A 65-year-old man was hospitalized with dyspnea and fever of a few days' duration. He complained of excessive malaise, fatigue, and weight loss but denied any hemoptysis. The patient had a history of alcohol abuse.
Bilateral crackles in both lower zones were audible. A chest film revealed right lower lobe alveolar infiltrates. Empiric antibiotic therapy was initiated, but the patient's condition worsened. Over the next few days, he became more hypoxemic and received mechanical ventilation. Crepitus developed over the chest wall.
A repeat chest film (Figure) showed bilateral infiltrates, evidence of pneumomediastinum, and air in the soft tissues, suggestive of subcutaneous emphysema. The history and roentgenographic data are compatible with the diagnosis of adult respiratory distress syndrome (ARDS).
Drs Mahesh Duggal, Achal Dhupa, and Arunabh of North Shore University Hospital at Forest Hills, NY, write that ARDS indicates the presence of noncardiogenic pulmonary edema and represents an underlying acute, severe lung injury. The syndrome is associated with very poor oxygenation, dense pulmonary bilateral infiltrates, and decreased lung compliance. Patients usually require mechanical ventilation; high pressures are needed to deliver adequate tidal volume.
Causes of ARDS include sepsis, fat embolism, aspiration, and pulmonary infection. Associated multiorgan dysfunction and uncontrolled infection contribute to the 50% to 70% mortality among patients with ARDS. This patient died 3 weeks after he was admitted to the hospital.