FDG-PET in patients at risk for acute respiratory distress syndrome: a preliminary report

Objective  To compare the pattern of lung uptake of 18F-fluorodeoxyglucose (FDG) by positron emission tomography (PET) imaging in patients with lung contusion that developed or did not progress to acute respiratory distress syndrome (ARDS). Design  Prospective, observational study. Setting  Trauma Center (academic urban hospital). Patients and interventions  Eight patients with blunt thoracic trauma and pulmonary contusion, confirmed by computed tomography (CT) on admission, underwent repeat CT and FDG-PET (on the same day) 24–72 h after admission. Results  No subjects met the criteria for ARDS at the time of the PET and second CT. Four subjects subsequently developed ARDS 1–3 days after the PET scan; the other four did not develop the syndrome. Three of the four subjects who subsequently developed ARDS showed diffuse FDG uptake throughout the entire lungs, while those who did not develop ARDS showed significant FDG uptake only in areas of focal lung opacity (non or poorly aerated lung units) on CT. FDG uptake in normally aerated lung regions was higher for those who subsequently developed ARDS than those who did not, approaching statistical significance. The normally aerated tissue:liver ratio was significantly higher in subjects who developed ARDS than in those who did not (P = 0.029). Conclusion  In this small series of patients with thoracic trauma, diffuse lung uptake of FDG was detected by PET imaging 1–3 days prior to clinically determined ARDS. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

108例急性呼吸窘迫综合征患者肺内和肺外源性因素分析

目的比较肺部原因诱发的急性呼吸窘迫综合征（acute respiratory distress syndrome of pulmonary origin,ARDSp）和肺外原因诱发的ARDS（ARDS of extra—pulmonary origin,ARDSexp）临床特征差异性。方法对2001—2002年上海市15个成人重症监护病房（intensive care unit,ICU）前瞻性调查确诊的108例ARDS（ARDSp 41例和ARDSexp 67例）患者进行年龄、性别、基础疾病、危险因素、疾病危重程度以及预后等因素分析比较。结果ARDSp和ARDSexp组患病率（以同期ICU收治危重病例为基数）分别为0．77％和1．26％,ARDSexp组显著高于ARDSp（P=0．012）。ARDSp患者以肺炎最多见,占肺部原因的90．2％;ARDSexp较多见的是急性重症胰腺炎,占22．4％。ARDSp与ARDSexp患者之间在入选时肺损伤评分分别为2．6分和2．4分,APACHEⅡ评分分别为20．1分和17．8分,差异无统计学意义（P分别为0．281和0．267）。住ICU时间分别为15．5d和15．9d（P=0．896）;机械通气时间分别为9．5d和9d（P=0．770）。住院期间病死率分别为78．0％及62．7％（P=0．095）。但两组患者主要死亡原因都是多脏器功能衰竭和呼吸衰竭。结论虽然ARDSexp组患病率显著高于ARDSp,但两组患者在疾病严重程度、病死率以及主要死亡原因等方面差异无统计学意义。     

Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients

Objective: To evaluate the prevalence and outcome of the acute respiratory distress syndrome (ARDS) among patients requiring mechanical ventilation. Design: A prospective, multi-institutional, initial cohort study including 28-day follow-up. Settings: Thirty-six French intensive care units (ICUs) from a working group of the French Intensive Care Society (SRLF). Patients: All the patients entering the ICUs during a 14-day period were screened prospectively. Hypoxemic patients, defined as having a PaO₂/FIO₂ ratio (P/F) of 300 mmHg or less and receiving mechanical ventilation, were classified into three groups, according to the Consensus Conference on ARDS: group 1 refers to ARDS (P/F: 200 mmHg or less and bilateral infiltrates on the chest X-ray); group 2 to acute lung injury (ALI) without having criteria for ARDS (200 < P/F ≤ 300 mmHg and bilateral infiltrates) and group 3 to patients with P/F of 300 mmHg or less but having exclusion criteria from the previous groups. Results: Nine hundred seventy-six patients entered the ICUs during the study period, 43 % of them being mechanically ventilated and 213 (22 %) meeting the criteria for one of the three groups. Among all the ICU admissions, ARDS, ALI and group 3 patients amounted, respectively, to 6.9 % (67), 1.8 % (17) and 13.3 % (129) of the patients, and represented 31.5 %, 8.1 % and 60.2 % of the hypoxemic, ventilated patients. The overall mortality rate was 41 % and was significantly higher in ARDS patients than in the others (60 % vs 31 % p < 0.01). In group 3, 42 patients had P/F less than 200 mmHg associated with unilateral lung injury; mortality was significantly lower (40.5 %) than in the ARDS group. In the whole group of hypoxemic, ventilated patients, septic shock and severity indices but not oxygenation indices were significantly associated with mortality, while the association with immunosuppression revealed only a trend (p = 0.06). Conclusions: In this survey we found that very few patients fulfilled the ALI non-ARDS criteria and that the mortality of the group with ARDS was high. Received: 21 September 1998 Final revision received: 3 February 1999 Accepted: 3 May 1999     

