Introduction

Acute Respiratory Distress Syndrome (ARDS) is a life threatening form of lung injury due to fluid build up in the air sacs (alveoli) and low blood oxygen levels. It is charcaterised by an inability to breathe, choking, gasping for air, sudden shortness of breath, tightness in chest, pain in arms, back, neck, or jaw. It can occur as a result of sepsis, infections, such as pneumonia, acute pancreatitis, drowning, smoke inhalation, severe injuries, having a blood transfusion or lung transplant. Immediate treatment is required as there is a high risk of mortality (death). Treatment involves ventilation (machine used to help someone breathe), oxygen mask, antibiotics to treat infection, and fluids for nutritional support given through a vein. 

Research demonstrates hospital mortality rates of ARDS have dropped significantly from 50% in the 1990s to 33% in 2006-2010.¹ Although there is an improvement, some data show that more than half the patients who received ventilation died two years following being affected by ARDS.² This indicates the need for more research and clinical initiatives on the long term effects of ARDS. 

Post-ARDS hospital recovery

Doctors perform a tracheostomy after 2-3 weeks of being on ventilator support. It is a procedure where an incision is made in the neck directly into the windpipe to allow the person to breathe when normal breathing through the nose or mouth is impaired. Many individuals require a tracheostomy and a feeding tube during the recovery phase and are admitted in the Intensive Care Unit (ICU). This is to let the person come off the ventilator, clear the mucus build up, and make them feel more comfortable. Individuals are usually bed bound and frequent repositioning is important to prevent bed sores and blood clots. 

Physical long-term effects 

ARDS can bring some serious physical long term effects especially as a result of ICU stay. Many acquire muscle weakness or muscle wasting (reduced strength) during critical illness and for some it continues after discharge.³ This can make daily activities and exercise much more difficult. 

Pulmonary function 

After mechanical ventilation, some pulmonary injuries persist such as pulmonary diffusion impairments (less transfer of oxygen and carbon dioxide between air spaces in the lungs) and fibrosis. Some people have a shortness of breath during physical exertion and some can’t return to work. In those who had severe ARDS, doctors have found changes in their lung CT scans up to 5 years after the illness.^4,5 These changes are: 

• Pulmonary fibrosis: scarring in the lung tissue which can make breathing difficult and can lead to hypoxia (lack of oxygen to the body) 
• Ground-glass opacities: hazy or cloudy areas on the CT scan showing inflammation and damage in the lungs 
• Traction bronchiectasis: widening of the airways caused by scarring and fibrosis in the lung tissues, characterised by increased phlegm, coughing, wheezing and shortness of breath 

Although, some research has shown that in most ARDS survivors lung function returns almost back to normal within 6 to 12 months.⁶ 

Neuromuscular weakness

Muscle systems are also affected due to ARDS and long ICU stays. It is usually characterised by reduced muscle mass and function making everyday life difficult. Research has shown neuromuscular injury and severe muscle weakness in individuals who had long hospital stays.⁷ This is called ICU-acquired weakness (ICUAW). People with ICUAW had a higher risk of dying, both in the long term and short term. In individuals with increased age, severity of ARDS, other illnesses (comorbidity), and length of stay in the ICU have been associated with long term physical function impairment.⁸ In some cases, where individuals have weak muscles after ARDS, can be due to the build up of muscle weakness before ARDS. Failure to recognize these pre-critical illness symptoms determines the risk of death and long-term physical impairment following ARDS. Hospital-based rehabilitation and physical therapy can improve long-term physical function.⁹

Cardiovascular effects 

During ARDS, some individuals showed heart-related markers in the blood that point toward higher risk of death in the long run.¹⁰ Some people can also develop signs of heart damage that can be seen on an echocardiogram (heat ultrasound), such as stress-related or sepsis-related heart problems. A review of studies looking at cardiovascular problems after ARDS or lung injury show that heart problems can be driven by inflammation in the body, and a relationship between COVID-19 and heart problems like irregular heartbeats and blocked arteries exist.⁷ 

