Intensive Care Medicine

, Volume 38, Issue 10, pp 1573–1582 | Cite as

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

  • Niall D. FergusonEmail author
  • 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



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.


Diagnosis 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.

Supplementary material

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


  1. 1.
    Ashbaugh DG, Bigelow DB, Petty TL, Levine BE (1967) Acute respiratory distress in adults. Lancet 2:319–323PubMedCrossRefGoogle Scholar
  2. 2.
    Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, LeGall JR, Morris A, Spragg R (1994) The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824PubMedGoogle Scholar
  3. 3.
    Artigas A, Bernard GR, Carlet J, Dreyfuss D, Gattinoni L, Hudson L, Lamy M, Marini JJ, Matthay MA, Pinsky MR, Spragg R, Suter PM (1998) The American-European Consensus Conference on ARDS, part 2: ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome. Am J Respir Crit Care Med 157:1332–1347PubMedGoogle Scholar
  4. 4.
    Phua J, Badia JR, Adhikari NK, Friedrich JO, Fowler RA, Singh JM, Scales DC, Stather DR, Li A, Jones A, Gattas DJ, Hallett D, Tomlinson G, Stewart TE, Ferguson ND (2009) Has mortality from acute respiratory distress syndrome decreased over time?: a systematic review. Am J Respir Crit Care Med 179:220–227PubMedCrossRefGoogle Scholar
  5. 5.
    Levy MM (2004) PEEP in ARDS–how much is enough? N Engl J Med 351:389–391PubMedCrossRefGoogle Scholar
  6. 6.
    Esteban A, Fernández-Segoviano P, Frutos-Vivar F, Aramburu JA, Nájera L, Ferguson ND, Alía I, Gordo F, Ríos F (2004) Comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings. Ann Intern Med 141:440–445PubMedGoogle Scholar
  7. 7.
    Ferguson ND, Frutos-Vivar F, Esteban A, Fernández-Segoviano P, Aramburu JA, Nájera L, Stewart TE (2005) Acute respiratory distress syndrome: under recognition by clinicians and diagnostic accuracy of three clinical definitions. Crit Care Med 33:2228–2234PubMedCrossRefGoogle Scholar
  8. 8.
    Kalhan R, Mikkelsen M, Dedhiya P, Christie J, Gaughan C, Lanken PN, Finkel B, Gallop R, Fuchs BD (2006) Underuse of lung protective ventilation: analysis of potential factors to explain physician behavior. Crit Care Med 34:300–306PubMedCrossRefGoogle Scholar
  9. 9.
    Rubenfeld GD, Cooper C, Carter G, Thompson BT, Hudson LD (2004) Barriers to providing lung-protective ventilation to patients with acute lung injury. Crit Care Med 32:1289–1293PubMedCrossRefGoogle Scholar
  10. 10.
    Villar J, Perez-Mendez L, Kacmarek RM (1999) Current definitions of acute lung injury and the acute respiratory distress syndrome do not reflect their true severity and outcome. Intensive Care Med 25:930–935PubMedCrossRefGoogle Scholar
  11. 11.
    Gowda MS, Klocke RA (1997) Variability of indices of hypoxemia in adult respiratory distress syndrome. Crit Care Med 25:41–45PubMedCrossRefGoogle Scholar
  12. 12.
    Ferguson ND, Kacmarek RM, Chiche J-D, Singh JM, Hallett DC, Mehta S, Stewart TE (2004) Screening of ARDS patients using standardized ventilator settings: influence on enrollment in a clinical trial. Intensive Care Med 30:1111–1116PubMedCrossRefGoogle Scholar
  13. 13.
    Villar J, Perez-Mendez L, Lopez J, Belda J, Blanco J, Saralegui I, Suarez-Sipmann F, Lopez J, Lubillo S, Kacmarek RM (2007) An Early PEEP/FIO2 trial identifies different degrees of lung injury in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 176:795–804PubMedCrossRefGoogle Scholar
  14. 14.
    Aboab J, Louis B, Jonson B, Brochard L (2006) Relation between PaO 2/FIO2 ratio and FIO2: a mathematical description. Intensive Care Med 32:1494–1497PubMedCrossRefGoogle Scholar
  15. 15.
