1
|
Cave C, Samano D, Sharma AM, Dickinson J, Salomon J, Mahapatra S. Acute respiratory distress syndrome: A review of ARDS across the life course. J Investig Med 2024:10815589241270612. [PMID: 39092841 DOI: 10.1177/10815589241270612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is a multifactorial, inflammatory lung disease with significant morbidity and mortality that predominantly requires supportive care in its management. Although initially described in adult patients, the diagnostic definitions for ARDS have evolved over time to accurately describe this disease process in pediatric and, more recently, neonatal patients. The management of ARDS in each age demographic has converged in the application of lung-protective ventilatory strategies to mitigate the primary disease process and prevent its exacerbation by limiting ventilator-induced lung injury. However, differences arise in the preferred ventilatory strategies or adjunctive pulmonary therapies used to mitigate each type of ARDS. In this review, we compare and contrast the epidemiology, common etiologies, pathophysiology, diagnostic criteria, and outcomes of ARDS across the lifespan. Additionally, we discuss in detail the different management strategies used for each subtype of ARDS and spotlight how these strategies were applied to mitigate poor outcomes during the COVID-19 pandemic. This review is geared toward both clinicians and clinician-scientists as it not only summarizes the latest information on disease pathogenesis and patient management in ARDS across the lifespan but also highlights knowledge gaps for further investigative efforts. We conclude by projecting how future studies can fill these gaps in research and what improvements may be envisioned in the management of NARDS and PARDS based on the current breadth of literature on adult ARDS treatment strategies.
Collapse
Affiliation(s)
- Caleb Cave
- Division of Neonatology, and Division of Pulmonology, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dannielle Samano
- Division of Pulmonary, Sleep, and Critical Care Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Abhineet M Sharma
- Division of Neonatology, and Division of Pulmonology, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - John Dickinson
- Division of Pulmonary, Sleep, and Critical Care Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jeffrey Salomon
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sidharth Mahapatra
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
2
|
Odetola FO, Gebremariam A. Epidemiology of Acute Respiratory Failure in US Children: Outcomes and Resource Use. Hosp Pediatr 2024; 14:622-631. [PMID: 38953120 DOI: 10.1542/hpeds.2023-007166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/15/2024] [Accepted: 04/08/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE Acute respiratory failure recalcitrant to conventional management often requires specialized organ-supportive technologies to optimize outcomes. Variation in the availability of these technologies prompted testing of the hypothesis that outcomes and resource use will vary by not only patient characteristics but also hospital characteristics and receipt of organ-supportive technology. METHODS Retrospective study of children 0 to 20 years old hospitalized for acute respiratory failure using the 2019 Kids' Inpatient Database. Multivariable regression models identified factors associated with mortality, length of hospitalization, and costs. RESULTS Of an estimated 75 365 hospitalizations nationally, 97% were to urban teaching hospitals, 57% were of children < 6 years, and 58% were of males. Complex chronic conditions (CCC) existed in 62%, multiorgan dysfunction in 35%, and extreme illness severity in 54%. Mortality was 7%, length of stay 15 days, and hospital costs $77 168. Elevated mortality was associated with cumulative organ dysfunction (odds ratio [OR]:2.31, 95% confidence interval [CI]: 2.22-2.42), CCC (OR: 5.49, 95% CI: 4.73-6.37), transfer, higher illness severity, and cardiopulmonary resuscitation. Lower mortality was associated with extracorporeal membrane oxygenation (OR: 0.36, 95% CI: 0.28-0.47) and new tracheostomy (OR: 0.30, 95% CI: 0.25-0.35). Longer hospitalization was associated with transfer, infancy, CCC, higher illness severity, cumulative organ dysfunction, and urban hospitals. Higher costs accrued with noninfants, cumulative organ dysfunction, private insurance, and urban teaching hospitals. CONCLUSIONS Hospitalizations for pediatric acute respiratory failure incurred substantial mortality and resource consumption. Efforts to reduce mortality and resource consumption should address interhospital transfer, access to organ-supportive technology, and drivers of higher severity-adjusted resource consumption at urban hospitals.
Collapse
Affiliation(s)
- Folafoluwa O Odetola
- Division of Pediatric Critical Care Medicine, Department of Pediatrics
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
3
|
Goodfellow LT, Miller AG, Varekojis SM, LaVita CJ, Glogowski JT, Hess DR. AARC Clinical Practice Guideline: Patient-Ventilator Assessment. Respir Care 2024; 69:1042-1054. [PMID: 39048148 PMCID: PMC11298231 DOI: 10.4187/respcare.12007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Given the important role of patient-ventilator assessments in ensuring the safety and efficacy of mechanical ventilation, a team of respiratory therapists and a librarian used Grading of Recommendations, Assessment, Development, and Evaluation methodology to make the following recommendations: (1) We recommend assessment of plateau pressure to ensure lung-protective ventilator settings (strong recommendation, high certainty); (2) We recommend an assessment of tidal volume (VT) to ensure lung-protective ventilation (4-8 mL/kg/predicted body weight) (strong recommendation, high certainty); (3) We recommend documenting VT as mL/kg predicted body weight (strong recommendation, high certainty); (4) We recommend an assessment of PEEP and auto-PEEP (strong recommendation, high certainty); (5) We suggest assessing driving pressure to prevent ventilator-induced injury (conditional recommendation, low certainty); (6) We suggest assessing FIO2 to ensure normoxemia (conditional recommendation, very low certainty); (7) We suggest telemonitoring to supplement direct bedside assessment in settings with limited resources (conditional recommendation, low certainty); (8) We suggest direct bedside assessment rather than telemonitoring when resources are adequate (conditional recommendation, low certainty); (9) We suggest assessing adequate humidification for patients receiving noninvasive ventilation (NIV) and invasive mechanical ventilation (conditional recommendation, very low certainty); (10) We suggest assessing the appropriateness of the humidification device during NIV and invasive mechanical ventilation (conditional recommendation, low certainty); (11) We recommend that the skin surrounding artificial airways and NIV interfaces be assessed (strong recommendation, high certainty); (12) We suggest assessing the dressing used for tracheostomy tubes and NIV interfaces (conditional recommendation, low certainty); (13) We recommend assessing the pressure inside the cuff of artificial airways using a manometer (strong recommendation, high certainty); (14) We recommend that continuous cuff pressure assessment should not be implemented to decrease the risk of ventilator-associated pneumonia (strong recommendation, high certainty); and (15) We suggest assessing the proper placement and securement of artificial airways (conditional recommendation, very low certainty).
Collapse
Affiliation(s)
- Lynda T Goodfellow
- Director of AARC Clinical Practice Guideline Development and is affiliated with American Association for Respiratory Care/Daedalus Enterprises, Irving, Texas, and Georgia State University, Atlanta, Georgia
| | | | | | | | | | - Dean R Hess
- Massachusetts General Hospital, Boston, Massachusetts; and Daedalus Enterprises, Irving, Texas
| |
Collapse
|
4
|
Moreno-Duarte I. Invited Commentary: Venovenous Extracorporeal Membrane Oxygenation Followed by Central Right Ventricular Assist Device Support in a Pediatric Patient with Severe Respiratory Complications After Hematopoietic Cell Transplantation. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00444-0. [PMID: 39084931 DOI: 10.1053/j.jvca.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 07/04/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Ingrid Moreno-Duarte
- Divisions of Adult and Pediatric Cardiothoracic Anesthesiology and Critical Care Medicine, University of Texas Southwestern, Dallas, TX
| |
Collapse
|
5
|
Wong JJM, Dang H, Gan CS, Phan PH, Kurosawa H, Aoki K, Lee SW, Ong JSM, Fan L, Tai CW, Chuah SL, Lee PC, Chor YK, Ngu L, Anantasit N, Liu C, Xu W, Wati DK, Gede SIB, Jayashree M, Liauw F, Pon KM, Huang L, Chong JY, Zhu X, Hon KLE, Leung KKY, Samransamruajkit R, Cheung YB, Lee JH. Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial. Crit Care Med 2024:00003246-990000000-00353. [PMID: 38920618 DOI: 10.1097/ccm.0000000000006357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVES Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN Multicenter prospective before-and-after comparison design study. SETTING Twenty-one PICUs. PATIENTS Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.
