{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T21:37:36Z","timestamp":1790199456285,"version":"4.1.0"},"reference-count":76,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,2,23]],"date-time":"2023-02-23T00:00:00Z","timestamp":1677110400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:p>According to the Berlin Definition of acute respiratory distress syndrome (ARDS), a positive end-expiratory pressure (PEEP) of at least 5\u2009cmH<jats:sub>2<\/jats:sub>O is required to diagnose and grade ARDS. While the Berlin consensus statement specifically acknowledges the role of non-invasive ventilation (NIV) in mild ARDS, this stratification has traditionally presumed a mechanically ventilated patient in the context of moderate to severe ARDS. This may not accurately reflect today\u2019s reality of clinical respiratory care. NIV and high-flow nasal cannula oxygen therapy (HFNO) have been used for managing of severe forms of acute hypoxemic respiratory failure with growing frequency, including in patients showing pathophysiological signs of ARDS. This became especially relevant during the COVID-19 pandemic. The levels of PEEP achieved with HFNO have been particularly controversial, and the exact FiO<jats:sub>2<\/jats:sub> it achieves is subject to variability. Pinpointing the presence of ARDS in patients receiving HNFO and the severity in those receiving NIV therefore remains methodically problematic. This narrative review highlights the evolution of the ARDS definition in the context of non-invasive ventilatory support and provides an overview of the parallel development of definitions and ventilatory management of ARDS. It summarizes the methodology applied in clinical trials to classify ARDS in non-intubated patients and the respective consequences on treatment. As ARDS severity has significant therapeutic and prognostic consequences, and earlier treatment in non-intubated patients may be beneficial, closing this knowledge gap may ultimately be a relevant step to improve comparability in clinical trial design and outcomes.<\/jats:p>","DOI":"10.3389\/fmed.2023.1088709","type":"journal-article","created":{"date-parts":[[2023,2,23]],"date-time":"2023-02-23T05:04:55Z","timestamp":1677128695000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":7,"title":["Usefulness and limitations of the acute respiratory distress syndrome definitions in non-intubated patients. A narrative review"],"prefix":"10.3389","volume":"10","author":[{"given":"Martin","family":"Zbiral","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maximilian","family":"Weber","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastian","family":"K\u00f6nig","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Felix","family":"Kraft","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roman","family":"Ullrich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katharina","family":"Krenn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2023,2,23]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"562","DOI":"10.1056\/NEJMra1608077","article-title":"Acute respiratory distress syndrome","volume":"377","author":"Thompson","year":"2017","journal-title":"N Engl J Med"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"319","DOI":"10.1016\/S0140-6736(67)90168-7","article-title":"Acute respiratory distress in adults","volume":"290","author":"Ashbaugh","year":"1967","journal-title":"Lancet"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"720","DOI":"10.1164\/ajrccm\/138.3.720","article-title":"An expanded definition of the adult respiratory distress syndrome","volume":"138","author":"Murray","year":"1988","journal-title":"Am Rev Respir Dis"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"2526","DOI":"10.1001\/jama.2012.5669","article-title":"Acute respiratory distress syndrome: the Berlin definition","volume":"307","year":"2012","journal-title":"JAMA"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"818","DOI":"10.1164\/ajrccm.149.3.7509706","article-title":"Definitions, mechanisms, relevant outcomes, and clinical trial coordination","volume":"149","author":"Bernard","year":"1994","journal-title":"Am J Respir Crit Care Med"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"32","DOI":"10.1186\/s40560-022-00615-6","article-title":"ARDS Clinical Practice Guideline 2021","volume":"10","author":"Tasaka","year":"2022","journal-title":"J Intensive Care"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"159","DOI":"10.1055\/a-1554-2625","article-title":"S3-Leitlinie Sauerstoff in der Akuttherapie beim Erwachsenen [German S3 guideline - oxygen therapy in the acute Care of Adult Patients]","volume":"76","author":"Gottlieb","year":"2022","journal-title":"Pneumologie"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"429","DOI":"10.1056\/NEJM199808133390703","article-title":"A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure","volume":"339","author":"Antonelli","year":"1998","journal-title":"N Engl J Med"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"851","DOI":"10.1007\/s00134-021-06459-2","article-title":"Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS","volume":"47","author":"Grieco","year":"2021","journal-title":"Intensive Care Med"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"2101269","DOI":"10.1183\/13993003.01269-2021","article-title":"Helmet noninvasive ventilation compared to facemask noninvasive ventilation and high-flow nasal cannula in acute respiratory failure: a systematic review and meta-analysis","volume":"59","author":"Chaudhuri","year":"2022","journal-title":"Eur Respir J"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"1602426","DOI":"10.1183\/13993003.02426-2016","article-title":"Official ERS\/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure","volume":"50","author":"Rochwerg","year":"2017","journal-title":"Eur Respir J"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"28","DOI":"10.1186\/s13054-020-2738-5","article-title":"Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study","volume":"24","author":"Ding","year":"2020","journal-title":"Crit Care"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1164\/rccm.201606-1306OC","article-title":"Noninvasive ventilation of patients with acute respiratory distress syndrome. 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