LIPS-B: Lung Injury Prevention Study With Budesonide and Beta

Inclusion Criteria: * Adult patients (age \> 18) * Admitted to the hospital through the emergency department (ED) * High risk of developing ARDS (Lung Injury Prediction Score (LIPS) greater than or equal to four) Exclusion Criteria: * Inhaled corticosteroid and/or beta agonist treatment on admission or within 7 days prior to admission (history of asthma or COPD necessitating therapy) * Chronic pulmonary disease requiring daytime oxygen supplementation therapy * Systemic steroid treatment on admission or within 7 days prior to admission equivalent to more than 5 mg of prednisone daily * Inability to obtain consent within 12 hours of hospital presentation * Acute lung injury prior to randomization * Receiving mechanical ventilation before current hospital admission (patient who is ventilator dependent) * Presentation believed to be purely due to heart failure without other known risk factors for ARDS * Allergy or other contraindication to either budesonide and/or formoterol use * Expected hospital stay and/or survival \<48 hours or admission for comfort or hospice care * Patient, surrogate or physician not committed to full support (exception: a patient will not be excluded if he/she would receive all supportive care except for attempts at resuscitation from cardiac arrest) * Previous enrollment in this trial. * Co-enrollment with LIPS-A trial is not allowed. * An active enrollment in other concomitant trial will be judged on case by case basis by PIs of both trials. * EKG and/or clinical presentation suggestive of acute coronary ischemia * New onset cardiac arrhythmia * Current atrial fibrillation with ventricular rate of \>110/minute * Persistent sinus tachycardia of \>130/minute despite early goal directed therapy with fluids, pressors, antibiotics and supplemental oxygen * Pregnant patients