The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material
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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.
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.
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.
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.
KeywordsDiagnosis International cooperation Prognosis Respiration, artificial Respiratory distress syndrome, adult Risk factors
Acute respiratory distress syndrome
Extracorporeal life support
Fraction of inspired oxygen
High frequency oscillation
Partial pressure of arterial oxygen
Positive end-expiratory pressure
We thank Salvatore Maggiore, MD, PhD (Department of Anesthesiology and Intensive Care, AgostinoGemelli University Hospital, UniversitàCattolica del SacroCuore, Rome, Italy) and Anders Larsson, MD, PhD (Department of Surgical Sciences, Anesthesiology and Critical Care Medicine, Uppsala University, Uppsala, Sweden), for attending the round table as representatives of the European Society of Intensive Care Medicine. They received no compensation for their roles. We would like to thank Karen Pickett, MB BCh (Department of Intensive Care, Erasme Hospital, UniversitéLibre de Bruxelles, Brussels, Belgium), for her technical assistance in helping draft an earlier version of this manuscript. She received compensation for her role.
Conflicts of interest
All authors have completed and submitted disclosure forms regarding their potential conflicts of interest. The meeting was convened and supported financially by the European Society of Intensive Care Medicine (ESICM). Dr. Ferguson is supported by a Canadian Institutes of Health Research New Investigator Award (Ottawa, Canada). Dr. Fan is supported by a Canadian Institutes of Health Research Fellowship Award (Ottawa, Canada). Dr. Rubenfeld is supported by the National Institutes of Health grant R01HL067939 (Bethesda, USA). None of the funding organizations or sponsors had any role in the design and conduct of the study; the collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.
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