Acute respiratory distress syndrome and lung injury: Pathogenetic mechanism and therapeutic implication

To review possible mechanisms and therapeutics for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). ALI/ARDS causes high mortality. The risk factors include head injury, intracranial disorders, sepsis, infections and others. Investigations have indicated the detrimental role of nitric oxide (NO) through the inducible NO synthase (iNOS). The possible therapeutic regimen includes extracorporeal membrane oxygenation, prone position, fluid and hemodynamic management and permissive hypercapnic acidosis etc. Other pharmacological treatments are anti-inflammatory and/or antimicrobial agents, inhalation of NO, glucocorticoids, surfactant therapy and agents facilitating lung water resolution and ion transports. β-adrenergic agonists are able to accelerate lung fluid and ion removal and to stimulate surfactant secretion. In conscious rats, regular exercise training alleviates the endotoxin-induced ALI. Propofol and N-acetylcysteine exert protective effect on the ALI induced by endotoxin. Insulin possesses anti-inflammatory effect. Pentobarbital is capable of reducing the endotoxin-induced ALI. In addition, nicotinamide or niacinamide abrogates the ALI caused by ischemia/reperfusion or endotoxemia. This review includes historical retrospective of ALI/ARDS, the neurogenic pulmonary edema due to head injury, the detrimental role of NO, the risk factors, and the possible pathogenetic mechanisms as well as therapeutic regimen for ALI/ARDS.     

急性呼吸窘迫综合征影像学表现

目的提高对急性呼吸窘迫综合征（ARDS）影像学表现的认识与鉴别,早期诊断ARDS以降低病死率。方法回顾分析18例不同病因引起的ARDS患者的普通x线、cT的影像学特点、病理、实验室检查等且与临床相结合,诊断ARDS。结果排除大片肺不张、自发性气胸、上气道阻塞、急性肺拴塞和心源性肺水肿等,通过x线表现与病史及临床表现相结合作出正确诊断。结论病因不同ARDS有共同生理学、病理学和影像学特征。     

The effect of aspirin in preventing the acute respiratory distress syndrome/acute lung injury: A meta-analysis

Background

The effects of aspirin in preventing the occurrence of acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) among adult patients are controversial. We aimed to further determine the effectiveness of aspirin in reducing the rate of ARDS/ALI.

俯卧位通气对急性肺损伤和急性呼吸窘迫综合征临床疗效影响的Meta分析

目的 系统评价俯卧位通气(PPV)对我国急性肺损伤(ALI)和急性呼吸窘迫综合征(ARDS)患者的短期临床疗效.方法 利用Cochrane系统评价法,全面检索2000年至2009年国内公开发表的所有ALI与ARDS患者PPV的临床研究资料.对纳入研究独立进行质量评价、资料提取、交叉核对后行Meta分析.结果 纳入研究8项共184例患者,PPV时患者动脉血氧分压(PaO2)、氧合指数(PaO2/FiO2)、呼吸系统总顺应性(C)均显著升高;动脉血二氧化碳分压(PaCO2)、中心静脉压(CVP)、呼吸道峰压(PIP)和呼吸系统总阻力(Raw)无显著的变化;心率(HR)与平均动脉压(MAP)显著升高. 结论 ALI与ARDS患者行PPV可增加呼吸系统总顺应性,改善患者低氧血症,相关临床研究结果基本一致.但因Meta分析的自身局限性,我们仍急需开展设计严谨的高质量大样本临床研究,明确PPV临床疗效、作用机制、科学的操作流程及PPV对患者血流动力学的影响等临床实际问题,改善国内ALI与ARDS患者的临床护理水平.     

