Objective To compare the chest computed tomography (CT) images of patients with acute respiratory distress syndrome (ARDS) and acute cardiogenic pulmonary edema (ACPE). Methods 30 cases of patients with ARDS and 30 cases of patients with ACPE from August 2016 to August 2018 were randomly selected. All patients underwent thoracic CT examination. The distributions of grinded glass density shadow (GGO) in the lungs and changes of extrapulmonary structure were statistically analyzed. Results The differences of distributions of GGO in the upper lobe, middle lobe, lower lobe and diffuse distribution between patients with ARDS and ACPE were not significant [16.7%(5/30), 0, 16.7%(5/30), 66.7%(20/30) vs 20.0%(6/30), 0, 20.0%(6/30), 60.0%(18/30), P>0.05]. The distributions of GGO in center lung [13.3%(4/30)] was significantly lower than patients with ACPE [46.7%(14/30)] (P 0.05]. The small boundary opacity of patients with ARDS [76.7%(23/30)] was significantly higher than patients with ACPE [26.7%(8/30)] (P<0.05), while the bronchial blood bundle thickening, pulmonary vascular shadow thickening, cardiac shadow enlargement, pericardial effusion were significantly lower than patients with ACPE [33.3% (10/30), 16.7%(5/30), 30.0%(9/30), 23.3%(7/30) vs 23.3%(7/30), 100.0%(30/30), 70.0%(21/30), 73.3%(22/30), 53.3%(16/30), P<0.05]. Conclusions The chest CT images of patients with ARDS and ACPE are different, mainly manifestated in small boundary opacity, bronchial blood bundle thickening, pulmonary vascular opacity, cardiac opacity, pericardial effusion. Key words: Respiratory distress syndrome, adult; Pulmonary edema; Edema, cardiac; Radiography, thoracic