ARDS is a frequent complication of major trauma, particularly severe thoracic injury, and this review sets out why it behaves differently from ARDS arising elsewhere. The pathophysiology is described as a multi-hit model: the initial injury, then a dysregulated inflammatory response, then secondary insults — transfusion, infection, fat embolism — converging on alveolar-capillary barrier disruption.
The practical consequence is that the hits after the first one are the ones a clinician can influence. Restrictive transfusion, timely fracture fixation, adequate analgesia so the patient can breathe deeply, and haemodynamic optimisation all sit upstream of the respiratory failure rather than downstream of it. Management once ARDS is established remains supportive and lung-protective, with non-invasive support in selected patients.
Two scenarios are called out as needing individual judgement rather than protocol. Traumatic brain injury brings brain-lung interactions into conflict — permissive hypercapnia and high PEEP each carry intracranial consequences. Hypothermia changes the physiology again. Imaging is central throughout, with lung ultrasound positioned alongside chest radiography and CT for diagnosis and monitoring rather than as a lesser alternative.
- Treat pain aggressively after thoracic trauma — inadequate analgesia produces shallow breathing, atelectasis and pneumonia.
- Keep transfusion restrictive where the physiology allows; transfusion is one of the named secondary hits.
- Use lung ultrasound serially rather than repeating chest radiographs; it detects consolidation and effusion earlier.
- In concurrent traumatic brain injury, do not apply a lung-protective protocol without considering intracranial pressure — permissive hypercapnia is not free here.
- Get definitive fracture fixation done in a timely way; delay is an inflammatory insult of its own.
Why it matters
The lung injury is treated as a respiratory problem when most of its modifiable causes are surgical and haemodynamic.
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This is a narrative review synthesising existing evidence, not a new trial or a formal guideline.
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