Acute Respiratory Distress Syndrome Definitions in Adults and Children: A Comparative Narrative Review.

Background

Acute Respiratory Distress Syndrome (ARDS) was first described in 1967 by Ashbaugh et al. as a severe acute hypoxemic respiratory failure with reduced lung compliance, representing a common end-path of severe pulmonary endothelial inflammation from diverse etiologies. Since then, several definitions for the adult syndrome have been proposed, culminating in the 2024 "New Global Definition" (Berlin 2.0). In pediatrics, dedicated criteria (pediatric ARDS, PARDS) have been established over the past decade, with the most recent update published by the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) in 2023.

Methods

We performed a narrative literature review of consensus statements and key studies defining ARDS in adult and pediatric (non-neonatal) populations. Primary sources included the full Berlin 2.0 and PALICC-2 documents, supplemented by PubMed, Embase, and society guidelines. Definitions were compared across major diagnostic domains: timing of onset, imaging requirements, oxygenation thresholds, inclusion of patients with chronic comorbidities, ventilatory support modalities, and applicability in resource-limited settings.

Results

Both definitions show convergence in incorporating non-invasive oxygenation indices and adaptability to resource-limited contexts. Key distinctions include the use of the Oxygenation Index (OI) or Oxygen Saturation Index (OSI) in invasively ventilated pediatric patients-metrics that integrate mean airway pressure and correlate more strongly than PaO2/FIO2 with short-term outcomes-and PALICC-2's explicit inclusion of patients with chronic lung disease or cyanotic congenital heart disease when acute deterioration is documented. Imaging criteria differ, with Berlin 2.0 requiring bilateral opacities (and permitting lung ultrasound) versus PALICC-2's acceptance of unilateral findings.

Conclusions

Berlin 2.0 and PALICC-2 represent substantial progress toward globally applicable ARDS definitions, but physiologic and structural differences remain. These distinctions have prognostic and research implications, and harmonization will be critical to improve cross-age comparability, optimize clinical trial design, and ultimately enhance patient outcomes.