Missed or delayed diagnosis of ARDS: a common and serious problem

Abstract

Clinical recognition of acute respiratory distress syndrome (ARDS) is delayed or missed entirely in a substantial proportion of patients. In the LUNG SAFE study, the largest international cohort of patients with ARDS, investigators were able to determine if ARDS was present, and at what stage the clinician made the diagnosis of ARDS. The diagnosis of ARDS was delayed or missed in two-thirds of patients, with the diagnosis missed entirely in 40% of patients, while ARDS recognition ranged from 51% in mild ARDS to 79% in severe cases. Failure to recognize ARDS in a timely fashion leads to failure to use strategies that improve survival in ARDS. Early diagnosis of ARDS may facilitate measures to abrogate progression of the lung injury, including protective mechanical ventilation, fluid restriction, and adjunctive measures proven to improve survival such as prone positioning. Information overload and a complex 'syndrome' diagnosis likely play key roles in ARDS under-recognition. Clinical under-recognition has important consequences particularly in terms of therapeutic options not considered. The development of approaches to enable more timely recognition has the potential to save lives.

Keywords: Acute respiratory distress syndrome; Diagnosis; Outcome; Recognition; Therapy.

Fig. 1

Barriers to the diagnosis of ARDS. Each item of the ARDS definition poses specific challenges that can impair ability to diagnose ARDS. In addition, other patient-specific issues and the general ICU environment may constitute further barriers to ARDS recognition. ABG arterial blood gas, CXR chest X-ray, CT computed tomography, PAC pulmonary artery catheter, PEEP positive end expiratory pressure, CPAP continuous positive airway pressure