Collapse
Affiliation(s)
- Judith Ju Ming Wong
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Children's Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Phuc Huu Phan
- Vietnam National Children's Hospital, Hanoi, Vietnam
| | | | - Kazunori Aoki
- Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Siew Wah Lee
- Sultanah Aminah Hospital, Johor, Malaysia
- Hospital Tengku Ampuan Rahimah, Selangor, Malaysia
| | | | - Lijia Fan
- Division of Paediatric Critical Care, National University Hospital, Singapore
| | - Chian Wern Tai
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Soo Lin Chuah
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Pei Chuen Lee
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | | | - Louise Ngu
- Sarawak General Hospital, Sarawak, Malaysia
| | | | - Chunfeng Liu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Wei Xu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Dyah Kanya Wati
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | - Suparyatha Ida Bagus Gede
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | | | - Felix Liauw
- Harapan Kita National Women and Children Health Center, Jakarta, Indonesia
| | | | - Li Huang
- Guangzhou Women and Children's Medical Center, Guangdong, China
| | - Jia Yueh Chong
- Hospital Tunku Azizah Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Xuemei Zhu
- Children's Hospital of Fudan University, Shanghai, China
| | - Kam Lun Ellis Hon
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yin Bun Cheung
- Duke-NUS Medical School, Singapore
- Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| |
Collapse
|
6
|
Colleti J, Lima-Setta F. Waiting for the Pediatric Acute Lung Injury Consensus Conference 3. CRITICAL CARE SCIENCE 2024; 36:e20240114en. [PMID: 38922238 PMCID: PMC11152441 DOI: 10.62675/2965-2774.20240114-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 06/27/2024]
Affiliation(s)
- José Colleti
- Hospital Israelita Albert EinteinSão PauloSPBrazilHospital Israelita Albert Eintein - São Paulo (SP), Brazil.
- Hospital da Luz Vila MarianaSão PauloSPBrazilHospital da Luz Vila Mariana - São Paulo (SP), Brazil.
| | - Fernanda Lima-Setta
- FIOCRUZInstituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes FigueiraRio de JaneiroRJBrazilInstituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira - FIOCRUZ - Rio de Janeiro (RJ), Brazil.
- Instituto D'Or de Pesquisa e EnsinoRio de JaneiroRJBrazilInstituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brazil.
| |
Collapse
|
7
|
Capela RC, de Souza RB, Sant’Anna MDFP, Sant’Anna CC. Evaluation of the classifications of severity in acute respiratory distress syndrome in childhood by the Berlin Consensus and the Pediatric Acute Lung Injury Consensus Conference. CRITICAL CARE SCIENCE 2024; 36:e20240229en. [PMID: 38865561 PMCID: PMC11152442 DOI: 10.62675/2965-2774.20240229-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/30/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE To compare two methods for defining and classifying the severity of pediatric acute respiratory distress syndrome: the Berlin classification, which uses the relationship between the partial pressure of oxygen and the fraction of inspired oxygen, and the classification of the Pediatric Acute Lung Injury Consensus Conference, which uses the oxygenation index. METHODS This was a prospective study of patients aged 0 - 18 years with a diagnosis of acute respiratory distress syndrome who were invasively mechanically ventilated and provided one to three arterial blood gas samples, totaling 140 valid measurements. These measures were evaluated for correlation using the Spearman test and agreement using the kappa coefficient between the two classifications, initially using the general population of the study and then subdividing it into patients with and without bronchospasm and those with and without the use of neuromuscular blockers. The effect of these two factors (bronchospasm and neuromuscular blocking agent) separately and together on both classifications was also assessed using two-way analysis of variance. RESULTS In the general population, who were 54 patients aged 0 - 18 years a strong negative correlation was found by Spearman's test (ρ -0.91; p < 0.001), and strong agreement was found by the kappa coefficient (0.62; p < 0.001) in the comparison between Berlin and Pediatric Acute Lung Injury Consensus Conference. In the populations with and without bronchospasm and who did and did not use neuromuscular blockers, the correlation coefficients were similar to those of the general population, though among patients not using neuromuscular blockers, there was greater agreement between the classifications than for patients using neuromuscular blockers (kappa 0.67 versus 0.56, p < 0.001 for both). Neuromuscular blockers had a significant effect on the relationship between the partial pressure of oxygen and the fraction of inspired oxygen (analysis of variance; F: 12.9; p < 0.001) and the oxygenation index (analysis of variance; F: 8.3; p = 0.004). CONCLUSION There was a strong correlation and agreement between the two classifications in the general population and in the subgroups studied. Use of neuromuscular blockers had a significant effect on the severity of acute respiratory distress syndrome.
Collapse
Affiliation(s)
- Roberta Costa Capela
- Program in Maternal and Child HealthInstituto de Puericultura e Pediatria Martagão GesteiraUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazilPostgraduate Program in Maternal and Child Health, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.
| | - Raquel Belmino de Souza
- Pediatric Intensive Care UnitInstituto de Puericultura e Pediatria Martagão GesteiraUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazilPediatric Intensive Care Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.
| | - Maria de Fátima Pombo Sant’Anna
- Program in Maternal and Child HealthInstituto de Puericultura e Pediatria Martagão GesteiraUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazilPostgraduate Program in Maternal and Child Health, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.
| | - Clemax Couto Sant’Anna
- Program in Maternal and Child HealthInstituto de Puericultura e Pediatria Martagão GesteiraUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazilPostgraduate Program in Maternal and Child Health, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.
| |
Collapse
|
8
|
Kortz TB, Mediratta RP, Smith AM, Nielsen KR, Agulnik A, Gordon Rivera S, Reeves H, O’Brien NF, Lee JH, Abbas Q, Attebery JE, Bacha T, Bhutta EG, Biewen CJ, Camacho-Cruz J, Coronado Muñoz A, deAlmeida ML, Domeryo Owusu L, Fonseca Y, Hooli S, Wynkoop H, Leimanis-Laurens M, Nicholaus Mally D, McCarthy AM, Mutekanga A, Pineda C, Remy KE, Sanders SC, Tabor E, Teixeira Rodrigues A, Yuee Wang JQ, Kissoon N, Takwoingi Y, Wiens MO, Bhutta A. Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis. Front Pediatr 2024; 12:1397232. [PMID: 38910960 PMCID: PMC11190367 DOI: 10.3389/fped.2024.1397232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/20/2024] [Indexed: 06/25/2024] Open
Abstract
In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.
