Acute Respiratory Distress Syndrome (ARDS)

Berlin Criteria Definition (1)

  1. PaO2/FiO2 < 300 (0-100 = severe, 101-200 = moderate, 201-300 = mild) on PEEP of at least 5 mmHg.
  2. Radiographic evidence of non-cardiogenic pulmonary edema (see picture below)
  3. Acute onset within 1 week of known insult


  • Sepsis
  • Aspiration
  • Pneumonia (including COVID-19 or influenza)
  • Trauma
  • Transfusion-Related Acute Lung Injury (TRALI)
  • Stem cell transplantation
  • Pancreatitis
  • Drugs/Alcohol

Basic Management

  • Ventilator settings
    • Tidal Volume: 6 mL/kg ideal body weight (2)
      • This may induce hypercapnea and respiratory acidosis, which is allowed to a limit of pH of 7.3
    • FiO2: Start at 100% and wean down as able
    • RR: Will have to start higher (~30 rpm) to compensate for low tidal volume to maintain an adequate minute ventilation volume (MVV = VT x RR)
    • PEEP: Controversial, but the idea is to keep the stress index at 1 (keeping the pressure-time curve linear instead of convex or concave)
      • Concave (Stress index < 1) indicates pressure rising too quickly, consider increasing PEEP to help inflate lung
      • Convex (Stress index >1) indicates pressure rising too slowly, consider decreasing PEEP
  • Diuresis
    • Attempts to diurese to a goal of CVP < 4 mmHg as long as patient remains well-perfused
  • Paralyzation
    • Mechanism of benefit is unclear, but decreases mortality likely as a result of decreasing asynchrony on the ventilator (3)
  • Proning
    • With the patient prone, gas will move in a dependent fashion toward the posterior lung fields, which carry a greater surface area, allowing for improved gas exchange.
    • Typically reserved for an SpO2/FiO2 ratio < 180 or PaO2/FiO2 ratio < 150
  • ECMO (Extracorporeal Membrane Oxygenation)
    • Can be considered in individuals not improving with above therapies
  • Inhaled Nitric Oxide not shown to have mortality benefit (4)
  • Surfactant not shown to have mortality benefit (5)
  • Steroids not shown to have mortality benefit (6)


  1. Amin, Zulkifli, et al. “Benefit of the Application of New ARDS Criteria (Berlin) Compared to Old Criteria (AECC) in a Tertiary Hospital in a Developing Country.” Indian Journal of Public Health Research & Development, vol. 8, no. 2, 2017, p. 273., doi:10.5958/0976-5506.2017.00125.5.
  2. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 45(1), 19-20. doi:10.1097/00132586-200102000-00017
  3. Mclean, D., & Eikermann, M. (2018). Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome. 50 Studies Every Intensivist Should Know, 123-128. doi:10.1093/med/9780190467654.003.0020
  4. Use of inhaled nitric oxide in patients with acute respiratory failure with low blood oxygen does not improve survival. (n.d.). Retrieved November 11, 2020, from
  5. Raghavendran, K., Willson, D., & Notter, R. (2011, July). Surfactant therapy for acute lung injury and acute respiratory distress syndrome. Retrieved November 11, 2020, from
  6. Khilnani, G., & Hadda, V. (n.d.). Corticosteroids and ARDS: A review of treatment and prevention evidence. Retrieved November 11, 2020, from

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: