Biuzzi Cesare, Modica Elena, De Filippis Noemi, Pizzirani Daria, Galgani Benedetta, Di Chiaro Agnese, Marianello Daniele, Franchi Federico, Taccone Fabio Silvio, Scolletta Sabino
Department of Medical Science, Surgery and Neurosciences, Urgency-Emergency Anesthesia and Intensive Care Unit, University Hospital of Siena, 53100 Siena, Italy.
Department of Medical Science, Surgery and Neurosciences, Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, University Hospital of Siena, 53100 Siena, Italy.
Diagnostics (Basel). 2025 Jul 31;15(15):1930. doi: 10.3390/diagnostics15151930.
Lower respiratory tract infections remain a leading cause of morbidity and mortality among Intensive Care Unit patients, with severe cases often progressing to acute respiratory distress syndrome (ARDS). This life-threatening syndrome results from alveolar-capillary membrane injury, causing refractory hypoxemia and respiratory failure. Early detection and management are critical to treat the underlying cause, provide protective lung ventilation, and, eventually, improve patient outcomes. The 2012 Berlin definition standardized ARDS diagnosis but excluded patients on non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) modalities, which are increasingly used, especially after the COVID-19 pandemic. By excluding these patients, diagnostic delays can occur, risking the progression of lung injury despite ongoing support. Indeed, sustained, vigorous respiratory efforts under non-invasive modalities carry significant potential for patient self-inflicted lung injury (P-SILI), underscoring the need to broaden diagnostic criteria to encompass these increasingly common therapies. Recent proposals expand ARDS criteria to include NIV and HFNCs, lung ultrasound, and the SpO/FiO ratio adaptations designed to improve diagnosis in resource-limited settings lacking arterial blood gases or advanced imaging. However, broader criteria risk overdiagnosis and create challenges in distinguishing ARDS from other causes of acute hypoxemic failure. Furthermore, inter-observer variability in imaging interpretation and inconsistencies in oxygenation assessment, particularly when relying on non-invasive measurements, may compromise diagnostic reliability. To overcome these limitations, a more nuanced diagnostic framework is needed-one that incorporates individualized therapeutic strategies, emphasizes lung-protective ventilation, and integrates advanced physiological or biomarker-based indicators like IL-6, IL-8, and IFN-γ, which are associated with worse outcomes. Such an approach has the potential to improve patient stratification, enable more targeted interventions, and ultimately support the design and conduct of more effective interventional studies.
下呼吸道感染仍然是重症监护病房患者发病和死亡的主要原因，严重病例常进展为急性呼吸窘迫综合征（ARDS）。这种危及生命的综合征是由肺泡-毛细血管膜损伤引起的，导致难治性低氧血症和呼吸衰竭。早期检测和管理对于治疗潜在病因、提供肺保护性通气并最终改善患者预后至关重要。2012年柏林定义对ARDS诊断进行了标准化，但排除了使用无创通气（NIV）或高流量鼻导管（HFNC）模式的患者，而这些模式的使用越来越多，尤其是在新冠疫情之后。通过排除这些患者，可能会出现诊断延迟，尽管有持续的支持，但仍有肺损伤进展的风险。事实上，在无创模式下持续、剧烈的呼吸努力具有患者自伤性肺损伤（P-SILI）的重大潜在风险，这突出了扩大诊断标准以涵盖这些日益常见疗法的必要性。最近的提议扩大了ARDS标准，包括NIV和HFNC、肺部超声以及为在缺乏动脉血气或先进成像的资源有限环境中改善诊断而设计的SpO/FiO比率调整。然而，更广泛的标准有过度诊断的风险，并在区分ARDS与其他急性低氧性呼吸衰竭病因方面带来挑战。此外，成像解读中的观察者间差异以及氧合评估中的不一致，特别是在依赖无创测量时，可能会损害诊断的可靠性。为了克服这些限制，需要一个更细致入微的诊断框架——一个纳入个体化治疗策略、强调肺保护性通气并整合基于先进生理或生物标志物的指标（如与更差预后相关的白细胞介素-6、白细胞介素-8和干扰素-γ）的框架。这样一种方法有可能改善患者分层，实现更有针对性的干预，并最终支持更有效干预性研究的设计和开展。