Collapse
Affiliation(s)
- Teresa B. Kortz
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Rishi P. Mediratta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Audrey M. Smith
- Department of Medicine, Miller School of Medicine, Miami, FL, United States
| | - Katie R. Nielsen
- Department of Pediatrics and Department of Global Health, University of Washington, Seattle, WA, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Stephanie Gordon Rivera
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Hailey Reeves
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nicole F. O’Brien
- Department of Pediatrics, Ohio State University/Nationwide Children’s Hospital, Columbus, OH, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Qalab Abbas
- Department of Pediatrics and Child Health, Section of Pediatric Critical Care Medicine, Aga Khan University, Karachi, Pakistan
| | - Jonah E. Attebery
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
- Barrow Global Health, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Tigist Bacha
- Department of Pediatric and Child Health, Saint Paul Hospital Medical College, Addis Ababa, Ethiopia
| | - Emaan G. Bhutta
- Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Carter J. Biewen
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Jhon Camacho-Cruz
- Department of Pediatrics, Universidad Nacional de Colombia, Fundación Universitaria de Ciencias de la Salud (FUCS), Sociedad de Cirugía de Bogota-Hospital San José, Fundación Universitaria Sanitas, Clínica Reina Sofia Pediátrica y Mujer Colsanitas, Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Bogotá D.C.,Colombia
| | - Alvaro Coronado Muñoz
- Pediatric Critical Care Division, Department of Pediatrics, Children’s Hospital at Montefiore, New York, NY, United States
| | - Mary L. deAlmeida
- Department of Pediatrics, Emory University, Atlanta, GA, United States
| | - Larko Domeryo Owusu
- Pediatric Emergency Unit, Child Health Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Yudy Fonseca
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Shubhada Hooli
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Hunter Wynkoop
- Department of Pediatrics, Ohio State University/Nationwide Children’s Hospital, Columbus, OH, United States
| | - Mara Leimanis-Laurens
- Department of Pediatrics and Human Development, Michigan State University, East Lansing and Helen DeVos Children’s Hospital, Grand Rapids, MI, United States
| | - Deogratius Nicholaus Mally
- Pediatric Intensive Care Unit, Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Amanda M. McCarthy
- Department of Pediatrics, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Andrew Mutekanga
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Carol Pineda
- Department of Pediatrics, Baystate Medical Center, University of Massachusetts Chan Medical School, Springfield, MA, United States
| | - Kenneth E. Remy
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, and Department of Internal Medicine, University Hospitals of Cleveland, Cleveland, OH, United States
| | - Sara C. Sanders
- Department of Pediatrics, Connecticut Children’s and University of Connecticut, Hartford, CT, United States
| | - Erica Tabor
- Department of Biology, Pennsylvania State University, University Park, PA, United States
| | | | - Justin Qi Yuee Wang
- Paediatric Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Edgbaston and NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Walimu, Kampala, Uganda
| | - Adnan Bhutta
- Department of Pediatrics, Indiana University School of Medicine and Riley Children’s Health, Indianapolis, IN, United States
| |
Collapse
|
9
|
Killien EY, Ohman RT, Dervan LA, Smith MB, Rivara FP, Watson RS. Pediatric Acute Respiratory Distress Syndrome Severity and Health-Related Quality of Life Outcomes: Single-Center Retrospective Cohort, 2011-2017. Pediatr Crit Care Med 2024:00130478-990000000-00349. [PMID: 38832835 DOI: 10.1097/pcc.0000000000003552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVES To determine factors associated with health-related quality of life (HRQL) decline among pediatric acute respiratory distress syndrome (PARDS) survivors. DESIGN Retrospective cohort study. SETTING Academic children's hospital. PATIENTS Three hundred fifteen children 1 month to 18 years old with an unplanned PICU admission from December 2011 to February 2017 enrolled in the hospital's Outcomes Assessment Program. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pre-admission baseline and median 6-week post-discharge HRQL were assessed using the Pediatric Quality of Life Inventory or the Functional Status II-R. Patients meeting retrospectively applied Second Pediatric Acute Lung Injury Consensus Conference criteria for PARDS were identified, and PARDS severity was classified using binary (mild/moderate, severe) and trichotomous (mild, moderate, severe) categorization for noninvasive ventilation and invasive mechanical ventilation (IMV). PARDS occurred in 41 of 315 children (13.0%). Clinically important HRQL decline (≥ 4.5 points) occurred in 17 of 41 patients (41.5%) with PARDS and 64 of 274 without PARDS (23.4%). On multivariable generalized linear regression adjusted for age, baseline Pediatric Overall Performance Category, maximum nonrespiratory Pediatric Logistic Organ Dysfunction score, diagnosis, length of stay, and time to follow-up, PARDS was associated with HRQL decline (adjusted relative risk [aRR], 1.70; 95% CI, 1.03-2.77). Four-hour and maximum PARDS severity were the only factors associated with HRQL decline. HRQL decline occurred in five of 18 patients with mild PARDS at 4 hours, five of 13 with moderate PARDS (aRR 2.35 vs. no PARDS [95% CI, 1.01-5.50]), and seven of ten with severe PARDS (aRR 2.56 vs. no PARDS [95% CI, 1.45-4.53]). The area under the receiver operating characteristic curve for discrimination of HRQL decline for IMV patients was 0.79 (95% CI, 0.66-0.91) for binary and 0.80 (95% CI, 0.69-0.93) for trichotomous severity categorization. CONCLUSIONS HRQL decline is common among children surviving PARDS, and risk of decline is associated with PARDS severity. HRQL decline from baseline may be an efficient and clinically meaningful endpoint to incorporate into PARDS clinical trials.
Collapse
Affiliation(s)
- Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
| | - Robert T Ohman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Frederick P Rivara
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
| |
Collapse
|
10
|
Kneyber MCJ, Cheifetz IM, Asaro LA, Graves TL, Viele K, Natarajan A, Wypij D, Curley MAQ. Protocol for the Prone and Oscillation Pediatric Clinical Trial (PROSpect). Pediatr Crit Care Med 2024:00130478-990000000-00347. [PMID: 38801306 DOI: 10.1097/pcc.0000000000003541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Respiratory management for pediatric acute respiratory distress syndrome (PARDS) remains largely supportive without data to support one approach over another, including supine versus prone positioning (PP) and conventional mechanical ventilation (CMV) versus high-frequency oscillatory ventilation (HFOV). DESIGN We present the research methodology of a global, multicenter, two-by-two factorial, response-adaptive, randomized controlled trial of supine versus PP and CMV versus HFOV in high moderate-severe PARDS, the Prone and Oscillation Pediatric Clinical Trial (PROSpect, www.ClinicalTrials.gov, NCT03896763). SETTING Approximately 60 PICUs with on-site extracorporeal membrane oxygenation support in North and South America, Europe, Asia, and Oceania with experience using PP and HFOV in the care of patients with PARDS. PATIENTS Eligible pediatric patients (2 wk old or older and younger than 21 yr) are randomized within 48 h of meeting eligibility criteria occurring within 96 h of endotracheal intubation. INTERVENTIONS One of four arms, including supine/CMV, prone/CMV, supine/HFOV, or prone/HFOV. We hypothesize that children with high moderate-severe PARDS treated with PP or HFOV will demonstrate greater than or equal to 2 additional ventilator-free days (VFD). MEASUREMENTS AND MAIN RESULTS The primary outcome is VFD through day 28; nonsurvivors receive zero VFD. Secondary and exploratory outcomes include nonpulmonary organ failure-free days, interaction effects of PP with HFOV on VFD, 90-day in-hospital mortality, and among survivors, duration of mechanical ventilation, PICU and hospital length of stay, and post-PICU functional status and health-related quality of life. Up to 600 patients will be randomized, stratified by age group and direct/indirect lung injury. Adaptive randomization will first occur 28 days after 300 patients are randomized and every 100 patients thereafter. At these randomization updates, new allocation probabilities will be computed based on intention-to-treat trial results, increasing allocation to well-performing arms and decreasing allocation to poorly performing arms. Data will be analyzed per intention-to-treat for the primary analyses and per-protocol for primary, secondary, and exploratory analyses. CONCLUSIONS PROSpect will provide clinicians with data to inform the practice of PP and HFOV in PARDS.
