Acute respiratory distress syndrome historical perspective

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Brian Shaller, M.D. [2]

Overview

Although the pathologic features of ARDS were first documented in the 19th century, the modern definition of ARDS did not arise until the 1960s. The diagnostic criteria of ARDS have continued to evolve over the latter half of the 20th century and into the 21st century, and they continue to evolve in tandem with our ability to diagnose the syndrome earlier on in its clinical course.

Historical Perspective

Although the first pathologic descriptions of what was likely ARDS date back to the 19th century, our understanding of the distinct pathophysiologic features of ARDS evolved alongside the development of medical technologies that facilitated a more in-depth study of the syndrome. The advent of radiography permitted visualization of the bilateral pulmonary infiltrates (originally termed double pneumonia), while the development of arterial blood gas measurement and positive-pressure mechanical ventilation allowed for identification of the impaired oxygenation and reduced lung compliance that are now recognized as central features of ARDS.

Ashbaugh and colleagues published he first description of what is now widely recognized as ARDS in a case series of 12 patients with rapidly progressive respiratory failure with bilateral pulmonary infiltrates and profound hypoxemia following trauma or infection in The Lancet in 1967. The clinical syndrome was called the "adult respiratory distress syndrome" (ARDS) to distinguish it from the respiratory distress syndrome of infancy due to hyaline membrane disease, although the A in ARDS was later changed from acute to adult once it was recognized that the syndrome could also present in infants as a distinct entity from hyaline membrane disease.

Until the formulation of the Berlin Definition of ARDS in 2012, the most widely used definition of ARDS was formulated by the American European Consensus Conference (AECC) in 1994. The AECC considered ARDS to be a severe form of acute lung injury (ALI), which they defined as a syndrome of lung inflammation and edema that could not be explained be elevated left atrial pressure. Their diagnostic criteria for ALI and ARDS were:

• Acute onset, bilateral infiltrates on chest radiography
• Pulmonary-artery wedge pressure of < 19 mm Hg or the absence of clinical evidence of left atrial hypertension
• Arterial partial pressure of oxygen (PaO₂)/fraction of inspired oxygen (FIO₂) ≤ 300 for ALI or ≤ 200 for ARDS

The AECC definition of ARDS was largely superseded by the |Berlin Definition of ARDS, published in 2012 by the ARDS Definition Task Force. In formulating their diagnostic criteria, the ARDS Definition Task Force removed the distinction between ALI and ARDS, choosing instead to risk-stratify ARDS according to severity (mild, moderate, or severe), each with its own associated mortality risk based on data from a large patient population. According to the Berlin Definition, what was once ALI is now classified as mild ARDS.