Psychological health 

ARDS can be a traumatic event in one’s life, especially with the risk of death being significantly high. Surviving ARDS comes with psychological trauma, depression, anxiety and lower health-related quality of life (HRQOL). Research has shown that individuals with a history of mental health conditions were at a higher risk of psychiatric problems after ARDS.¹¹ Risk factors for post-ARDS psychiatric conditions were younger age, people assigned female at birth, unemployment and alcohol misuse.¹² In a study, 38% of individuals have recurring symptoms of anxiety, 32% had depression, and 23% had Post Traumatic Stress Syndrome (PTSD) five years after ARDS. This highlights how long of a psychological effect traumatic medical events, procedures, and ICU stays can be for an individual. 

Impact on quality of life 

Most individuals find it difficult to cope with day-to-day life after ARDS. Physical health issues, such as breathing difficulties and body pain, can make life difficult. Although there is a significant improvement in one’s quality of life right after discharge from the hospital,¹³ mental health difficulties and physical health issues persist. 

Pulmonary symptoms persisting a year after ARDS can impact one’s quality of life in physical functioning, bodily pain, general health, and energy levels.¹⁴ 33% of individuals find it difficult to walk and carry out daily activities after hospital discharge and 9% of individuals continue to struggle two years after the event.¹⁵ This goes on to affect one’s ability to take care of themselves (self-care activities), their independence, and ability to go back to work. 

Difficulty in productivity and going back to work can make it difficult to meet financial needs. The economic burden of medical costs and need for long-term care and rehabilitation make it difficult for one to cope and have a good quality of life. Moreover, caregivers may also experience burnout and stress due to the declining health of the individual. The inability to participate in social activities and step out of the house may lead to feelings of loneliness and isolation. This warrants for more support from families, community, and mental health services. 

Strategies for long-term management

After surviving ARDS, many individuals need attention well after they have been discharged. Support systems to improve both physical and mental well-being need to be in place. 

Pulmonary rehabilitation and physical therapy 

Pulmonary rehabilitation means using exercises to improve lung function, manage breathlessness, and quality of life. Difficulty breathing can affect daily living even years after critical illness. Being on a ventilator and bed ridden for long periods can lead to prolonged muscle weakness and breathing issues. This is why early rehabilitation and physical therapy in the acute illness stage is essential in treating physical health in the long-run. Improving lung function can also reduce the risk of complications in the future.¹⁶ It is important to talk to a healthcare professional before trying any breathing exercises and physical movements. Gradual increase in physical movement is essential right after discharge or during hospital stay to prevent blood clots and exercise intolerance. 

Multidisciplinary follow-Up care

Due to the various health issues that persist, a combination of professionals and support systems, such as psychologists, rehabilitation therapists, physiotherapists, nutritionists, and social workers, are required for the individual’s specific needs and maintaining their overall quality of life. Ongoing monitoring of an ARDS survivor is crucial to ensure a smooth transition out of hospital and back to daily living. Regular check-ups, lung tests, scans, and mental health screenings help to identify any problems and prevent its escalation. 

Summary 

ARDS is a serious life threatening condition that occurs when one’s lungs are impaired. It is characterised by breathlessness, choking, tightness in chest and pain. Few survive this critical health event and most need to be admitted to the ICU. Long hospital stays and the intensity of the critical condition leads to physical, psychological and emotional long-term effects spanning up to even five years after experiencing ARDS. Breathing difficulties and muscle weakness continue making day-to-day activities and work life harder. ARDS and intense medical procedures increase the risk of mental health conditions, such as depression, anxiety, and PTSD, especially if one has had a history of psychiatric illness. Due to the prolonged health issues, one’s quality of life is deeply affected post-ARDS. A structured and carefully designed rehabilitation and physical therapy plan is crucial in improving one’s physical health, independence, emotional well-being and quality of life.