Collapse
Affiliation(s)
- Martin C J Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Critical Care, Anesthesiology, Peri-operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Ira M Cheifetz
- Division of Cardiac Critical Care, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | | | - Aruna Natarajan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Anesthesia and Critical Care Medicine-Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
11
|
Bhalla AK, Klein MJ, Hotz J, Kwok J, Bonilla-Cartagena JE, Baron DA, Kohler K, Bornstein D, Chang D, Vu K, Armenta-Quiroz A, Nelson LP, Newth CJL, Khemani RG. Noninvasive Surrogate for Physiologic Dead Space Using the Carbon Dioxide Ventilatory Equivalent: Testing in a Single-Center Cohort, 2017-2023. Pediatr Crit Care Med 2024:00130478-990000000-00344. [PMID: 38771137 DOI: 10.1097/pcc.0000000000003539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
OBJECTIVES We sought to evaluate the association between the carbon dioxide (co2) ventilatory equivalent (VEqco2 = minute ventilation/volume of co2 produced per min), a marker of dead space that does not require a blood gas measurement, and mortality risk. We compared the strength of this association to that of physiologic dead space fraction (VD/Vt = [Paco2-mixed-expired Pco2]/Paco2) as well as to other commonly used markers of dead space (i.e., the end-tidal alveolar dead space fraction [AVDSf = (Paco2-end-tidal Pco2)/Paco2], and ventilatory ratio [VR = (minute ventilation × Paco2)/(age-adjusted predicted minute ventilation × 37.5)]). DESIGN Retrospective cohort data, 2017-2023. SETTING Quaternary PICU. PATIENTS One hundred thirty-one children with acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All dead space markers were calculated at the same 1-minute timepoint for each patient within the first 72 hours of using invasive mechanical ventilation. The 131 children had a median (interquartile range, IQR) age of 5.8 (IQR 1.4, 12.6) years, oxygenation index (OI) of 7.5 (IQR 4.6, 14.3), VD/Vt of 0.47 (IQR 0.38, 0.61), and mortality was 17.6% (23/131). Higher VEqco2 (p = 0.003), VD/Vt (p = 0.002), and VR (p = 0.013) were all associated with greater odds of mortality in multivariable models adjusting for OI, immunosuppressive comorbidity, and overall severity of illness. We failed to identify an association between AVDSf and mortality in the multivariable modeling. Similarly, we also failed to identify an association between OI and mortality after controlling for any dead space marker in the modeling. For the 28-day ventilator-free days outcome, we failed to identify an association between VD/Vt and the dead space markers in multivariable modeling, although OI was significant. CONCLUSIONS VEqco2 performs similarly to VD/Vt and other surrogate dead space markers, is independently associated with mortality risk, and may be a reasonable noninvasive surrogate for VD/Vt.
Collapse
Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Justin Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Jeni Kwok
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | | | - David A Baron
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Kristen Kohler
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Dinnel Bornstein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Daniel Chang
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Kennedy Vu
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Anabel Armenta-Quiroz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lara P Nelson
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| |
Collapse
|
12
|
Zurawel AA, Coates BM. Time to split: biomarker trajectories in pediatric acute respiratory distress syndrome hint at underlying disease. J Clin Invest 2024; 134:e180662. [PMID: 38747286 PMCID: PMC11093594 DOI: 10.1172/jci180662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024] Open
Abstract
Pediatric acute respiratory distress syndrome (ARDS) is severe, noncardiac hypoxemic respiratory failure that carries a substantial risk of death. Given the complexity of this clinically defined syndrome and the repeated failure of therapeutic trials, there has been an effort to identify subphenotypes of ARDS that may share targetable mechanisms of disease. In this issue of the JCI, Yehya and colleagues measured 19 plasma biomarkers in 279 children over the first seven days of ARDS. Increases in select tissue injury makers and inflammatory cytokines in peripheral blood were associated with multiple organ dysfunction syndrome and death, but not persistent ARDS. These findings argue that splitting patients by clinical and molecular phenotype may be more informative than lumping them under the umbrella diagnosis of ARDS. However, future studies are needed to determine whether these plasma factors represent targetable pathways in lung injury or are a consequence of systemic organ dysfunction.
Collapse
Affiliation(s)
- Ashley A. Zurawel
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bria M. Coates
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
13
|
Maddux AB, Miller KR, Sierra YL, Bennett TD, Watson RS, Spear M, Pyle LL, Mourani PM. Recovery Trajectories in Children Requiring 3 or More Days of Invasive Ventilation. Crit Care Med 2024; 52:798-810. [PMID: 38193769 PMCID: PMC11018493 DOI: 10.1097/ccm.0000000000006187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVES To characterize health-related quality of life (HRQL) and functional recovery trajectories and risk factors for prolonged impairments among critically ill children receiving greater than or equal to 3 days of invasive ventilation. DESIGN Prospective cohort study. SETTING Quaternary children's hospital PICU. PATIENTS Children without a preexisting tracheostomy who received greater than or equal to 3 days of invasive ventilation, survived hospitalization, and completed greater than or equal to 1 postdischarge data collection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated 144 children measuring HRQL using proxy-report Pediatric Quality of Life Inventory and functional status using the Functional Status Scale (FSS) reflecting preillness baseline, PICU and hospital discharge, and 1, 3, 6, and 12 months after hospital discharge. They had a median age of 5.3 years (interquartile range, 1.1-13.0 yr), 58 (40%) were female, 45 (31%) had a complex chronic condition, and 110 (76%) had normal preillness FSS scores. Respiratory failure etiologies included lung disease ( n = 49; 34%), neurologic failure ( n = 23; 16%), and septic shock ( n = 22; 15%). At 1-month postdischarge, 68 of 122 (56%) reported worsened HRQL and 35 (29%) had a new functional impairment compared with preillness baseline. This improved at 3 months to 54 (46%) and 24 (20%), respectively, and remained stable through the remaining 9 months of follow-up. We used interaction forests to evaluate relative variable importance including pairwise interactions and found that therapy consultation within 3 days of intubation was associated with better HRQL recovery in older patients and those with better preillness physical HRQL. During the postdischarge year, 76 patients (53%) had an emergency department visit or hospitalization, and 62 (43%) newly received physical, occupational, or speech therapy. CONCLUSIONS Impairments in HRQL and functional status as well as health resource use were common among children with acute respiratory failure. Early therapy consultation was a modifiable characteristic associated with shorter duration of worsened HRQL in older patients.
Collapse
Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
| | - Kristen R. Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Yamila L. Sierra
- Research Institute, Pediatric Critical Care, Children’s Hospital Colorado, Aurora, CO
| | - Tellen D. Bennett
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, CO
| | - R. Scott Watson
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington School of Medicine and Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Matthew Spear
- Department of Pediatrics, Dell Children’s Medical Center, The University of Texas at Austin Dell Medical School, Austin, TX
| | - Laura L. Pyle
- Children’s Hospital Colorado, Aurora, CO
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s, Little Rock, AR
| |
Collapse
|
14
|
Lacarra B, Hayotte A, Naudin J, Maroni A, Geslain G, Poncelet G, Levy M, Resche-Rigon M, Dauger S. Air leak test in the Paediatric Intensive Care Unit (ALTIPICU): rationale and protocol for a prospective multicentre observational study. BMJ Open 2024; 14:e081314. [PMID: 38688666 PMCID: PMC11086494 DOI: 10.1136/bmjopen-2023-081314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION In children, respiratory distress due to upper airway obstruction (UAO) is a common complication of extubation. The quantitative cuff-leak test (qtCLT) is a simple, rapid and non-invasive test that has not been extensively studied in children. The objective of the ongoing study whose protocol is reported here is to investigate how well the qtCLT predicts UAO-related postextubation respiratory distress in paediatric intensive care unit (PICU) patients. METHODS AND ANALYSIS Air Leak Test in the Paediatric Intensive Care Unit is a multicentre, prospective, observational study that will recruit 900 patients who are aged 2 days post-term to 17 years and ventilated through a cuffed endotracheal tube for at least 24 hours in any of 19 French PICUs. Within an hour of planned extubation, the qtCLT will be performed as a sequence of six measurements of the tidal volume with the cuff inflated then deflated. The primary outcome is the occurrence within 48 hours after extubation of severe UAO defined as combining a requirement for intravenous corticosteroid therapy and/or ventilator support by high-flow nasal cannula and/or by non-invasive ventilation or repeat invasive mechanical ventilation with a Westley score ≥4 with at least one point for stridor at each initiation. The results of the study are expected to identify risk factors for UAO-related postextubation respiratory distress and extubation failure, thereby identifying patient subgroups most likely to require preventive interventions. It will also determine whether qtCLT appears to be a reliable method to predict an increased risk for postextubation adverse events as severe UAO. ETHICS AND DISSEMINATION The study was approved by the Robert Debré University Hospital institutional review board (IRB) on September 2021 (approval #2021578). The report of Robert Debré University Hospital IRB is valid for all sites, given the nature of the study with respect to the French law. The results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT05328206.
