Acute Respiratory Distress Syndrome: Contemporary Management and Novel Approaches During COVID-19

George W. Williams, M.D.; Nathaniel K. Berg, B.S.; Alexander Reskallah, M.D.; Xiaoyi Yuan, Ph.D.; Holger K. Eltzschig, M.D., Ph.D.


Anesthesiology. 2021;134(2):270-282. 

In This Article

Abstract and Introduction


Acute respiratory distress syndrome (ARDS) is defined as hypoxemia secondary to a rapid onset of noncardiogenic pulmonary edema.[1] Etiologic risk factors for ARDS encompass both direct and indirect lung injuries including but not limited to pneumonia, sepsis, noncardiogenic shock, aspiration, trauma, contusion, transfusion, and inhalation injuries. Although clinical recognition and management of ARDS have improved significantly over the past 25 yr, it is still a leading cause of death in critically ill patients, with mortality rates consistently reported around 30 to 40%.[2] An important factor in the high mortality rate in ARDS is that treatment is mainly focused on clinical management and no targeted therapies currently exist. Furthermore, ARDS management is often challenging as it commonly occurs in a clinical setting of multiple organ failure and can also lead to the development of nonpulmonary organ injury, such as acute kidney injury.[3] Recently, the pandemic caused by coronavirus disease 2019 (COVID-19), which results from infection by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has led to a dramatic incidence in COVID-19–related ARDS. Thirty to forty percent of COVID-19 hospitalized patients develop ARDS, and it is associated with 70% of fatal cases.[4,5] At the time of this writing (July 31, 2020), there are more than 4.5 million COVID-19 cases and 152,000 related deaths in the United States.[6] Here, we describe select management strategies that have become foundations of ARDS clinical management and provide an update of emerging approaches for the treatment of ARDS related to COVID-19.