Intensive Care Medicine

, Volume 38, Issue 10, pp 1573–1582

The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material

  • Niall D. Ferguson
  • Eddy Fan
  • Luigi Camporota
  • Massimo Antonelli
  • Antonio Anzueto
  • Richard Beale
  • Laurent Brochard
  • Roy Brower
  • Andrés Esteban
  • Luciano Gattinoni
  • Andrew Rhodes
  • Arthur S. Slutsky
  • Jean-Louis Vincent
  • Gordon D. Rubenfeld
  • B. Taylor Thompson
  • V. Marco Ranieri
Special Article

DOI: 10.1007/s00134-012-2682-1

Cite this article as:
Ferguson, N.D., Fan, E., Camporota, L. et al. Intensive Care Med (2012) 38: 1573. doi:10.1007/s00134-012-2682-1

Abstract

Purpose

Our objective was to revise the definition of acute respiratory distress syndrome (ARDS) using a conceptual model incorporating reliability and validity, and a novel iterative approach with formal evaluation of the definition.

Methods

The European Society of Intensive Care Medicine identified three chairs with broad expertise in ARDS who selected the participants and created the agenda. After 2 days of consensus discussions a draft definition was developed, which then underwent empiric evaluation followed by consensus revision.

Results

The Berlin Definition of ARDS maintains a link to prior definitions with diagnostic criteria of timing, chest imaging, origin of edema, and hypoxemia. Patients may have ARDS if the onset is within 1 week of a known clinical insult or new/worsening respiratory symptoms. For the bilateral opacities on chest radiograph criterion, a reference set of chest radiographs has been developed to enhance inter-observer reliability. The pulmonary artery wedge pressure criterion for hydrostatic edema was removed, and illustrative vignettes were created to guide judgments about the primary cause of respiratory failure. If no risk factor for ARDS is apparent, however, objective evaluation (e.g., echocardiography) is required to help rule out hydrostatic edema. A minimum level of positive end-expiratory pressure and mutually exclusive PaO2/FiO2 thresholds were chosen for the different levels of ARDS severity (mild, moderate, severe) to better categorize patients with different outcomes and potential responses to therapy.

Conclusions

This panel addressed some of the limitations of the prior ARDS definition by incorporating current data, physiologic concepts, and clinical trials results to develop the Berlin definition, which should facilitate case recognition and better match treatment options to severity in both research trials and clinical practice.

Keywords

DiagnosisInternational cooperationPrognosisRespiration, artificialRespiratory distress syndrome, adultRisk factors

Abbreviations

ARDS

Acute respiratory distress syndrome

ECLS

Extracorporeal life support

FiO2

Fraction of inspired oxygen

HFO

High frequency oscillation

PaO2

Partial pressure of arterial oxygen

PEEP

Positive end-expiratory pressure

Supplementary material

134_2012_2682_MOESM1_ESM.docx (1.4 mb)
Supplementary material 1 (DOCX 1430 kb)

Copyright information

© Copyright jointly held by Springer and ESICM 2012

Authors and Affiliations

  • Niall D. Ferguson
    • 1
  • Eddy Fan
    • 2
  • Luigi Camporota
    • 3
  • Massimo Antonelli
    • 4
  • Antonio Anzueto
    • 5
  • Richard Beale
    • 3
  • Laurent Brochard
    • 6
  • Roy Brower
    • 7
  • Andrés Esteban
    • 8
  • Luciano Gattinoni
    • 9
  • Andrew Rhodes
    • 10
  • Arthur S. Slutsky
    • 11
  • Jean-Louis Vincent
    • 12
  • Gordon D. Rubenfeld
    • 13
  • B. Taylor Thompson
    • 14
  • V. Marco Ranieri
    • 15
  1. 1.Interdepartmental Division of Critical Care Medicine, and Department of Medicine, Division of Respirology, University Health Network and Mount Sinai HospitalUniversity of TorontoTorontoCanada
  2. 2.Interdepartmental Division of Critical Care Medicine, and Department of Medicine, University Health Network and Mount Sinai HospitalUniversity of TorontoTorontoCanada
  3. 3.Division of Asthma, Allergy and Lung Biology, King’s College London and Department of Adult Critical CareGuy’s and St Thomas’ NHS Foundation Trust, King’s Health PartnersLondonUK
  4. 4.Dipartimento di Anestesia e RianimazioneUniversita Cattolica del Sacro CuoreRomeItaly
  5. 5.Pulmonary/Critical CareUniversity of Texas Health Sciences Center at San Antonio, and South Texas Veterans Health Care SystemSan AntonioUSA
  6. 6.Medical-Surgical Intensive Care UnitHopitaux Universitaires de GeneveGenevaSwitzerland
  7. 7.Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreUSA
  8. 8.Servicio de Cuidados Intensivos, Hospital Universitario de Getafe. CIBER de Enfermedades RespiratoriasInstituto Salud Carlos IIIMadridSpain
  9. 9.Istituto di Anestesiologia e RianimazioneUniversita degli Studi di MilanoMilanItaly
  10. 10.Department of Intensive Care MedicineSt. George’s Healthcare NHS TrustLondonUK
  11. 11.Keenan Research Center of the Li KaShing Knowledge Institute of St. Michael’s Hospital; Interdepartmental Division of Critical Care MedicineUniversity of TorontoTorontoCanada
  12. 12.Department of Intensive Care, Erasme University HospitalUniversité Libre de BruxellesBrusselsBelgium
  13. 13.Interdepartmental Division of Critical Care MedicineUniversity of TorontoTorontoCanada
  14. 14.Pulmonary/Critical Care Unit, Department of MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonUSA
  15. 15.Department of Anesthesia and Intensive Care MedicineUniversity of TurinTurinItaly