Collapse
Affiliation(s)
- Boris Lacarra
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Aurélie Hayotte
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
- Université Paris Cité, Paris, France
| | - Jérôme Naudin
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Arielle Maroni
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Guillaume Geslain
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Géraldine Poncelet
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Michael Levy
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
- Université Paris Cité, Paris, France
| | - Matthieu Resche-Rigon
- Université Paris Cité, Paris, France
- ECSTRRA Team-CRESS-UMR 1153, INSERM U1153, Paris, Île-de-France, France
| | - Stéphane Dauger
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
- Université Paris Cité, Paris, France
| |
Collapse
|
15
|
Yehya N, Booth TJ, Ardhanari GD, Thompson JM, Lam LM, Till JE, Mai MV, Keim G, McKeone DJ, Halstead ES, Lahni P, Varisco BM, Zhou W, Carpenter EL, Christie JD, Mangalmurti NS. Inflammatory and tissue injury marker dynamics in pediatric acute respiratory distress syndrome. J Clin Invest 2024; 134:e177896. [PMID: 38573766 PMCID: PMC11093602 DOI: 10.1172/jci177896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUNDThe molecular signature of pediatric acute respiratory distress syndrome (ARDS) is poorly described, and the degree to which hyperinflammation or specific tissue injury contributes to outcomes is unknown. Therefore, we profiled inflammation and tissue injury dynamics over the first 7 days of ARDS, and associated specific biomarkers with mortality, persistent ARDS, and persistent multiple organ dysfunction syndrome (MODS).METHODSIn a single-center prospective cohort of intubated pediatric patients with ARDS, we collected plasma on days 0, 3, and 7. Nineteen biomarkers reflecting inflammation, tissue injury, and damage-associated molecular patterns (DAMPs) were measured. We assessed the relationship between biomarkers and trajectories with mortality, persistent ARDS, or persistent MODS using multivariable mixed effect models.RESULTSIn 279 patients (64 [23%] nonsurvivors), hyperinflammatory cytokines, tissue injury markers, and DAMPs were higher in nonsurvivors. Survivors and nonsurvivors showed different biomarker trajectories. IL-1α, soluble tumor necrosis factor receptor 1, angiopoietin 2 (ANG2), and surfactant protein D increased in nonsurvivors, while DAMPs remained persistently elevated. ANG2 and procollagen type III N-terminal peptide were associated with persistent ARDS, whereas multiple cytokines, tissue injury markers, and DAMPs were associated with persistent MODS. Corticosteroid use did not impact the association of biomarker levels or trajectory with mortality.CONCLUSIONSPediatric ARDS survivors and nonsurvivors had distinct biomarker trajectories, with cytokines, endothelial and alveolar epithelial injury, and DAMPs elevated in nonsurvivors. Mortality markers overlapped with markers associated with persistent MODS, rather than persistent ARDS.FUNDINGNIH (K23HL-136688, R01-HL148054).
Collapse
Affiliation(s)
- Nadir Yehya
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas J. Booth
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
| | - Gnana D. Ardhanari
- Division of Pediatric Cardiac Critical Care Medicine, Children’s Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Jill M. Thompson
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
| | - L.K. Metthew Lam
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
| | - Jacob E. Till
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark V. Mai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia, USA
| | - Garrett Keim
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J. McKeone
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and
| | - E. Scott Halstead
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Patrick Lahni
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Brian M. Varisco
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, Arkansas, USA
| | - Wanding Zhou
- Center for Computational and Genomic Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erica L. Carpenter
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
- Center for Clinical Epidemiology and Biostatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nilam S. Mangalmurti
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
| |
Collapse
|
16
|
Patel BM, Reilly JP, Bhalla AK, Smith LS, Khemani RG, Jones TK, Meyer NJ, Harhay MO, Yehya N. Association between Age and Mortality in Pediatric and Adult Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:871-878. [PMID: 38306669 PMCID: PMC10995578 DOI: 10.1164/rccm.202310-1926oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/02/2024] [Indexed: 02/04/2024] Open
Abstract
Rationale: The epidemiology, management, and outcomes of acute respiratory distress syndrome (ARDS) differ between children and adults, with lower mortality rates in children despite comparable severity of hypoxemia. However, the relationship between age and mortality is unclear.Objective: We aimed to define the association between age and mortality in ARDS, hypothesizing that it would be nonlinear.Methods: We performed a retrospective cohort study using data from two pediatric ARDS observational cohorts (n = 1,236), multiple adult ARDS trials (n = 5,547), and an adult observational ARDS cohort (n = 1,079). We aligned all datasets to meet Berlin criteria. We performed unadjusted and adjusted logistic regression using fractional polynomials to assess the potentially nonlinear relationship between age and 90-day mortality, adjusting for sex, PaO2/FiO2, immunosuppressed status, year of study, and observational versus randomized controlled trial, treating each individual study as a fixed effect.Measurements and Main Results: There were 7,862 subjects with median ages of 4 years in the pediatric cohorts, 52 years in the adult trials, and 61 years in the adult observational cohort. Most subjects (43%) had moderate ARDS by Berlin criteria. Ninety-day mortality was 19% in the pediatric cohorts, 33% in the adult trials, and 67% in the adult observational cohort. We found a nonlinear relationship between age and mortality, with mortality risk increasing at an accelerating rate between 11 and 65 years of age, after which mortality risk increased more slowly.Conclusions: There was a nonlinear relationship between age and mortality in pediatric and adult ARDS.
Collapse
Affiliation(s)
- Bhavesh M Patel
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Anoopindar K Bhalla
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Robinder G Khemani
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Tiffanie K Jones
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Michael O Harhay
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
17
|
Gertz SJ, Bhalla A, Chima RS, Emeriaud G, Fitzgerald JC, Hsing DD, Jeyapalan AS, Pike F, Sallee CJ, Thomas NJ, Yehya N, Rowan CM. Immunocompromised-Associated Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study. Pediatr Crit Care Med 2024; 25:288-300. [PMID: 38236083 PMCID: PMC10994753 DOI: 10.1097/pcc.0000000000003421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVES To characterize immunocompromised-associated pediatric acute respiratory distress syndrome (I-PARDS) and contrast it to PARDS. DESIGN This is a secondary analysis of the 2016-2017 PARDS incidence and epidemiology (PARDIE) study, a prospective observational, cross-sectional study of children with PARDS. SETTING Dataset of 145 PICUs across 27 countries. PATIENTS During 10 nonconsecutive weeks (from May 2016 to June 2017), data about immunocompromising conditions (ICCs, defined as malignancy, congenital/acquired immunodeficiency, posttransplantation, or diseases requiring immunosuppression) were collected. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 708 subjects, 105 (14.8%) had ICC. Before the development of I-PARDS, those with ICC were more likely to be hospitalized (70% vs. 35%, p < 0.001), have more at-risk for PARDS ( p = 0.046), and spent more hours at-risk (20 [interquartile range, IQR: 8-46] vs. 11 [IQR: 4-33], [ p = 0.002]). Noninvasive ventilation (NIV) use was more common in those with ICC ( p < 0.001). Of those diagnosed with PARDS on NIV ( n = 161), children with ICC were more likely to be subsequently intubated ( n = 28/40 [70%] vs n = 53/121 [44%], p = 0.004). Severe PARDS was more common (32% vs 23%, p < 0.001) in I-PARDS. Oxygenation indices were higher at diagnosis and had less improvement over the first 3 days of PARDS ( p < 0.001). Children with I-PARDS had greater nonpulmonary organ dysfunction. Adjusting for Pediatric Risk of Mortality IV and oxygenation index, children with I-PARDS had a higher severity of illness-adjusted PICU mortality (adjusted hazard ratio: 3.0 [95% CI, 1.9-4.7] p < 0.001) and were less likely to be extubated alive within 28 days (subdistribution hazard ratio: 0.47 [95% CI, 0.31-0.71] p < 0.001). CONCLUSIONS I-PARDS is a unique subtype of PARDS associated with hospitalization before diagnosis and increased: time at-risk for PARDS, NIV use, hypoxia, nonpulmonary organ dysfunction, and mortality. The opportunity for early detection and intervention seems to exist. Dedicated study in these patients is imperative to determine if targeted interventions will benefit these unique patients with the ultimate goal of improving outcomes.
