Rapid Oxygenation Recovery in Drowning-Associated ARDS Managed With Early Lung-Protective Ventilation

Abstract

Background: Drowning is a major cause of accidental injury worldwide, accounting for an estimated 236,000 deaths annually, and may lead to acute respiratory distress syndrome (ARDS) due to aspiration-induced lung injury. Epidemiological data from Indonesia remain limited; retrospective studies from Bali and North Sulawesi report drowning-related mortality rates ranging from 0.18 to 1.73 per 100,000 population, reflecting provincial-level data and suggesting potential underestimation of the national burden. Although freshwater and seawater aspiration have traditionally been considered pathophysiologically distinct, clinical outcomes appear to be influenced more by the severity of hypoxaemia and early respiratory management than by water salinity.

Case: We report two cases of drowning-associated ARDS in young adult males. The first patient developed moderate ARDS following seawater drowning, while the second presented with severe ARDS after freshwater drowning. Both patients underwent early endotracheal intubation and were managed with lung-protective mechanical ventilation using low tidal volumes and appropriate positive end-expiratory pressure. In both cases, oxygenation improved rapidly, with PaO₂/FiO₂ ratios increasing to greater than 250 within hours of ventilation. Serial chest radiographs demonstrated progressive resolution of bilateral alveolar infiltrates, allowing successful ventilator weaning and extubation on day four and day six, respectively.

Discussion: Despite differences in initial ARDS severity and the type of aspirated water, both patients demonstrated similar patterns of rapid oxygenation recovery and radiological improvement. This supports the concept that the extent of aspiration and early disruption of the alveolar–capillary membrane, rather than water composition, are the primary determinants of clinical severity. Early lung-protective ventilation likely mitigated further ventilator-induced lung injury, promoted alveolar recruitment, and facilitated rapid reversibility of hypoxaemia in both cases.

Conclusion: Drowning-associated ARDS, regardless of freshwater or seawater aspiration, may represent a highly reversible form of acute lung injury when managed with early airway control and lung-protective mechanical ventilation.