1307–1315.
33. Wang CY, Calfee CS, Paul DW, et al. One-year mortality and predictors of
&& death among hospital survivors of acute respiratory distress syndrome.
Intensive Care Med 2014; 40:388–396.
A large observational study in which the authors found that important predictors of
1-year mortality were age, malignancies, and chronic kidney disease present at the
time of admission and not living at home prior to admission.
34. Needham DM, Colantuoni E, Mendez-Tellez PA, et al. Lung protective
mechanical ventilation and two years survival in patients with acute lung
injury: prospective cohort study. BMJ 2012; 344:e2124.
Volume 22 " Number 1 " February 2016