Reply to Tobin

From the Authors:

We read with interest Dr. Tobin’s provocative comments on the ontology and epistemology of acute respiratory distress syndrome (ARDS), the validity of randomized trials, and the nature of coronavirus disease (COVID-19). Unfortunately, we could not understand how they relate directly to our Critical Care Perspective (1), which focused on a framework for critical care definitions. Indeed Dr. Tobin’s reflections are virtually identical to those in his 2020 Commentary (2), which was written well before our article appeared.

We agree that syndromes, like ARDS, sepsis, depression, heart failure, and many more—which are by definition, creations of mankind rather than of natural law—are only valuable insofar as they are useful to clinicians or researchers. We also agree that there are many more important decisions at the critical care bedside than whether a patient does or does not “have ARDS.”

The purpose of our editorial was not to add fuel to the fire of the decades-long debate about whether a syndrome called ARDS exists or is merely a compilation of multiple heterogeneous causes of acute hypoxemic respiratory failure (the old lumper vs. splitter debate) (3, 4). Instead, we provided a framework that we hoped would address many of the concerns related to previous definitions of ARDS (and other critical care syndromes), with a strong focus on the need to empirically test reliability, feasibility, and validity of any new definition.

Finally, Dr. Tobin strongly implies that the “fetish fixation on the Berlin definition” likely contributed to “patient mortality at the height of the pandemic.” In the spirit of honesty, which Tobin highlighted in his letter, it would be helpful if he provided data in support of this inflammatory statement and not simply a reference to his own Commentary, which did not address this issue (2).