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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
Key components
Severity
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
Now obsolete
defined similarly to ARDS, except that the PaO2/FIO2 ratio needed only be <300
Pros
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?