D16 ADVANCING THE SCIENCE OF ARDS AND ACUTE RESPIRATORY FAILURE / Mini Symposium / Wednesday, May 24/08:00 AM-10:00

AM / Walter E. Washington
Convention Center, Ballroom B (Level 3)

A New Global Definition of Acute Respiratory Distress Syndrome

M. A. Matthay1, Y. Arabi2, A. C. Arroliga3, G. R. Bernard4, A. D. Bersten5, L. J. Brochard6, C. S. Calfee7, A. Combes8, B. Daniel9,

N. D. Ferguson10, M. N. Gong11, J. E. Gotts12, M. S. Herridge13, J. G. Laffey14, K. D. Liu15, F. R. Machado16, T. R. Martin17, D. F.
McAuley18, A. Mercat19, M. Moss20, R. A. Mularski21, A. Pesenti 22, H. qiu23, N. Ramakrishnan24, M. Ranieri 25, E. D. Riviello26, E.
Rubin27, A. Slutsky28, B. Thompson29, T. Twagirumugabe30, L. B. Ware31, K. D. Wick32; 1Medicine, Anesthesia, and
Cardiovascular Research Institute, Univ of California At San Francisco, San Francisco, CA, United States, 2King Abdulaziz
Medical City, Riyadh, Saudi Arabia, 3College of Med Scott & White, Texas A&M Hlth Sci Ctr, Temple, TX, United States, 4Pulm &
Crit Care Med T-1218 MCN, Vanderbilt Univ Ctr for Lung Research, Nashville, TN, United States, 5Flinders Medical Ctr,
Adelaide, Australia, 6Critical Care Medicine Dept, St Michael''s Hospital, Toronto, ON, Canada, 7Univ of California At San
Francisco, San Francisco, CA, United States, 8MIR CARDIO PITIE, Paris, France, 9Respiratory Therapy, Univ of California At
San Francisco, San Francisco, CA, United States, 10Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada,
11Department of Medicine, Montefiore Med Ctr, Bronx, NY, United States, 12Medicine and Anesthesia, UCSF, San Francisco,

CA, United States, 13Critical Care Medicine, Toronto General Hosp, Toronto, ON, Canada, 14Anesthesia, University Hospital
Galway, Galway, Ireland, 15Medicine and Anesthesia, Univ of California At San Francisco, San Francisco, CA, United States,
16Anesthesiology, Pain and Intensive Care, Universidade Federal de Sao Paulo, Sao Paulo, Brazil, 17Medicine, University of

Washington, Seattle, WA, United States, 18Centre for Experimental Medicine, Queen's University Belfast, Belfast, United
Kingdom, 19Critical Care Medicine, University of Angers, Angers, France, 20Medicine, Univ of Colorado Denver, Aurora, CO,
United States, 21The Center for Health Research, Kaiser Permanente, Portland, OR, United States, 22Dipartimento di Anestesia
Rianimazione ed Emergenza Urgenza, Ospedale Maggiore Policlinico, Milan, Italy, 23Critical Care Medicine, Zhongda Hospital,
Nanjing, China, 24Critical Care Medicine, Apollo Hospitals, Chenai, India, 25Anaesthesia and Critical Care Medicine, University
of Turin, Turin, Italy, 26Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United
States, 27ARDS Foundation, Northbrook, IL, United States, 28Critical Care Medicine, St. Michael''s Hospital, Toronto, ON,
Canada, 29Pulmonary and Critical Care Medicine, Massachusetts General Hosp, Boston, MA, United States, 30Anesthesia and
Critical Care, University of Rawanda, Kigali, Rwanda, 31Medicine, Vanderbilt Univ Sch of Med, Nashville, TN, United States,
32Medicine, University Of California at Davis, San Francisco, CA, United States.

Corresponding author's email: michael.matthay@ucsf.edu

Rationale. Since the 2012 Berlin Definition of ARDS, several developments support the need for a revised Global Definition of
ARDS: (1) the use of high flow nasal oxygen (HFNO) to manage severe hypoxemic acute respiratory failure has markedly
expanded, but these patients do not meet the Berlin Definition; (2) SpO2/FiO2 by pulse oximetry has been validated as a criterion
for ARDS in observational studies and clinical trials; (3) there is a need to re-evaluate the requirement for bilateral versus
unilateral opacities on chest imaging and the use of ultrasound as an additional method for chest imaging; and (4) the Berlin
Definition has limited applicability in resource-variable settings because diagnostic (chest radiograph, arterial blood gas
analysis) and treatment (positive pressure ventilation) modalities are often unavailable. Methods. A consensus conference was
convened using a cascading recruitment process including 32 critical care ARDS experts (clinicians and investigators),
emphasizing diverse clinical, geographic, racial, sex and ethnic backgrounds. The consensus conference had six virtual meetings
(June 2021-March 2022) and obtained input from members of several global critical care societies (June-September 2022).
Results. The four main recommendations (Table) are (1) to include HFNO with a minimum flow rate ≥30 L/min, or NIV/CPAP with
at least 5 cm H2O end-expiratory pressure; (2) to use either PaO2/FiO2 ≤300 mmHg or SpO2/FiO2 ≤315mmHg with SpO2 ≤97%
to identify hypoxemia; (3) to retain bilateral opacities for imaging criteria by chest radiograph or computed tomography and to add
ultrasound (if the operator is well trained); and (4) for resource-variable settings, to not require PEEP, oxygen flow, or specific
respiratory support devices to diagnose ARDS. These recommendations were endorsed by 100% of the consensus conference
members. Conclusions. This new Global Definition of ARDS expands upon the Berlin Definition of ARDS. Acutely ill patients
being treated with HFNO ≥30 L/min can be diagnosed with ARDS and represent a new category of non-intubated ARDS. Pulse
oximetry can be used instead of arterial blood gases for the diagnosis of ARDS. Bilateral opacities should be retained as a
required criterion, and ultrasound is an acceptable imaging modality. Patients in resource-variable settings will no longer be
excluded from the definition of ARDS and will be included in epidemiology, clinical research, and clinical trials. The
recommendations identify areas for future research, including prospective assessments of feasibility, reliability, and prognostic
validity and the relationship of biological categories of ARDS to the Global Definition.
This abstract is funded by: None

Am J Respir Crit Care Med 2023;207:A6229

Internet address: www.atsjournals.org Online Abstracts Issue