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

H2O

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
european consensus
conference )
Timing Acute onset
ALI category (Acute Lung All patients with PaO2/FiO2 <
Injury) 300mmHg
Oxygenation PaO2/FiO2 ≤300 mmHg
(regardless of PEEP)
Chest radiograph Bilateral infiltrates observed
on frontal chest radiograph
PAWP (pulmonary artery PAWP ≤ 18 mmHg when
wedge pressure) measured or no clinical
evidence of left atrial
hypertension
Risk factor None
AECC Limitations /
No definition of acute
Misinterpreted as
PaO2/FiO2=201-300, leading
to confusing ALI/ARDS term
Inconsistency of PaO2/FiO2
ratio due to the effect of PEEP
and/or FiO2
Poor interobserver reliability
of chest radiograph
interpretation
High PAWP and ARDS may
coexist
Poor interobserver reliability
of PAWP and clinical
assesments of left atrial
hypertension
Not formally included in
definition
Addressed in Berlin
Definition
Acute time frame specified
3 mutually exclusive
subgroups of ARDS by
severity
ALI term removed
Minimal PEEP level added
across subgroups
FiO2 effect less relevant in
severe ARDS group
Chest radiograph criteria
clarified
Example radiographs created
PAWP requirement removed
Hydrostatic edema not the
primary cause of respiratory
failure
Clinical vignettes created to
help exclude hydrostatic
edema
Included when none
identified 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
174
CXR alveolar None 1Q 2Q 3Q 4Q
consolidation
PEEP <5 6-8 9-11 12-14 >15
Compliance >80 60-79 40-59 20-39 <19
 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
Leukocytosis
Bilateral v v v
infiltrat
PaO2/ v v V
FiO2<200
mmHg
PAOP < 18 v v v
mmHg