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The Berlin Definition of ARDS

Timing Within 1 week of a known clinical insult or new or

worsening respiratory symptoms

Chest imaging Bilateral opacities-not fully explained by effusions,

lobar/ lung collapse, or nodule

Origin of edema Respiratory failure not fully explained by cardiac

failure or fluid overload need objective assesment (eg,
echocardiography) to exclude hydrostatic edema if no
risk factor present

Oxygenation 200 mmHg<PaO2/FiO2≤300mmHg with PEEP or

Mild CPAP≥5 cm H2O

Moderate 100 mmHg<PaO2/FiO2≤200mmHg with PEEP ≥5 cm


Severe PaO2/FiO2 ≤ 100 mmHg with PEEP≥5 cm H2O

SpO2 can be substituted for the PaO2 to calculate the SpO2/FiO2 ratio, which may
be more a feasible method of identifying severely ill patients in these resource –
limited environment
ARDS AECC Definition (american AECC Limitations / Addressed in Berlin Definition
european consensus
conference )

Timing Acute onset No definition of acute Acute time frame specified

ALI category (Acute Lung Injury) All patients with PaO2/FiO2 < Misinterpreted as 3 mutually exclusive subgroups
300mmHg PaO2/FiO2=201-300, leading to of ARDS by severity
confusing ALI/ARDS term ALI term removed

Oxygenation PaO2/FiO2 ≤300 mmHg Inconsistency of PaO2/FiO2 Minimal PEEP level added
(regardless of PEEP) ratio due to the effect of PEEP across subgroups
and/or FiO2 FiO2 effect less relevant in
severe ARDS group

Chest radiograph Bilateral infiltrates observed on Poor interobserver reliability of Chest radiograph criteria
frontal chest radiograph chest radiograph interpretation clarified
Example radiographs created

PAWP (pulmonary artery wedge PAWP ≤ 18 mmHg when High PAWP and ARDS may PAWP requirement removed
pressure) measured or no clinical coexist Hydrostatic edema not the
evidence of left atrial Poor interobserver reliability of primary cause of respiratory
hypertension PAWP and clinical assesments of failure
left atrial hypertension Clinical vignettes created to
help exclude hydrostatic edema

Risk factor None Not formally included in Included when none identified
definition need to objectively rule out
hydroostatic edema
Definition of Severe
Acute Respiratory Distress Syndrome
Score 0 1 2 3 4
P/F ratio > 300 225-299 175-224 100- <100
CXR alveolar None 1Q 2Q 3Q 4Q
PEEP <5 6-8 9-11 12-14 >15
Compliance >80 60-79 40-59 20-39 <19
Clinical Disorders Associated With The
Development of ARDS
Direct insult Indirect insult

• Common • Common
• aspiration pneumonia • Sepsis
• Pneumonia • Severe trauma
• Shock
• Less common
• Inhalation injury • Less common
• Pulmonary contusions • acute pancreatitis
• Fat emboli • Cardiopulmonary bypass
• Near drawning • transfusion related TRALI
• Reperfusion injury • DIC
• Burns
• Head injury
• Drug overdose
Schematic representation of the time course of the acute respiratory distress
syndrome (ARDS). During the early or exudative phase, the lesion is charaterized by
high permeability pulmonary edema followed by the formation of hyaline membranes.
After seven to ten days, a proliferative phase may develop, with marked interstitial
inflammation, fibrosis and disordered healing.
Features Shared by ARDS & Other Causes of Acute
Respiratory Failure
Feature ARDS Severe Pulmonary Cardiogenic
Pneumonia Embolism Lung Edema
Acute onset v v v v
Fever, v v v If acute MI
Bilateral v v v
PaO2/ v v V
PAOP < 18 v v v