Ulinastatin for acute lung injury and acute respiratory distress syndrome: A systematic review and meta-analysis

AIM: To investigate the efficacy and safety of ulinastatin for patients with acute lung injury (ALI) and those with acute respiratory distress syndrome (ARDS).METHODS: A systematic review of randomized controlled trials (RCTs) of ulinastatin for ALI/ARDS was conducted. Oxygenation index, mortality rate [intensive care unit (ICU) mortality rate, 28-d mortality rate] and length of ICU stay were compared between ulinastatin group and conventional therapy group. Meta-analysis was performed by using Rev Man 5.1.RESULTS: Twenty-nine RCTs with 1726 participants were totally included, the basic conditions of which were similar. No studies discussed adverse effect. Oxygenation index was reported in twenty-six studies (1552 patients). Ulinastatin had a significant effect in improving oxygenation [standard mean difference (SMD) = 1.85, 95%CI: 1.42-2.29, P < 0.00001, I² = 92%]. ICU mortality and 28-d mortality were respectively reported in eighteen studies (987 patients) and three studies (196 patients). We found that ulinastatin significantly decreased the ICU mortality [I² = 0%, RR = 0.48, 95%CI: 0.38-0.59, number needed to treat (NNT) = 5.06, P < 0.00001], while the 28-d mortality was not significantly affected (I² = 0%, RR = 0.78, 95%CI: 0.51-1.19, NNT = 12.66, P = 0.24). The length of ICU stay (six studies, 364 patients) in the ulinastatin group was significantly lower than that in the control group (SMD = -0.97, 95%CI: -1.20--0.75, P < 0.00001, I² = 86%).CONCLUSION: Ulinastatin seems to be effective for ALI and ARDS though most trials included were of poor quality and no information on safety was provided.     

Increased plasma levels of heparin-binding protein in patients with acute respiratory distress syndrome

Introduction

Heparin-binding protein (HBP) is an antimicrobial protein stored in neutrophil granules and plays a role in endothelial permeability regulation. The aim was to assess the diagnostic and prognostic value of measuring HBP in patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS).

Methods

Plasma HBP was collected from 78 patients with ALI/ARDS, 28 patients with cardiogenic pulmonary edema (CPE) and 20 healthy volunteers at enrollment. Levels of HBP were measured by ELISA.

Results

Patients with ALI/ARDS had significantly higher median levels of HBP compared with patients with CPE (17.15 (11.95 to 24.07) ng/ml vs. 9.50 (7.98 to 12.18) ng/ml, P <0.001) at enrollment. There was no significant difference between CPE patients and healthy subjects in terms of HBP value (P = 0.372). The HBP levels of nonsurvivors was significantly higher than that of survivors (23.90 (14.81 to 32.45) ng/ml vs. 16.01 (10.97 to 21.06) ng/ml, P = 0.012) and multivariate logistic regression showed HBP (odds ratio =1.52, P = 0.034) was the independent predictor for 30-day mortality in patients with ALI/ARDS.

Conclusions

Plasma HBP levels of ALI/ARDS patients were significantly higher than that of CPE patients. HBP was a strong prognostic marker for short-term mortality in ALI/ARDS.     

Mechanism of injury influences quality of life in survivors of acute respiratory distress syndrome

