Elsevier

Medicina Intensiva

Volume 36, Issue 8, November 2012, Pages 571-575
Medicina Intensiva

Point of view
The American-European Consensus Conference definition of the acute respiratory distress syndrome is dead, long live positive end-expiratory pressure!La definición del síndrome de distrés respiratorio agudo según la Conferencia de Consenso Americana-Europea está muerta, ¡larga vida a la presión positiva espiratoria final!

https://doi.org/10.1016/j.medin.2012.08.010Get rights and content

Abstract

In 1994, an American-European Consensus Conference (AECC) formalized the criteria for the diagnosis of the acute respiratory distress syndrome (ARDS). Although that definition is simple to apply in the clinical setting, it has been challenged over the years in several studies since the assessment of the oxygenation defect does not require standardized ventilatory support. We were the first to propose new guidelines, based on a specific, standard method of evaluating oxygenation status, a proposal that was later advocated by others. To address the limitations of the AECC definition, a modified ARDS definition has been proposed by a task force panel of experts, referred to as the Berlin Defintion, using a terminology similar to that we previously proposed. However, that proposal has several methodological flaws. Since all ARDS patients start off with terrible oxygenation, the Berlin Definition offers no room for stratifying and identifyng true ARDS patients since there is no further re-evaluation of the hypoxemia under standard ventilator setting in a specific time period. In this Point of View, we review the history of the definition of ARDS and discussed the methodological concerns regarding adopting this new, revised ARDS definition.

Resumen

En 1994, una Conferencia de Consenso Americana-Europea (CCAE) formalizó los criterios para el diagnóstico del Síndrome de Distrés Respiratorio Agudo (SDRA). Aunque esa definición es sencilla de aplicar en la clínica, ha sido criticada en varios estudios ya que la medida del defecto de oxigenación no requiere de la estandarización del soporte ventilatorio. Nosotros fuimos los primeros en proponer nuevas guías basadas en un método estándar específico para evaluar el estado de la oxigenación, una propuesta que más tarde fue apoyada por otros autores. Para solucionar las limitaciones de la definición de la CCAE del SDRA, una modificación de esta definición ha sido propuesta por un panel de expertos, denominada Definición de Berlín, utilizando una terminología similar a la que nosotros habíamos propuesto previamente. Sin embargo, esta nueva propuesta tiene varios fallos metodológicos. Debido a que todos los pacientes con SDRA presentan inicialmente una oxigenación terrible, la Definición de Berlín no facilita la estratificación e identificación de verdaderos pacientes con SDRA porque no da la posibilidad de volver a evaluar el grado de hipoxemia bajo un patrón estándar de ventilación en un tiempo determinado. En este Punto de Vista revisaremos la historia de la definición del SDRA y analizaremos los problemas metodológicos relacionados con la adopción de esta nueva revisión de la definición del SDRA.

Section snippets

Introduction and historical remarks

In August 1967, Ashbaugh et al.9 described for the first time a syndrome that they termed the ARDS. They studied a cohort of 272 patients who were receiving respiratory support, and from this cohort they identified 12 patients with a syndrome that was similar to the Infant Respiratory Distress Syndrome. The respiratory distress was defined as sudden, catastrophic, and often associated with a multiorgan system insult which led to tachypnea, hypoxemia, decreased respiratory system compliance, and

An early PEEP/FiO2 trial identifies different degrees of ARDS severity

In 1999, Villar et al.3 proposed the need for different guidelines, based on a specific, standard method of evaluating oxygenation status, a proposal that was later advocated by others.11 In order to determine the impact of various PEEP and FiO2 levels on the stratification of patients meeting the AECC ARDS definition, Villar et al.5 evaluated the impact of standard ventilation settings applied on the day patients met the AECC ARDS criteria and 24 h later. They studied 170 patients and found

The “Berlin Definition”

A proposal for an update of the AECC ARDS definition has been published recently6 by a task force panel of experts using a similar terminology as we had previously reported. Using teleconferencing, in-person discussions and retrospective data, they proposed an ARDS classification with three severity categories (mild, moderate, and severe) for empirical evaluation. The term “mild” ARDS was used for defining those patients who are considered as ALI in the AECC definition (300  PaO2/FiO2 > 200 mmHg).

Funding

Supported by Instituto de Salud Carlos III, Spain (PI 10/0393) and the Asociación Científica Pulmón y Ventilación Mecánica.

Conflict of interest

The authors have no conflict of interest to declare.

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