AcuteRespiratoryDistressSyndrome(ARDS)Definitions

|LITFL:LifeintheFastLaneMedicalBlog

Reviewedandrevised15September2014OVERVIEW
definitionsofacutelunginjury(ALI)andacuterespiratorydistresssyndrome(ARDS)havevaried
overtime
ARDSwasfirstdescribedbyAshbaughandPettyin1967inacaseseriesof12ICUpatientswho
sharedthecommonfeaturesofunusuallypersistenttachypneaandhypoxemiaaccompaniedby
opacificationonchestradiographsandpoorlungcompliance,despitedifferentunderlyingcauses
formorethan20years,therewasnocommondefinitionofARDS
inconsistentdefinitionsledtothepublishedprevalenceinICUrangingfrom10to90%ofpatients
The1994AECCdefinitionbecamegloballyaccepted,buthadlimitations
ThecurrentdefinitionistheBerlinDefinitionpublishedin2013,whichwascreatedbya
consensuspanelofexpertsconvenedin2011(aninitiativeoftheEuropeanSocietyofIntensiveCare
MedicineendorsedbytheAmericanThoracicSocietyandtheSocietyofCriticalCareMedicine)

BERLINDEFINITION
ARDSisanacutediffuse,inflammatorylunginjury,leadingtoincreasedpulmonaryvascular
permeability,increasedlungweight,andlossofaeratedlungtissue[with]hypoxemiaandbilateral
radiographicopacities,associatedwithincreasedvenousadmixture,increasedphysiologicaldead
spaceanddecreasedlungcompliance.

Keycomponents

1.acute,meaningonsetover1weekorless
2.bilateralopacitiesconsistentwithpulmonaryedemamustbepresentandmaybedetectedon
CTorchestradiograph
3.PFratio<300mmHgwithaminimumof5cmH20PEEP(orCPAP)
4.mustnotbefullyexplainedbycardiacfailureorfluidoverload,inthephysiciansbestestimation
usingavailableinformationanobjectiveassessment(e.g.echocardiogram)shouldbe
performedinmostcasesifthereisnoclearcausesuchastraumaorsepsis.

Severity

ARDSiscategorizedasbeingmild,moderate,orsevere:

ARDSSeverity PaO2/FiO2* Mortality**

Mild 200300 27%

Moderate 100200 32%

Severe <100 45%

*onPEEP5+**observedincohort

Changesfromthe1994AECCdefinition

thetermacutelunginjurywasabandoned
measurementofthePaO2/FIO2ratiowaschangedtorequireaspecificminimumamountofPEEP
3categoriesofARDSwereproposed(mild,moderate,andsevere)basedonthePaO2/FIO2ratio
Radiographiccriteriawerechangedtoimproveinterraterreliability
 PCWPcriterionwasremovedandadditionalclaritywasaddedtoimprovetheabilitytoexclude
cardiaccausesofbilateralinfiltrates

IssueswiththeBerlindefinition

abilitytopredictmortalityisstillpoor,butslightlybetter(basedonmetaanalysisof4188patients):
BerlinROCAUC=0.577comparedto0.536forAECC
4ancillaryvariablesforsevereARDSwereassessedbutdidnothaveadditionalpredictivevalue,so
werenotincludedinthedefinition:
radiographicseverity,respiratorysystemcompliance(40mL/cmH2O),positiveendexpiratory
pressure(10cmH2O),andcorrectedexpiredvolumeperminute(10L/min)
Berlindefinitiondoesntincludeunderlyingaetiologyandlacksadirectmeasureoflunginjury
useofvasopressorsatthetimeofdiagnosisofARDSisassociatedwithamuchhighermortality
regardlessofthePFratio(notaccountedforintheBerlindefinition)
DoesnotallowearlyidentificationofpateintswhomaybeamenabletotherapiesbeforeARDS
becomesestablished
unclearhowtheBerlindefinitionwillaffectdiagnosisandmanagementintherealworld
BerlindefinitionstillallowsCXRtobeusedfordiagnosis,whichcomparedpoorlywithCTchestwhen
studiedbyFigueroaCasaetal,2013:
Sensitivity0.73specificity,0.70positiveandnegativepredictivevalues0.88and0.47
TheBerlindefinitionhaslowsensitivitywhencomparedtoautopsyfindings:
Thilleetal(2013)foundthattheBerlinDefinitionhadasensitivityof89%andspecificityof63%to
identifyARDS,basedonautopsiesof356patientswithclinicalcriteriaforARDSusingevidenceof
diffusealveolardamageasthegoldstandard

1994AECCDEFINITION
Nowobsolete

FourkeycomponentsmustbepresentforthediagnosisofARDS:

thesyndromemustpresentacutely
hypoxemia,measuredasPaO2/FIO2ratio<200(theratiois>450inhealthypersons)
bilateralinfiltratesonchestradiograph
cannotbeduetocardiacfailure(elevatedleftatrialpressure),asevidencedbyeitherclinical
examinationoraPCWP>18cmH2O

TheAECCalsointroducedtheconceptofacutelunginjury:

definedsimilarlytoARDS,exceptthatthePaO2/FIO2rationeededonlybe<300

Pros

citedbythousandsofpapers
definedtheentrycriteriaintothepracticechangingARDsnetARMAtrialthatledtothewidespread
adoptionofprotectivelungventilation
incorporatedintopracticebundles

Cons

otherdefinitionssuchastheLungInjuryScoreandtheDelphidefinitionhaveagreatersensitivity
whenmatchedagainstautopsyevidence
acuteisilldefined
PFratiocanbemanipulatedbyadjustingPEEP
CXRinterpretationisunreliable
 PACsarerarelyused
PCWPmayoscillateaboveandbelowthecutoffandmaybeelevatedforreasonsotherthanheart
failure
ALIwasusedinconsistently,justPFratio200to300,orallpatients<300includingARDS?

TheseconsledtothedevelopmentoftheBerlindefinition

ReferencesandLinks

Journalarticles
ARDSDefinitionTaskForce,RanieriVM,RubenfeldGD,ThompsonBT,FergusonND,CaldwellE,
FanE,CamporotaL,SlutskyAS.Acuterespiratorydistresssyndrome:theBerlinDefinition.JAMA.
2012Jun20307(23):252633.doi:10.1001/jama.2012.5669.PubMedPMID:22797452.
AngusDC.Theacuterespiratorydistresssyndrome:whatsinaname?JAMA.2012Jun
20307(23):25424.doi:10.1001/jama.2012.6761.PubMedPMID:22797455.[FullText]
FigueroaCasas.Accuracyofthechestradiographtoidentifybilateralpulmonaryinfiltratesconsistent
withthediagnosisofacuterespiratorydistresssyndromeusingcomputedtomographyasreference
standard.JCritCare2013epublishedApril5th[ArticleLink]
PhillipsCR.TheBerlindefinition:realchangeortheemperorsnewclothes?CritCare.2013Aug
117(4):174.doi:10.1186/cc12761.PubMedPMID:23905752PubMedCentralPMCID:
PMC4057493.
ThilleAW,EstebanA,FernndezSegovianoP,RodriguezJM,AramburuJA,PeuelasO,Corts
PuchI,CardinalFernndezP,LorenteJA,FrutosVivarF.ComparisonoftheBerlindefinitionfor
acuterespiratorydistresssyndromewithautopsy.AmJRespirCritCareMed.2013Apr1187(7):761
7.doi:10.1164/rccm.2012111981OC.PubMedPMID:23370917.[ArticleLink]

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