Objective Growing evidence suggests that acute respiratory distress syndrome (ARDS) occurring as a consequence of primary (direct) lung injury differs from that resulting from secondary (indirect) lung injury in terms of radiographic appearance, response to interventions, and outcomes. We examined whether there are differences in quality of life (QOL) in survivors of ARDS attributable to the mechanism of underlying lung injury.Design and setting Prospective observational cohort study in 54 intensive care units in Canada and the United States.Patients and participants Survivors of ARDS (n = 73) were grouped according to underlying cause of ARDS (i.e., primary vs. secondary lung injury) and followed prospectively for 12 months.Measurements and results QOL was assessed using the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) and the St. George's Respiratory Questionnaire (SGRQ), and spirometry was performed at each outpatient follow-up visit. At 3 months mortality and QOL outcomes were similar between the groups, but by 12 months patients with primary lung injury had significantly better QOL scores in four of eight SF-36 domains and in two of three domains of the SGRQ. Differences were not attributable to duration of ICU or hospital length of stay, duration of mechanical ventilation, comorbidities prior to the index illness, or differences in spirometry during the follow-up period.Conclusions QOL in survivors of ARDS appears to be influenced by the mechanism of lung injury (primary vs. secondary), lending support to the concept that ARDS is a heterogeneous condition.This article is discussed in the editorial available at:     

Effect of inspired oxygen fraction on alveolar derecruitment in acute respiratory distress syndrome

Objective High fractions of inspired oxygen (FIO₂) used in acute lung injury (ALI) may promote resorption atelectasis. The impact of derecruitment related to high FIO₂ in ALI is debated. We evaluated derecruitment with 100% vs. 60% FIO₂ at two levels of positive end-expiratory pressure (PEEP).Patients Fourteen consecutive patients with ALI were studied.Interventions Recruited volume at two PEEP levels was computed from two pressure-volume curves, recorded from PEEP and from zero end-expiratory pressure, using the sinusoidal flow modulation method. PEEP-induced recruitment was measured during prolonged expiration as the difference between the two curves at a given pressure. PaO₂/FIO₂ was also measured. PEEP was 5 ± 1 or 14 ± 3 cmH₂O and FIO₂ was 60% or 100%, yielding four combinations. We looked for differences between the beginning and end of a 30-min period with each combination.Measurement and results With low PEEP and 100% FIO₂, recruited volume decreased significantly from 68 ± 53 to 39 ± 43 ml and PaO₂/FIO₂ from 196 ± 104 to 153 ± 83 mmHg. With the three other combinations (low PEEP and 60% FIO₂ or high PEEP and 60% or 100% FIO₂) none of the parameters decreased significantly.Conclusion In mechanically ventilated patients with ALI the breathing of pure oxygen leads to derecruitment, which is prevented by high PEEP.Electronic supplementary material Supplementary material is available in the online version of this article at and is accessible for authorized users.This article is discussed in the editorial available at:     

长链非编码RNAs在急性呼吸窘迫综合征中的作用

急性呼吸窘迫综合征(ARDS)是以顽固性低氧血症为特征的临床常见危重综合征,免疫炎症反应失衡、氧化应激和内皮功能障碍在其中发挥了重要作用。长链非编码RNAs(lncRNAs)可通过调控细胞核的结构和转录以及调节细胞质中的mRNA稳定性、转录和翻译后修饰,进而调控机体免疫炎症等信号转导网络,参与ARDS发生发展过程。该文综述lncRNAs在ARDS临床研究中的新发现及其在免疫炎症反应、血管内皮损伤及组织修复等ARDS病理过程中的作用。     

Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review

Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. Prone positioning is a supplementary strategy available in managing patients with ARDS. It was first described 40 years ago and it proves to be in alignment with two major ARDS pathophysiological lung models; the “sponge lung” - and the “shape matching” -model. Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle. The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients’ response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.     

Acute respiratory distress syndrome due to falciparum malaria in a pregnant woman

We report the case of a pregnant woman (29 th week), living in a Paris suburb, about 20 miles from an international airport. She presented with septic shock and severe acute respiratory distress syndrome (ARDS). A few parasitized erythrocytes were discovered in a hemorrhagic bronchoalveolar lavage (BAL), specimen and many were found on examination of the placenta after a caesarean section had been performed. The patient's condition dramatically improved once given quinine therapy. This is an uncommon case on account of: (1) the unusual clinical course with no organ failure but ARDS, (2) the unusual way the diagnosis was made, (3) the very unusual way the patient became contaminated (airport malaria), (4) the pregnant condition of the patient. Received: 28 October 1996 Accepted: 15 April 1997     

