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"Imitators" of the ARDS: implications for diagnosis and treatment.

A cute lung injury (ALI) and ARDS (ALI/ARDS) are defined as follows: (1) an illness having an acute onset, (2) an arterial oxygen tension/inspired oxygen fraction 200 mm Hg (or 300 mm Hg for ALI), (3) the presence of bilateral infiltrates on frontal chest radiographs, and (4) a pulmonary artery occlusion pressure 18 mm Hg if measured, or no clinical evidence of left atrial hypertension when not measured.1,2 There are a group of diffuse, noninfectious parenchymal lung diseases that often present in an acute fashion and fulfill all of the clinical, physiologic, and radiographic criteria for ALI/ARDS. Some of these have distinct BAL characteristics and/or specific histologic findings. It is important to distinguish these from ALI/ARDS because most cases seem to respond to the early initiation of systemic corticosteroid therapy. In addition, studies evaluating novel interventions for ALI/ARDS should not include these patients because their outcomes are dissimilar from ALI/ARDS. This opinion article summarizes what is known about these diffuse noninfectious parenchymal diseases and focuses on the differences in their histologies, BAL findings, prognoses, and treatment responsiveness. We suggest that these conditions should be considered, prompting further diagnostic testing, in every patient thought to have ALI/ARDS ascribed to “pneumonia,” and in those without a well-recognized predisposing factor.