New insights into the pathology of acute respiratory failure

Purpose of review: The purpose of this review is to provide a historical perspective and to analyze the recent advances in the understanding of the cellular and tissue pathology of acute respiratory failure, specifically of the acute respiratory distress syndrome. The scope of mechanisms involved in acute lung injury and acute respiratory distress syndrome is far too great to do it justice in a single review. Therefore, this review will focus only on recent advances in the understanding of the morphologic changes that occur in acute lung injury, acute respiratory distress syndrome, and ventilator-induced lung injury. Recent findings: The use of fluorescent labels brought a novel method to identify and quantify cell wounding in the whole organ animal model of ventilator-induced lung injury. Real-time in vivo microscopy demonstrated the injurious effects of alveolar instability in the pathogenesis of ventilator-induced lung injury. Lipid tether mechanics, using laser tweezers, have advanced the understanding of the mechanical properties of the plasma membrane in response to mechanical stress. New animal injury models have brought forward new insights into the pathogenesis and structural abnormalities seen in acute respiratory distress syndrome. Apoptosis and epithelial wounding and repair have been examined in novel methods, and new mechanisms in lung edema formation have been proposed. Summary: New mechanisms in the pathology of acute respiratory failure have shifted the focus to lung mechanics, tissue damage, remodeling, and the systemic effects derived from the mechanical stress imposed by the ventilator in patients with adult respiratory distress syndrome.