脑钠肽对急性呼吸窘迫综合征患者预后评估的价值

目的 探讨脑钠肽(BNP)对急性呼吸窘迫综合征(ARDS)患者预后评估的价值.方法 回顾分析2004年1月至2009年5月收治的86例左室射血分数(LVEF)正常的ARDS患者的临床资料.记录患者的基本病情,比较存活组和死亡组患者血浆BNP浓度与Murray肺损伤评分(LIS),并对二者进行相关性分析,评价BNP浓度与LIS对预测ARDS患者死亡的风险.结果 86例患者确诊后14 d死亡55例,存活31例.与死亡组患者相比,存活组肺动脉高压占的比例(25.8%比72.7%)、静脉使用大剂量去甲肾上腺素的比例(38.7%比94.5%)明显减小,14 d内未行机械通气的时间E(8.63±3.26)d比(0.38±0.02)d]明显延长,血浆BNP浓度[(179.5±84.5)ng/L比(550.8±337.1)ng/L3及LIS[(1.37±0.65)分比(2.29±0.46)分]均显著降低(P<0.05或P<0.01).BNP浓度与LIS高度相关(r=0.786,P<0.01).将BNP为329.5 ng/L作为截断点,其预测死亡的特异性为96.8%;将LIS为1.875分作为截断点,其预测死亡的敏感性为80.0%.结论 在LVEF正常的ARDS患者中,死亡患者血浆BNP浓度和LIS均较存活患者显著增高,可以使用BNP浓度预测ARDS患者的死亡风险.     

重型颅脑损伤并发急性呼吸窘迫综合征危险因素分析

目的　探讨重型颅脑损伤并发急性呼吸窘迫综合征 (ARDS)的危险因素。方法对 2 4例重型颅脑损伤并发ARDS患者的临床资料进行回顾性分析 ,分析年龄、性别、GCS评分、肋骨骨折、肺挫伤、血气胸、呕吐误吸、PaO2 /FiO2 等相关因素与急性呼吸窘迫综合征的关系。结果年龄、GCS评分、肋骨骨折、肺挫伤、血气胸、呕吐误吸、PaO2 /FiO2 等因素统计学分析有显著性差异 (P <0 .0 5 )。结论年龄、GCS评分、胸部外伤程度、呕吐误吸是重型颅脑损伤并发急性呼吸窘迫综合征的危险因素 ,PaO2 /FiO2 是判断伤情发展趋势的重要指标。     

Impact of positive end-expiratory pressure on the definition of acute respiratory distress syndrome

Objective We examined whether PEEP during the first hours of ARDS can induce such a change in oxygenation that could mask fulfillment of the AECC criteria of a PaO₂/FIO₂ 200 essential for ARDS diagnosis.Design and setting Observational, prospective cohort in two medical-surgical ICU in teaching hospitals.Patients 48 consecutive patients who met AECC criteria of ARDS on 0 PEEP (ZEEP) at the moment of diagnosis.Measurements and results PaO₂/FIO₂ and lung mechanics were recorded on admission (0 h) to the ICU on ZEEP, and after 6, 12, and 24 h on PEEP levels selected by attending physicians. Lung Injury Score (LIS) was calculated at 0 and 24 h. PaO₂/FIO₂ rose significantly from 121±45 on ZEEP at 0 h, to 234±85 on PEEP of 12.8±3.7 cmH₂O after 24 h. LIS did not change significantly (2.34±0.53 vs. 2.42±0.62). These variables behaved similarly in pulmonary and extrapulmonary ARDS, and in survivors and nonsurvivors. After 24 h only 18 patients (38%) still had a PaO₂/FIO₂ of 200 or lower. Their mortality was similar to that in the remaining patients (61% vs. 53%).Conclusions The use of PEEP improved oxygenation such that one-half of patients after 6 h, and most after 24 h did not fulfill AECC hypoxemia criteria of ARDS. However, LIS remained stable in the overall series. These results suggest that PEEP level should be taken into consideration for ARDS diagnosis.     

Effects of dynamic ventilatory factors on ventilator-induced lung injury in acute respiratory distress syndrome dogs

BACKGROUND:

Mechanical ventilation is a double-edged sword to acute respiratory distress syndrome (ARDS) including lung injury, and systemic inflammatory response high tidal volumes are thought to increase mortality. The objective of this study is to evaluate the effects of dynamic ventilatory factors on ventilator induced lung injury in a dog model of ARDS induced by hydrochloric acid instillation under volume controlled ventilation and to investigate the relationship between the dynamic factors and ventilator-induced lung injuries (VILI) and to explore its potential mechanisms.

