Acute Respiratory Distress Syndrome (ARDS) in critically ill patients with cirrhosis

Patients with liver cirrhosis admitted to the intensive care unit (ICU) are among the most vulnerable in modern medicine. When acute respiratory distress syndrome (ARDS) develops in this population, outcomes are particularly poor. However, robust data describing the prevalence, prognosis, and prognostic factors of ARDS in patients with cirrhosis have remained scarce, largely retrospective, and often limited by small sample sizes.

A new bicentric retrospective cohort study conducted in two tertiary ICUs in France provides the most comprehensive evaluation to date of ARDS in mechanically ventilated patients with cirrhosis, highlighting an extremely high short-term mortality that has not improved over the past 15 years, despite advances in intensive care practices. The study led by Dr. Alexandre Demoule was published online on February 20, 2026 in the Journal of Intensive Medicine.
 

ARDS affects more than one in four ventilated patients with cirrhosis

Between 2007 and 2021, the investigators screened 816 ICU admissions of patients with cirrhosis. Among the 621 patients who required invasive mechanical ventilation, 165 (26.6%) met ARDS criteria during their ICU stay. Importantly, ARDS was not identified based on discharge diagnoses alone: each case was confirmed through a detailed manual review of clinical data, imaging, and oxygenation parameters, addressing the well-known issue of ARDS under-recognition in routine practice.

ARDS developed early, typically within two days after ICU admission, and was severe in more than half of cases. Pneumonia was the leading risk factor, but many patients developed ARDS secondary to complications of cirrhosis, such as gastrointestinal bleeding with shock or sepsis.
 

An extremely high mortality that has not improved over time

The study’s most striking finding is the persistently high mortality. Twenty-eight-day mortality reached 75.2%, and 90-day mortality exceeded 83%. Although ICU severity scores slightly improved over time, mortality did not significantly decrease between the periods 2007–2014 and 2015–2021.

These outcomes contrast sharply with those observed in the general ARDS population, where mortality has steadily declined over recent decades. The findings suggest that patients with cirrhosis and ARDS represent a distinct, high-risk subgroup that has not benefited to the same extent from advances in ARDS management.
 

Three key prognostic factors identify distinct patient profiles

Using multivariable analysis, the authors identified three independent factors associated with 28-day mortality:

• Severity of liver disease, assessed by the Model for End-Stage Liver Disease (MELD) score
• Severity of hypoxemia, reflected by the PaO₂/FiO₂ ratio at ARDS onset
• Reason for ICU admission, with patients admitted primarily for acute respiratory failure having a significantly better prognosis than those who developed ARDS secondary to other complications

These findings reveal two clinically meaningful patient profiles. Patients admitted for acute respiratory failure—often pneumonia-related—had a lower mortality (~67%) compared with patients initially admitted for non-respiratory complications who subsequently developed ARDS (~84%). While causality cannot be inferred, this distinction may help clinicians refine prognostic assessment and guide discussions regarding treatment intensity.
 

Implications for clinical practice and ethics

Beyond epidemiology, the study raises important clinical and ethical considerations. ARDS remains frequently under-recognized in patients with cirrhosis, potentially limiting the timely application of lung-protective ventilation strategies known to improve outcomes in ARDS. Systematic screening for ARDS in this population could therefore represent a simple, actionable target for quality improvement.

At the same time, the extremely high mortality observed underscores the need for early, multidisciplinary discussions about goals of care, particularly in patients with advanced liver disease and multiple organ failures. Identifying patients with a realistic chance of recovery—including those eligible for liver transplantation—remains crucial to avoid both disproportionate therapeutic escalation and premature limitation of care.
 

The largest cohort to date, with clear directions for future research

This study represents the largest cohort of patients with cirrhosis and ARDS reported so far, and the first to identify independent prognostic factors for short-term mortality in this population. By integrating hepatic severity, respiratory severity, and ICU admission context, it helps reconcile conflicting results from prior smaller studies.

Future research should focus on identifying phenotypes within this high-risk group, optimizing ARDS management strategies tailored to cirrhosis-related constraints, and evaluating the role of earlier liver transplantation assessment—before the onset of critical respiratory failure.

***

Reference

DOI: https://doi.org/10.1016/j.jointm.2025.12.008