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Acute Respiratory Distress Syndrome (ARDS): Definition, Incidence, and Outcome

Remi Coudroy, Florence Boissier, and Arnaud W. Thille

Definition of ARDS

From the First Clinical Description to the First Consensus Definition of ARDS

In 1967, Ashbaugh and colleagues reported for the first time the clinical and physiological characteristics in 12 patients with sudden respiratory failure that they called “acute respiratory distress syndrome” (ARDS) [1]. None of these patients had past history of cardiac or pulmonary disease, and they rapidly developed acute hypoxemia, stiff lungs, and diffuse bilateral alveolar infiltration on chest X-ray a few days later after a precipitating factor. Their outcome was dramatic as 7 of the 12 patients (58%) died. An autopsy was performed in all deceased patients, and six of them (86%) had a characteristic histological pattern of diffuse alveolar damage including hyaline membranes, edema, cell necrosis, or fibrosis [1].

In 1971, Petty and Ashbaugh described principles of management of ARDS based mainly on mechanical ventilation using high FiO2 and positive end-expiratory pressure (PEEP) [2]. Whereas cyanosis refractory to oxygen was one of the clinical

R. Coudroy, MD • F. Boissier, MD, PhD

CHU de Poitiers, Reanimation Medicale, Poitiers, France

INSERM CIC 1402 (ALIVE Group), Universite de Poitiers, Faculte de Medecine, Poitiers, France

A.W. Thille, MD, PhD (*)

CHU de Poitiers, Reanimation Medicale, Poitiers, France

INSERM CIC 1402 (ALIVE Group), Universite de Poitiers, Faculte de Medecine, Poitiers, France

Reanimation Medicale, CHU de Poitiers,

2 rue la Miletrie, 86021 Poitiers Cedex, France e-mail: This email address is being protected from spam bots, you need Javascript enabled to view it © Springer International Publishing Switzerland 2017 D. Chiumello (ed.), Acute Respiratory Distress Syndrome (ARDS), DOI 10.1007/978-3-319-41852-0_1

criteria for ARDS, the authors did not specify any hypoxemia threshold. Five years later, Bone and colleagues proposed a threshold of hypoxemia below 70 mmHg despite FiO2 of at least 0.5 and PEEP [3]. In 1982, Pepe and colleagues added to the definition the presence of new diffuse bilateral infiltrates on chest X-ray and a pulmonary wedge pressure lower than 18 mmHg, thereby excluding cardiogenic pulmonary edema [4]. In 1988, Murray and colleagues proposed the lung injury score (LIS) as a means of assessing the severity of ARDS according to the PaO2/FiO2 ratio, the PEEP level, respiratory system compliance, and the number of quadrants with infiltration seen on chest X-ray [5].

Since this original description, the definition of ARDS has considerably evolved over the time, but it was not until 1994 that an international American-European Consensus Conference (AECC) laid the foundations for the first clinical definition of ARDS [6]. This consensus conference aimed to bring uniformity to the definition of ARDS for research, epidemiologic studies, and individual patient care [6]. ARDS was consequently defined using the following four criteria: (1) the acute onset of hypoxemia, (2) a PaO2 to FiO2 ratio <200 mmHg regardless of PEEP level, (3) the presence of bilateral infiltrates on chest X-ray, and (4) pulmonary artery wedge pressure <18 mmHg or no clinical sign of left atrial hypertension [6]. Patients meeting all these criteria but having less severe hypoxemia with a PaO2 to FiO2 ratio between 201 and 300 mmHg were considered as having acute lung injury (ALI) and not ARDS. However, this clinical definition has been criticized on each criterion [7] leading to the establishment of a new definition in 2012, the Berlin definition [8].

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