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.
- 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.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
- 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
- 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
- 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
- 21.ESCIM Congress Highlights (2011) ARDS: The “Berlin Definition”. Available at: http://www.esicm.org/07-congresses/0A-annual-congress/webTv.asp. Accessed June 4, 2015
- 22.The ARDS Definition Task Force (2012) Acute respiratory distress syndrome: the Berlin definition. JAMA 307:2526–2533Google Scholar
- 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.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
- 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
- 48.Froese AB, Ferguson ND (2012) High-Frequency Ventilation. In: Tobin MJ (ed) Mechanical Ventilation (3rd edn). McGraw-Hill, New York, In PressGoogle Scholar