Chapter 16. Acute Lung Injury/Acute Respiratory Distress Syndrome

Jesse B Hall, MD, FCCP
DOI: 10.1378/critcare.21.16
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  • Review the pathophysiology and epidemiology of acute lung injury (ALI)/ARDS.

  • Review research guiding thinking about the use of standard ventilator approaches, salvage, and innovative therapies that can be used in addition or in lieu of standard techniques.

  • Examine long-term outcomes from this ICU syndrome.


Patients with diverse surgical and medical conditions may suffer acute lung injury, characterized by damage to the endothelial-epithelial lung interface with resultant interruption of endothelial barrier function. When this injury is significant, lung flooding occurs despite normal cardiovascular function, so-called low-pressure pulmonary edema or pulmonary capillary leak. Gross gas exchange and pulmonary mechanical abnormalities result with associated hypoxemic respiratory failure. When this syndrome occurs, supportive management is necessary while the patient is protected from further lung injury (eg, intubation to prevent further aspiration) and/or underlying predisposing conditions are treated (eg, management of septic shock). Supportive management requires a ventilator strategy that recruits collapsed and flooded lung while avoiding further lung damage associated with the interaction of the ventilator with the damaged respiratory system. Much research has helped to identify the details of implementing lung-protective ventilation, but interest continues in new modalities of treatment to further improve outcome in these challenging patients. Even when patients are supported through the period of respiratory failure, significant morbidity may persist for extended periods and with incomplete resolution.


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