Collapse
Affiliation(s)
- Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles and University of Southern California, Los Angeles, CA
| | - Ranjit S Chima
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH
| | - Guillaume Emeriaud
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montreal, QC, Canada
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Deyin D Hsing
- Department of Pediatrics, New York Presbyterian Hospital and Weill Cornell Medical College, New York, NY
| | - Asumthia S Jeyapalan
- Division of Critical Care Medicine, Department of Pediatrics, University of Miami, Miami, FL
| | - Francis Pike
- Department of Biostatistics, Indiana University, Indianapolis, IN
| | - Colin J Sallee
- Division of Pediatric Critical Care, Department of Pediatrics, UCLA Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Courtney M Rowan
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, IN
| |
Collapse
|
18
|
Schmidt EP, Randolph AG. Adolescents and Young Adults: An Understudied, yet Likely Informative, Population in ARDS. Am J Respir Crit Care Med 2024; 209:785-786. [PMID: 38387007 PMCID: PMC10995567 DOI: 10.1164/rccm.202402-0304ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/22/2024] [Indexed: 02/24/2024] Open
Affiliation(s)
- Eric P Schmidt
- Division of Pulmonary and Critical Care Medicine Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine Boston Children's Hospital Boston, Massachusetts
- Departments of Anaesthesia and Pediatrics Harvard Medical School Boston, Massachusetts
| |
Collapse
|
19
|
Wong JJM, Tan HL, Sultana R, Ma YJ, Aguilan AB, Goh CY, Lee WC, Kumar P, Lee JH. Respiratory Support After Extubation in Children With Pediatric ARDS. Respir Care 2024; 69:422-429. [PMID: 38538015 PMCID: PMC11108100 DOI: 10.4187/respcare.11334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
BACKGROUND Postextubation respiratory support in pediatric ARDS may be used to support the recovering respiratory system and promote timely, successful liberation from mechanical ventilation. This study's aims were to (1) describe the use of postextubation respiratory support in pediatric ARDS from the time of extubation to hospital discharge, (2) identify potential risk factors for postextubation respiratory support, and (3) provide preliminary data for future larger studies. METHODS This pilot single-center prospective cohort study recruited subjects with pediatric ARDS. Subjects' respiratory status up to hospital discharge, the use of postextubation respiratory support, and how it changed over time were recorded. Analysis was performed comparing subjects who received postextubation respiratory support versus those who did not and compared its use among pediatric ARDS severity categories. Multivariable logistic regression was used to determine variables associated with the use of postextubation respiratory support and included oxygenation index (OI), ventilator duration, and weight. RESULTS Seventy-three subjects with pediatric ARDS, with median age and OI of 4 (0.6-10.5) y and 7.3 (4.9-12.7), respectively, were analyzed. Postextubation respiratory support was provided to 54/73 (74%) subjects: 28/45 (62.2%), 19/21 (90.5%), and 7/7 (100%) for mild, moderate, and severe pediatric ARDS, respectively, (P = .01). OI and mechanical ventilation duration were higher in subjects who received postextubation respiratory support (8.7 [5.4-14] vs 4.6 [3.7-7], P < .001 and 10 [7-17] d vs 4 [2-7] d, P < .001) compared to those who did not. At hospital discharge, 12/67 (18.2%) survivors received home respiratory support (6 subjects died prior to hospital discharge). In the multivariable model, ventilator duration (adjusted odds ratio 1.3 [95% CI 1.0-1.7], P = .050) and weight (adjusted odds ratio 0.95 [95% CI 0.91-0.99], P = .02) were associated with the use of postextubation respiratory support. CONCLUSIONS The majority of intubated subjects with pediatric ARDS received respiratory support postextubation, and a substantial proportion continued to require it up to hospital discharge.
Collapse
Affiliation(s)
- Judith Ju Ming Wong
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore.
| | - Herng Lee Tan
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Rehena Sultana
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Yi-Jyun Ma
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Apollo Bugarin Aguilan
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Chen Yun Goh
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Wen Cong Lee
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Pavanish Kumar
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Jan Hau Lee
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| |
Collapse
|
20
|
Zhang X, Cheng Z, Zeng M, He Z. The efficacy of extracellular vesicles for acute lung injury in preclinical animal models: a meta-analysis. BMC Pulm Med 2024; 24:128. [PMID: 38481171 PMCID: PMC10935944 DOI: 10.1186/s12890-024-02910-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/15/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND With the increasing research on extracellular vesicles (EVs), EVs have received widespread attention as biodiagnostic markers and therapeutic agents for a variety of diseases. Stem cell-derived EVs have also been recognized as a new viable therapy for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). To assess their efficacy, we conducted a meta-analysis of existing preclinical experimental animal models of EVs for ALI treatment. METHODS The database was systematically interrogated for pertinent data encompassing the period from January 2010 to April 2022 concerning interventions involving extracellular vesicles (EVs) in animal models of acute lung injury (ALI). The lung injury score was selected as the primary outcome measure for statistical analysis. Meta-analyses were executed utilizing RevMan 5.3 and State15.1 software tools. RESULTS The meta-analyses comprised 31 studies, exclusively involving animal models of acute lung injury (ALI), categorized into two cohorts based on the presence or absence of extracellular vesicle (EV) intervention. The statistical outcomes from these two study groups revealed a significant reduction in lung injury scores with the administration of stem and progenitor cell-derived EVs (SMD = -3.63, 95% CI [-4.97, -2.30], P < 0.05). Conversely, non-stem cell-derived EVs were associated with an elevation in lung injury scores (SMD = -4.34, 95% CI [3.04, 5.63], P < 0.05). EVs originating from stem and progenitor cells demonstrated mitigating effects on alveolar neutrophil infiltration, white blood cell counts, total cell counts in bronchoalveolar lavage fluid (BALF), lung wet-to-dry weight ratios (W/D), and total protein in BALF. Furthermore, pro-inflammatory mediators exhibited down-regulation, while anti-inflammatory mediators demonstrated up-regulation. Conversely, non-stem cell-derived EVs exacerbated lung injury. CONCLUSION In preclinical animal models of acute lung injury (ALI), the administration of extracellular vesicles (EVs) originating from stem and progenitor cells demonstrably enhances pulmonary function. This ameliorative effect is attributed to the mitigation of pulmonary vascular permeability and the modulation of immune homeostasis, collectively impeding the progression of inflammation. In stark contrast, the utilization of EVs derived from non-stem progenitor cells exacerbates the extent of lung injury. These findings substantiate the potential utility of EVs as a novel therapeutic avenue for addressing acute lung injury.
Collapse
Affiliation(s)
- Xuefeng Zhang
- The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zongyong Cheng
- The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Menghao Zeng
- The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhihui He
- Department of Critical Care Medicine, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China.