METHODS:

Thirty-six healthy dogs were randomly divided into a control group and an experimental group. Subjects in the experimental group were then further divided into four groups by different inspiratory stages of flow. Two mL of alveolar fluid was aspirated for detection of IL-8 and TNF-α. Lung tissue specimens were also extracted for total RNA, IL-8 by western blot and observed under an electronic microscope.

RESULTS:

IL-8 protein expression was significantly higher in group B than in groups A and D. Although the IL-8 protein expression was decreased in group C compared with group B, the difference was not statistically significant. The TNF-α ray degree of group B was significantly higher than that in the other groups (P<0.01), especially in group C (P>0.05). The alveolar volume of subjects in group B was significantly smaller, and cavity infiltration and cell autolysis were marked with a significant thicker alveolar septa, disorder of interval structures, and blurring of collagenous and elastic fiber structures. A large number of necrotic debris tissue was observed in group B.

CONCLUSION:

Mechanical ventilation with a large tidal volume, a high inspiratory flow and a high ventilation frequency can cause significant damage to lung tissue structure. It can significantly increase the expression of TNF-α and IL-8 as well as their mRNA expression. Furthermore, the results of our study showed that small tidal ventilation significantly reduces the release of pro-inflammatory media. This finding suggests that greater deterioration in lung injury during ARDS is associated with high inspiratory flow and high ventilation rate.KEY WORDS: Acute respiratory distress syndrome, Dynamic factors, Inspiratory flow, Ventilator-induced lung injury     

Acute respiratory failure in intensive care units. FINNALI: a prospective cohort study

Objective  To evaluate the incidence, treatment and mortality of acute respiratory failure (ARF) in Finnish intensive care units (ICUs). Study design  Prospective multicentre cohort study. Methods  All adult patients in 25 ICUs were screened for use of invasive or non-invasive ventilatory support during an 8-week period. Patients needing ventilatory support for more than 6 h were included and defined as ARF patients. Risk factors for ARF and details of prior chronic health status were assessed. Ventilatory and concomitant treatments were evaluated and recorded daily throughout the ICU stay. ICU and 90-day mortalities were assessed. Results  A total of 958 (39%) from the 2,473 admitted patients were treated with ventilatory support for more than 6 h. Incidence of ARF, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) was 149.5, 10.6 and 5.0/100,000 per year, respectively. Ventilatory support was started with non-invasive interfaces in 183 of 958 (19%) patients. Ventilatory modes allowing triggering of spontaneous breaths were preferred (81%). Median tidal volume/predicted body weight was 8.7 (7.6–9.9) ml/kg and plateau pressure 19 (16–23) cmH₂O. The 90-day mortality of ARF was 31%. Conclusions  While the incidence of ARF requiring ventilatory support is higher, the incidence of ALI and ARDS seems to be lower in Finland than previously reported in other countries. Tidal volumes are higher than recommended in the concept of lung protective strategy. However, restriction of peak airway pressure was used in the majority of ARF patients. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. This article is discussed in the editorial available at: doi:.     

Nonsteroidal anti-inflammatory drug-induced acute respiratory distress syndrome

Drug induced acute respiratory distress syndrome (ARDS) is a common clinical condition. Patients typically present with noncardiogenic pulmonary edema. Large number of ARDS cases reported induced by antineoplastic drugs and other drug intoxications. The pathophysiologic mechanisms of drug induced ARDS remains unknown. One of the postulated mechanisms of drug induced ARDS is anaphylaxis. We present a case of acute respiratory distress syndrome complicated by anaphylactic shock after use of two different nonsteroidal antiinflammatory drugs (NSAID). To the best of our knowledge, ARDS following normal doses of NSAID ingestion has not been reported previously. The case showed that ARDS may occur after ingestion of therapeutic doses of NSAID. NSAID ingestion should be considered in the differential diagnosis of patients with non-cardiogenic pulmonary edema.