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ARDS

OVERVIEW

definitions of acute lung injury (ALI) and acute respiratory distress syndrome
(ARDS) have varied over time
ARDS was first described by Ashbaugh and Petty in 1967 in a case series of 12
ICU patients who shared the common features of unusually persistent tachypnea
and hypoxemia accompanied by opacification on chest radiographs and poor
lung compliance, despite different underlying causes
for more than 20 years, there was no common definition of ARDS
inconsistent definitions led to the published prevalence in ICU ranging from 10 to
90% of patients
The 1994 AECC definition became globally accepted, but had limitations
The current definition is the Berlin Definition published in 2013, which was
created by a consensus panel of experts convened in 2011 (an initiative of the
European Society of Intensive Care Medicine endorsed by the American
Thoracic Society and the Society of Critical Care Medicine)

BERLIN DEFINITION

ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary


vascular permeability, increased lung weight, and loss of aerated lung tissue[with]
hypoxemia and bilateral radiographic opacities, associated with increased venous
admixture, increased physiological dead space and decreased lung compliance.

Key components

1. acute, meaning onset over 1 week or less


2. bilateral opacities consistent with pulmonary edema must be present
and may be detected on CT or chest radiograph
3. PF ratio <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP)
4. must not be fully explained by cardiac failure or fluid overload, in the
physicians best estimation using available information an objective
assessment (e.g. echocardiogram) should be performed in most cases if
there is no clear cause such as trauma or sepsis.

Severity

ARDS is categorized as being mild, moderate, or severe:

ARDS Severity PaO2/FiO2* Mortality**

Mild 200 300 27%

Moderate 100 200 32%

Severe < 100 45%

*on PEEP 5+; **observed in cohort

Changes from the 1994 AECC definition

the term acute lung injury was abandoned


measurement of the PaO2/FIO2 ratio was changed to require a specific minimum
amount of PEEP
3 categories of ARDS were proposed (mild, moderate, and severe) based on the
PaO2/FIO2 ratio
Radiographic criteria were changed to improve interrater reliability
PCWP criterion was removed and additional clarity was added to improve the
ability to exclude cardiac causes of bilateral infiltrates

Issues with the Berlin definition

ability to predict mortality is still poor, but slightly better (based on meta-analysis
of 4188 patients): Berlin ROC AUC = 0.577 compared to 0.536 for AECC
4 ancillary variables for severe ARDS were assessed but did not have additional
predictive value, so were not included in the definition:
radiographic severity, respiratory system compliance (40 mL/cm H2O),
positive end-expiratory pressure (10 cm H2O), and corrected expired volume
per minute (10 L/min)
Berlin definition doesnt include underlying aetiology and lacks a direct measure
of lung injury
use of vasopressors at the time of diagnosis of ARDS is associated with a much
higher mortality regardless of the PF ratio (not accounted for in the Berlin
definition)
Does not allow early identification of pateints who may be amenable to therapies
before ARDS becomes established
unclear how the Berlin definition will affect diagnosis and management in the real
world
Berlin definition still allows CXR to be used for diagnosis, which compared poorly
with CT chest when studied by Figueroa-Casa et al, 2013:
Sensitivity 0.73; specificity, 0.70; positive and negative predictive values 0.88
and 0.47
The Berlin definition has low sensitivity when compared to autopsy findings:
Thille et al (2013) found that the Berlin Definition had a sensitivity of 89% and
specificity of 63% to identify ARDS, based on autopsies of 356 patients with
clinical criteria for ARDS using evidence of diffuse alveolar damage as the gold
standard

1994 AECC DEFINITION

Now obsolete

Four key components must be present for the diagnosis of ARDS:

the syndrome must present acutely


hypoxemia, measured as PaO2/FIO2 ratio <200 (the ratio is >450 in healthy
persons)
bilateral infiltrates on chest radiograph
cannot be due to cardiac failure (elevated left atrial pressure), as evidenced by
either clinical examination or a PCWP >18 cm H2O
The AECC also introduced the concept of acute lung injury:

defined similarly to ARDS, except that the PaO2/FIO2 ratio needed only be <300

Pros

cited by thousands of papers


defined the entry criteria into the practice changing ARDsnet ARMA trial that led
to the widespread adoption of protective lung ventilation
incorporated into practice bundles

Cons

other definitions such as the Lung Injury Score and the Delphi definition have a
greater sensitivity when matched against autopsy evidence
acute is ill defined
PF ratio can be manipulated by adjusting PEEP
CXR interpretation is unreliable
PACs are rarely used
PCWP may oscillate above and below the cut-off and may be elevated for
reasons other than heart failure
ALI was used inconsistently, just PF ratio 200 to 300, or all patients <300
including ARDS?

These cons led to the development of the Berlin definition