- 138 Tongzibo Road, Yuelu District, Changsha, Hunan, 410013, China.
| |
Collapse
|
21
|
Qin W, Mao L, Shen Y, Zhao L. Prone position in the mechanical ventilation of acute respiratory distress syndrome children: a systematic review and meta-analysis. Front Pediatr 2024; 12:1293453. [PMID: 38516357 PMCID: PMC10955119 DOI: 10.3389/fped.2024.1293453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/27/2024] [Indexed: 03/23/2024] Open
Abstract
Background Prone position has been well recognized for the treatment of adult acute respiratory distress syndrome (ARDS). We aimed to evaluate the role of prone position in the mechanical ventilation in children with ARDS, to provide evidence to the treatment and care of children with ARDS. Methods We searched the Pubmed et al. databases by computer until January 23, 2024 for randomized controlled trials (RCTs) on the role of prone position in the mechanical ventilation in children with ARDS. We evaluated the quality of included studies according to the quality evaluation criteria recommended by the Cochrane library. RevMan 5.3 software was used for meta-analysis. Results 7 RCTs involving 433 children with ARDS were included. Meta-analysis indicated that prone position is beneficial to improve the arterial oxygenation pressure [MD = 4.27 mmHg, 95% CI (3.49, 5.06)], PaO2/FiO2 [MD = 26.97, 95% CI (19.17, 34.77)], reduced the oxygenation index [MD = -3.52, 95% CI (-5.41, -1.64)], mean airway pressure [MD = -1.91 cmH2O, 95% CI (-2.27, -1.55)] and mortality [OR = 0.33, 95% CI (0.15, 0.73), all P < 0.05]. There were no statistical differences in the duration of mechanical ventilation between the prone position group and control group [MD = -17.01, 97.27, 95% CI (-38.28, 4.26), P = 0.12]. Egger test results showed that no significant publication bias was found (all P > 0.05). Conclusions Prone position ventilation has obvious advantages in improving oxygenation, but there is no significant improvement in the time of mechanical ventilation in the treatment of children with ARDS. In the future, more large-sample, high-quality RCTs are still needed to further analyze the role of prone position in the mechanical ventilation in children with ARDS.
Collapse
Affiliation(s)
- Wen Qin
- Department of Emergency, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lei Mao
- Department of Emergency, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yue Shen
- PICU, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Li Zhao
- Department of Emergency, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| |
Collapse
|
22
|
Kneyber MCJ. Positive end-expiratory pressure in the pediatric intensive care unit. Paediatr Respir Rev 2024; 49:5-8. [PMID: 38030513 DOI: 10.1016/j.prrv.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023]
Abstract
Application of positive end-expiratory pressure (PEEP) targeted towards improving oxygenation is one of the components of the ventilatory management of pediatric acute respiratory distress syndrome (PARDS). Low end-expiratory airway pressures cause repetitive opening and closure of unstable alveoli, leading to surfactant dysfunction and parenchymal shear injury. Consequently, there is less lung volume available for tidal ventilation when there are atelectatic lung regions. This will increase lung strain in aerated lung areas to which the tidal volume is preferentially distributed. Pediatric critical care practitioners tend to use low levels of PEEP and inherently accept higher FiO2, but these practices may negatively affect patient outcome. The Pediatric Acute Lung Injury Consensus Conference (PALICC) suggests that PEEP should be titrated to oxygenation/oxygen delivery, hemodynamics, and compliance measured under static conditions as compared to other clinical parameters or any of these parameters in isolation in patients with PARDS, while limiting plateau pressure and/or driving pressure limits.
Collapse
Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Anaesthesiology, Peri-operative & Emergency Medicine, University of Groningen, Groningen, the Netherlands.
| |
Collapse
|
23
|
Sallee CJ, Hippensteel JA, Miller KR, Oshima K, Pham AT, Richter RP, Belperio J, Sierra YL, Schwingshackl A, Mourani PM, Schmidt EP, Sapru A, Maddux AB. Endothelial Glycocalyx Degradation Patterns in Sepsis-Associated Pediatric Acute Respiratory Distress Syndrome: A Single Center Retrospective Observational Study. J Intensive Care Med 2024; 39:277-287. [PMID: 37670670 PMCID: PMC10845819 DOI: 10.1177/08850666231200162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Sepsis-associated destruction of the pulmonary microvascular endothelial glycocalyx (EGCX) creates a vulnerable endothelial surface, contributing to the development of acute respiratory distress syndrome (ARDS). Constituents of the EGCX shed into circulation, glycosaminoglycans and proteoglycans, may serve as biomarkers of endothelial dysfunction. We sought to define the patterns of plasma EGCX degradation products in children with sepsis-associated pediatric ARDS (PARDS), and test their association with clinical outcomes. METHODS We retrospectively analyzed a prospective cohort (2018-2020) of children (≥1 month to <18 years of age) receiving invasive mechanical ventilation for acute respiratory failure for ≥72 h. Children with and without sepsis-associated PARDS were selected from the parent cohort and compared. Blood was collected at time of enrollment. Plasma glycosaminoglycan disaccharide class (heparan sulfate, chondroitin sulfate, and hyaluronan) and sulfation subtypes (heparan sulfate and chondroitin sulfate) were quantified using liquid chromatography tandem mass spectrometry. Plasma proteoglycans (syndecan-1) were measured through an immunoassay. RESULTS Among the 39 mechanically ventilated children (29 with and 10 without sepsis-associated PARDS), sepsis-associated PARDS patients demonstrated higher levels of heparan sulfate (median 639 ng/mL [interquartile range, IQR 421-902] vs 311 [IQR 228-461]) and syndecan-1 (median 146 ng/mL [IQR 32-315] vs 8 [IQR 8-50]), both p = 0.01. Heparan sulfate subtype analysis demonstrated greater proportions of N-sulfated disaccharide levels among children with sepsis-associated PARDS (p = 0.01). Increasing N-sulfated disaccharide levels by quartile were associated with severe PARDS (n = 9/29) with the highest quartile including >60% of the severe PARDS patients (test for trend, p = 0.04). Higher total heparan sulfate and N-sulfated disaccharide levels were independently associated with fewer 28-day ventilator-free days in children with sepsis-associated PARDS (all p < 0.05). CONCLUSIONS Children with sepsis-associated PARDS exhibited higher plasma levels of heparan sulfate disaccharides and syndecan-1, suggesting that EGCX degradation biomarkers may provide insights into endothelial dysfunction and PARDS pathobiology.
Collapse
Affiliation(s)
- Colin J. Sallee
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Joseph A. Hippensteel
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristen R. Miller
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kaori Oshima
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Andrew T. Pham
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robert P. Richter
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - John Belperio
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles and Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - Yamila L. Sierra
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Andreas Schwingshackl
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Peter M. Mourani
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Eric P. Schmidt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Anil Sapru
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
24
|
De Luca D, Pezza L, Vivalda L, Di Nardo M, Lepainteur M, Baraldi E, Piastra M, Ricciardi W, Conti G, Gualano MR. Critical care of severe bronchiolitis during shortage of ICU resources. EClinicalMedicine 2024; 69:102450. [PMID: 38333363 PMCID: PMC10850123 DOI: 10.1016/j.eclinm.2024.102450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/10/2024] Open
Abstract
Large seasonal outbreaks of bronchiolitis put pressure on healthcare systems and particularly on intensive care units (ICUs). ICU admission is necessary to provide respiratory support to the severest cases, otherwise bronchiolitis can result in substantial mortality. ICU resources are often insufficient and there is scant evidence to guide the ICU clinical management. Most available studies do not cover the ICU-admitted cases and do not consider the associated public health issues. We review this topic through a multidisciplinary approach from both the clinical and public health perspectives, with an analysis based on pathophysiology and cost-effectiveness. We suggest ways to optimise respiratory care, minimise ICU stay, "protect" ICU beds and, whenever possible, make them available for other critically ill children. We also provide guidance on how to prepare ICUs to work under stressful conditions due to outbreaks and to reduce the risk of nosocomial cross-contamination, particularly in ICUs caring for high-risk children. Funding None.
