The Berlin definition of acute respiratory distress syndrome: should patients receiving high-flow nasal oxygen be included?

Michael A Matthay, B Taylor Thompson, Lorraine B Ware, Michael A Matthay, B Taylor Thompson, Lorraine B Ware

Abstract

The 2012 Berlin definition of acute respiratory distress syndrome (ARDS) provided validated support for three levels of initial arterial hypoxaemia that correlated with mortality in patients receiving ventilatory support. Since 2015, high-flow nasal oxygen (HFNO) has become widely used as an effective therapeutic support for acute respiratory failure, most recently in patients with severe COVID-19. We propose that the Berlin definition of ARDS be broadened to include patients treated with HFNO of at least 30 L/min who fulfil the other criteria for the Berlin definition of ARDS. An expanded definition would make the diagnosis of ARDS more widely applicable, allowing patients at an earlier stage of the syndrome to be recognised, independent of the need for endotracheal intubation or positive-pressure ventilation, with benefits for the testing of early interventions and the study of factors associated with the course of ARDS. We identify key questions that could be addressed in refining an expanded definition of ARDS, the implementation of which could lead to improvements in clinical practice and clinical outcomes for patients.

Conflict of interest statement

Declaration of interests MAM receives fees as a consultant for Novartis and Citius Pharmaceuticals, outside of the present work. BTT receives fees as a consultant for Bayer, Novartis, and Thetis, outside of the present work. LBW receives fees as a consultant for Boehringer and Citius, outside of the present work.

Copyright © 2021 Elsevier Ltd. All rights reserved.

Figures

Figure
Figure
Proposed expansion of the Berlin definition of ARDS ARDS=acute respiratory distress syndrome. HFNO=high-flow nasal oxygen. PaO2/FiO2=ratio of partial pressure of arterial oxygen to fraction of inspired oxygen.

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