    Britos M, Smoot E, Liu KD, Thompson BT, Checkley W, Brower RG, National Institutes of Health Acute Respiratory Distress Syndrome Network Investigators (2011) The value of positive end-expiratory pressure and Fio2 criteria in the definition of the acute respiratory distress syndrome. Crit Care Med 39:2025–2030PubMedCrossRefGoogle Scholar
  16. 16.
    Rubenfeld GD, Caldwell E, Granton JT, Hudson LD, Matthay MA (1999) Interobserver variability in applying a radiographic definition for ARDS. Chest 116:1347–1353PubMedCrossRefGoogle Scholar
  17. 17.
    Meade MO, Cook RJ, Guyatt GH, Groll RJ, Kachura JR, Bedard M, Cook DJ, Slutsky AS, Stewart TE (2000) Interobserver variation in interpreting chest radiographs for the diagnosis of acute respiratory distress syndrome. Am J Respir Crit Care Med 161:85–90PubMedGoogle Scholar
  18. 18.
    Ferguson ND, Meade MO, Hallett DC, Stewart TE (2002) High values of the pulmonary artery wedge pressure in patients with acute lung injury and acute respiratory distress syndrome. Intensive Care Med 28:1073–1077PubMedCrossRefGoogle Scholar
  19. 19.
    National Heart Lung and Blood Institute Acute Respiratory Distress Syndrome ARDS Clinical Trials Network, Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF, Hite RD, Harabin AL (2006) Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med 354:2213–2224PubMedCrossRefGoogle Scholar
  20. 20.
    Rubenfeld GD (2003) Epidemiology of acute lung injury. Crit Care Med 31(Supplement):S276–S284PubMedCrossRefGoogle Scholar
  21. 21.
    ESCIM Congress Highlights (2011) ARDS: The “Berlin Definition”. Available at: Accessed June 4, 2015
  22. 22.
    The ARDS Definition Task Force (2012) Acute respiratory distress syndrome: the Berlin definition. JAMA 307:2526–2533Google Scholar
  23. 23.
    Hansell DM, Bankier AA, MacMahon H, McLoud TC, Muller NL, Remy J (2008) Fleischner Society: glossary of terms for thoracic imaging. Radiology 246:697–722PubMedCrossRefGoogle Scholar
  24. 24.
    Katzenstein AL, Bloor CM, Leibow AA (1976) Diffuse alveolar damage—the role of oxygen, shock, and related factors. A review. Am J Pathol 85:209–228PubMedGoogle Scholar
  25. 25.
    Hudson LD, Milberg JA, Anardi D, Maunder RJ (1995) Clinical risks for development of the acute respiratory distress syndrome. Am J Respir Crit Care Med 151:293–301PubMedGoogle Scholar
  26. 26.
    Gajic O, Dabbagh O, Park PK, Adesanya A, Chang SY, Hou P, Anderson H 3rd, Hoth JJ, Mikkelsen ME, Gentile NT, Gong MN, Talmor D, Bajwa E, Watkins TR, Festic E, Yilmaz M, Iscimen R, Kaufman DA, Esper AM, Sadikot R, Douglas I, Sevransky J, Malinchoc M, U.S. Critical Illness and Injury Trials Group: Lung Injury Prevention Study Investigators (USCIITG-LIPS) (2011) Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med 183:462–470PubMedCrossRefGoogle Scholar
  27. 27.
    Rice TW, Wheeler AP, Bernard GR, Hayden DL, Schoenfeld DA, Ware LB, for the National Institutes of Health, National Heart, Lung, and Blood Institute ARDS Network (2007) Comparison of the SpO2/FIO2 ratio and the PaO2/FIO2 ratio in patients with acute lung injury or ARDS. Chest 132:410–417PubMedCrossRefGoogle Scholar
  28. 28.
    de Louw Van, Cracco C, Cerf C, Harf A, Duvaldestin P, Lemaire F, Brochard L (2001) Accuracy of pulse oximetry in the intensive care unit. Intensive Care Med 27:1606–1613PubMedCrossRefGoogle Scholar
  29. 29.
    The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308CrossRefGoogle Scholar
  30. 30.
    Sud S, Friedrich JO, Taccone P et al (2010) Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Med 36:585–599PubMedCrossRefGoogle Scholar
  31. 31.
    Hager DN, Krishnan JA, Hayden DL, Brower RG (2005) Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med 172:1241–1245PubMedCrossRefGoogle Scholar
  32. 32.
    Murray JF, Matthay MA, Luce JM, Flick MR (1988) An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 138:720–723PubMedGoogle Scholar
