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DEFINITION OF ARDS
Niall D. Ferguson, MD, FRCPC, MSc
Interim Director, Critical Care Medicine
University Health Network & Mount Sinai Hospital
Associate Professor of Medicine & Physiology
Interdepartmental Division of Critical Care Medicine
University of Toronto
Endorsed by
Available at www.jama.com
jamanetwork.com
Why Do We Need an
ARDS Defintion AT ALL?
ESSENTIAL
to Conduct and
Interpret Clinical Research
Importance to Researchers
Enable epidemiological studies
Facilitate enrolment into clinical trials
Allow comparison between studies
Enhance linkages between clinical and basic science
Phenotype Genotype relationship
Importance to Clinicians
Ability to implement results of positive RCTs in clinical
practice
Lower Vt for ALI
patients/families
Importance to Administrators
Epidemiological studies need definitions
These in turn may be useful in planning resource allocation
PaO2/FIO2 200 *
Acute onset
CXR with bilateral infiltrates
PAWP 18
&
&
&
PAW = 22
PaO2/FIO2 = 80
PAW = 30
PaO2/FIO2 = 281
included
Inconsistency of PaO2/FIO2 ratio
effect of PEEP
effect of FIO2
% of
patients
with PA
catheters
<15
15-18
19-22
23-26
>26
Interobserver variability in
applying a radiographic
definition of ARDS
Rubenfeld et al. Chest 1999 116:1347-53
Other Diseases
Specific Test
Non-Specific Test
Process
Appointment of Chairs
Selection of Panelists
Presentations & consensus discussions
Sept 30 Oct 1 2011, Berlin, Germany
Empiric evaluation of draft definition
Focus on feasibility, reliability, validity
Consensus revisions
Society endorsements
Evaluation of Berlin Definition
Timing
Origin of Edema
Oxygenation
Chest Imaging
Ancillary Physiology
Moderate
Severe
200<PaO2/FiO2< 300
with
PEEP or CPAP 5 cmH2O
100<PaO2/FiO2<200
with
PEEP 5 cmH2O
PaO2/FiO2<100
with
PEEP 10 cmH2O
N/A
N/A
AECC Limitations
Berlin Modifications
onset defined
Acute
No definition
of acute
ALI
eliminated
ALI/ARDS
confusion
No definition of acute
ALI/ARDS confusion
Inconsistency of PaO2/FIO2
ratio
Effect of PEEP
Effect of FIO2
ratio
Inconsistency of PaO2/FIO2 ratio
of PEEP
Effect
Minumum
PEEP required
F
with Severe
Effect
of Freduced
IO2 effect
I O2
CXR
+ examples
CXRclarified
has poor
reliability
PAWP
removed
PAWP
& ARDS can coexist
Risk factors included
Physiological Cohort
269 Patients
Sites
Years enrolled
Age (mean)
Gender (% male)
Primary Risk Factor
Pulmonary Sepsis
Other Sepsis
Trauma
Other/None
PaO2/FiO2 ratio mean
PaO2/FiO2 < 200
CXR with > 3
quadrants
Mortality
N=4188
N=4188
56-79
1996-2007
54.5
57%
35%
34%
7%
24%
150
76%
73%
34%
Evaluation of Severe
Ancillary variables identify a smaller group of patients with similar mortality
45% Mortality
Severe
14%
Severe
28%
Mild
22%
Mild
22%
Moderate
64%
Draft ARDS
PaO2/FiO2 < 100 mmHg
PEEP > 10 cm H2O
3 or 4 quadrant opacities on CXR
Crs < 40 ml/cm H2O
VeCorr > 10 L/min
Moderate
50%
Mortality
45%
Final ARDS
PaO2/FiO2 < 100 mmHg
PEEP > 5 cm H2O
Bilateral opacities on CXR
ARDS
22%
27%
Mortality
3670
28%
50%
Mild
32%
Mortality
Moderate
45%
Mortality
Severe
30
Mortality %
20
30
20
10
10
0
Mild
Moderate Severe
Mortality
Mild
Moderate
Severe
VFD
30
25
20
15
10
5
0
Mild
Moderate
Severe
VFD
3670
28%
50%
Mild
29%
Moderate
13%
4%
Severe
Conclusions
First study to combine consenus and evaluation of a critical
Members
Massimo Antonelli
Antonio Anzueto
Richard Beale
Laurent Brochard
Roy Brower
Luigi Camporota
Andrs Esteban
Eddy Fan
Niall D Ferguson
Luciano Gattinoni
Andrew Rhodes
Arthur S. Slutsky
Jean-Louis Vincent
n.ferguson@utoronto.ca