Abstract: Objective To compare the clinical characteristics of elderly patients with pulmonary and extra-pulmonary acute respiratory distress syndrome (ARDS). Methods Clinical data about 74 ARDS patients with their age> 60 years admitted to our hospital from January 2000 to June 2012 were retrospectively analyzed. Results Pneumonia was most common in elderly pulmonary ARDS patients (77.6%) and sepsis was most common in elderly extra-pulmonary ARDS patients (43.8%). The APACHEⅡscore was 20.4 and 2.7, the lung injury score was 20.7 and 2.5, the sequential organ failure assessment (SOFA) score was 6.1 and 8.4, and in-hospital mortality was 58.6% and 43.8%, respectively, in elderly pulmonary ARDS patients and extra- pulmonary ARDS patients, respectively (P=0.898, P=0.385, P=0.013, P=0.289). Multiple organ dysfunction syndrome and severe respiratory failure were the major causes of death in both pulmonary and extra-pulmonary patients. Conclusion The organ failure is severer in elderly extrapulmonary ARDS patients than in elderly pulmonary ARDS patients, but no significant difference is found in their APACHEⅡand lung injury scores, in-hospital mortality, and major causes of death．