  33. 33.
    Gattinoni L, Vagginelli F, Carlesso E, Taccone P, Conte V, Chiumello D, Valenza F, Caironi P, Pesenti A, Prone-Supine Study Group (2003) Decrease in PaCO2 with prone position is predictive of improved outcome in acute respiratory distress syndrome. Crit Care Med 31:2727–2733PubMedCrossRefGoogle Scholar
  34. 34.
    Nuckton TJ, Alonso JA, Kallet RH, Daniel BM, Pittet J-F, Eisner MD, Matthay MA (2002) Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med 346:1281–1286PubMedCrossRefGoogle Scholar
  35. 35.
    Wexler HR, Lok P (1981) A simple formula for adjusting arterial carbon dioxide tension. Can Anaesth Soc J 28:370–372PubMedCrossRefGoogle Scholar
  36. 36.
    Sakka SG, Rühl CC, Pfeiffer UJ, Beale R, McLuckie A, Reinhart K, Meier-Hellmann A (2000) Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med 26:180–187PubMedCrossRefGoogle Scholar
  37. 37.
    Camporota L, De Neef M, Beale R (2012) Extravascular lung water in acute respiratory distress syndrome: potential clinical value, assumptions and limitations. Crit Care 16:114PubMedCrossRefGoogle Scholar
  38. 38.
    Barnett N, Ware LB (2011) Biomarkers in acute lung injury—marking forward progress. Crit Care Clinics 27:661–683CrossRefGoogle Scholar
  39. 39.
    Flores C, Pino-Yanes MM, Casula M, Villar J (2010) Genetics of acute lung injury: past, present and future. Minerva Anestesiol 76:860–864PubMedGoogle Scholar
  40. 40.
    Calfee CS, Ware LB, Glidden DV, Eisner MD, Parsons PE, Thompson BT, Matthay MA (2011) Use of risk reclassification with multiple biomarkers improves mortality prediction in acute lung injury. Crit Care Med 39:711–717PubMedCrossRefGoogle Scholar
  41. 41.
    Papazian L, Doddoli C, Chetaille B, Gernez YL, Thirion X, Roch A, Donati Y, Bonnety M, Zandotti C, Thomas P (2007) A contributive result of open-lung biopsy improves survival in acute respiratory distress syndrome patients. Crit Care Med 35:755–762PubMedCrossRefGoogle Scholar
  42. 42.
    Papazian L, Thomas P, Bregeon F, Garbe L, Zandotti C, Saux P, Gaillat F, Drancourt M, Auffray JP, Gouin F (1998) Open-lung biopsy in patients with acute respiratory distress syndrome. Anesthesiology 88:935–944PubMedCrossRefGoogle Scholar
  43. 43.
    Kraus PA, Lipman J, Lee CC, Wilson WE, Scribante J, Barr J, Mathivha LR, Brown JM (1993) Acute lung injury at Baragwanath ICU. An eight-month audit and call for consensus for other organ failure in the adult respiratory distress syndrome. Chest 103:1832–1836PubMedCrossRefGoogle Scholar
  44. 44.
    Shah CV, Lanken PN, Localio AR, Gallop R, Bellamy S, Ma SF, Flores C, Kahn JM, Finkel B, Fuchs BD, Garcia JG, Christie JD (2010) An alternative method of acute lung injury classification for use in observational studies. Chest 138:1054–1061PubMedCrossRefGoogle Scholar
  45. 45.
    Gattinoni L, Caironi P, Pelosi P, Goodman LR (2001) What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 164:1701–1711PubMedGoogle Scholar
  46. 46.
    Rubenfeld GD, Caldwell E, Peabody E, Weaver J, Martin DP, Neff M, Stern EJ, Hudson LD (2005) Incidence and outcomes of acute lung injury. N Engl J Med 353:1685–1693PubMedCrossRefGoogle Scholar
  47. 47.
    Zhao Z, Steinmann D, Frerichs I, Guttmann J, Möller K (2010) PEEP titration guided by ventilation homogeneity: a feasibility study using electrical impedance tomography. Crit Care 14:R8PubMedCrossRefGoogle Scholar
  48. 48.
    Froese AB, Ferguson ND (2012) High-Frequency Ventilation. In: Tobin MJ (ed) Mechanical Ventilation (3rd edn). McGraw-Hill, New York, In PressGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2012

Authors and Affiliations

  • Niall D. Ferguson
    • 1
    Email author
  • 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

Personalised recommendations