Collapse
Affiliation(s)
- Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, “A. Béclère” Hospital, APHP-Paris Saclay University, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Lucilla Pezza
- Division of Paediatrics and Neonatal Critical Care, “A. Béclère” Hospital, APHP-Paris Saclay University, Paris, France
| | - Laura Vivalda
- Division of Paediatrics and Neonatal Critical Care, “A. Béclère” Hospital, APHP-Paris Saclay University, Paris, France
| | - Matteo Di Nardo
- Paediatric Intensive Care Unit, “Bambino Gesù” Children's Hospital-IRCCS, Rome, Italy
| | - Margaux Lepainteur
- Division of Bacteriology-Hygiene, “A. Béclère” Hospital, APHP-Paris Saclay University, Paris, France
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
- Respiratory Syncytial Virus Network (RESVINET) Foundation, Zeist, the Netherlands
| | - Marco Piastra
- Paediatric Intensive Care Unit, “A. Gemelli” University Hospital Foundation-IRCCS, Rome, Italy
- Department of Biotechnological Sciences, Intensive and Perioperative Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Walter Ricciardi
- Leadership Research Centre, Catholic University of Sacred Heart, Rome, Italy
| | - Giorgio Conti
- Paediatric Intensive Care Unit, “A. Gemelli” University Hospital Foundation-IRCCS, Rome, Italy
- Department of Biotechnological Sciences, Intensive and Perioperative Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Maria Rosaria Gualano
- UniCamillus - Saint Camillus International University of Health and Medical Sciences, Rome, Italy
| |
Collapse
|
25
|
Raab DL, Ely K, Israel K, Lin L, Donnellan A, Saupe J, Klein M, Zackoff MW. Impact of Virtual Reality Simulation on New Nurses' Assessment of Pediatric Respiratory Distress. Am J Crit Care 2024; 33:115-124. [PMID: 38424023 DOI: 10.4037/ajcc2024878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Children often experience respiratory illnesses requiring bedside nurses skilled in recognizing respiratory decompensation. Historically, recognizing respiratory distress has relied on teaching during direct patient care. Virtual reality simulation may accelerate such recognition among novice nurses. OBJECTIVE To determine whether a virtual reality curriculum improved new nurses' recognition of respiratory distress and impending respiratory failure in pediatric patients based on assessment of physical examination findings and appropriate escalation of care. METHODS New nurses (n = 168) were randomly assigned to complete either an immersive virtual reality curriculum on recognition of respiratory distress (intervention) or the usual orientation curriculum (control). Group differences and changes from 3 months to 6 months after the intervention were examined. RESULTS Nurses in the intervention group were significantly more likely to correctly recognize impending respiratory failure at both 3 months (23.4% vs 3.0%, P < .001) and 6 months (31.9% vs 2.6%, P < .001), identify respiratory distress without impending respiratory failure at 3 months (57.8% vs 29.6%, P = .002) and 6 months (57.9% vs 17.8%, P < .001), and recognize patients' altered mental status at 3 months (51.4% vs 18.2%, P < .001) and 6 months (46.8% vs 18.4%, P = .006). CONCLUSIONS Implementation of a virtual reality-based training curriculum was associated with improved recognition of pediatric respiratory distress, impending respiratory failure, and altered mental status at 3 and 6 months compared with standard training approaches. Virtual reality may offer a new approach to nurse orientation to enhance training in pediatrics-specific assessment skills.
Collapse
Affiliation(s)
- Dana L Raab
- Dana L. Raab is Clinical Director for Patient Services Research and the Research Foundation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kelly Ely
- Kelly Ely is a nurse specialist for the Center of Simulation and Research, Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center
| | - Keith Israel
- Keith Israel is an education consultant, Patient Services, Cincinnati Children's Hospital Medical Center
| | - Li Lin
- Li Lin is an epidemiologist/biostatistician in the Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center
| | - Amy Donnellan
- Amy Donnellan is a nurse practitioner for the Heart Institute, Cincinnati Children's Hospital Medical Center
| | - Jennifer Saupe
- Jennifer Saupe is a director for the Center for Professional Excellence, Patient Services, Cincinnati Children's Hospital Medical Center
| | - Melissa Klein
- Melissa Klein is a professor in the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center
| | - Matthew W Zackoff
- Matthew W. Zackoff is an assistant professor in the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center
| |
Collapse
|
26
|
Zhang DW, Lu JL, Dong BY, Fang MY, Xiong X, Qin XJ, Fan XM. Gut microbiota and its metabolic products in acute respiratory distress syndrome. Front Immunol 2024; 15:1330021. [PMID: 38433840 PMCID: PMC10904571 DOI: 10.3389/fimmu.2024.1330021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/30/2024] [Indexed: 03/05/2024] Open
Abstract
The prevalence rate of acute respiratory distress syndrome (ARDS) is estimated at approximately 10% in critically ill patients worldwide, with the mortality rate ranging from 17% to 39%. Currently, ARDS mortality is usually higher in patients with COVID-19, giving another challenge for ARDS treatment. However, the treatment efficacy for ARDS is far from satisfactory. The relationship between the gut microbiota and ARDS has been substantiated by relevant scientific studies. ARDS not only changes the distribution of gut microbiota, but also influences intestinal mucosal barrier through the alteration of gut microbiota. The modulation of gut microbiota can impact the onset and progression of ARDS by triggering dysfunctions in inflammatory response and immune cells, oxidative stress, cell apoptosis, autophagy, pyroptosis, and ferroptosis mechanisms. Meanwhile, ARDS may also influence the distribution of metabolic products of gut microbiota. In this review, we focus on the impact of ARDS on gut microbiota and how the alteration of gut microbiota further influences the immune function, cellular functions and related signaling pathways during ARDS. The roles of gut microbiota-derived metabolites in the development and occurrence of ARDS are also discussed.
Collapse
Affiliation(s)
- Dong-Wei Zhang
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Inflammation & Allergic Diseases Research Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Department of Respiratory and Critical Care Medicine, Liuzhou People’s Hospital, Guangxi Medical University, Liuzhou, Guangxi, China
- Key Laboratory of Diagnosis, Treatment and Research of Asthma and Chronic Obstructive Pulmonary Disease, Liuzhou, Guangxi, China
| | - Jia-Li Lu
- Department of Respiratory and Critical Care Medicine, Liuzhou People’s Hospital, Guangxi Medical University, Liuzhou, Guangxi, China
- Key Laboratory of Diagnosis, Treatment and Research of Asthma and Chronic Obstructive Pulmonary Disease, Liuzhou, Guangxi, China
| | - Bi-Ying Dong
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Inflammation & Allergic Diseases Research Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Department of Respiratory and Critical Care Medicine, Liuzhou People’s Hospital, Guangxi Medical University, Liuzhou, Guangxi, China
- Key Laboratory of Diagnosis, Treatment and Research of Asthma and Chronic Obstructive Pulmonary Disease, Liuzhou, Guangxi, China
| | - Meng-Ying Fang
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Inflammation & Allergic Diseases Research Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xia Xiong
- Department of Dermatology, The Affiliated Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Xue-Jun Qin
- Department of Respiratory and Critical Care Medicine, Liuzhou People’s Hospital, Guangxi Medical University, Liuzhou, Guangxi, China
- Key Laboratory of Diagnosis, Treatment and Research of Asthma and Chronic Obstructive Pulmonary Disease, Liuzhou, Guangxi, China
| | - Xian-Ming Fan
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Inflammation & Allergic Diseases Research Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| |
Collapse
|
27
|
Arias AV, Lintner-Rivera M, Shafi NI, Abbas Q, Abdelhafeez AH, Ali M, Ammar H, Anwar AI, Adabie Appiah J, Attebery JE, Diaz Villalobos WE, Ferreira D, González-Dambrauskas S, Irfan Habib M, Lee JH, Kissoon N, Tekleab AM, Molyneux EM, Morrow BM, Nadkarni VM, Rivera J, Silvers R, Steere M, Tatay D, Bhutta AT, Kortz TB, Agulnik A. A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus. Lancet Glob Health 2024; 12:e331-e340. [PMID: 38190831 PMCID: PMC11089938 DOI: 10.1016/s2214-109x(23)00537-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 01/10/2024]
Abstract
The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.
Collapse
Affiliation(s)
- Anita V Arias
- Division of Critical Care and Pulmonary Medicine, Department of Pediatrics, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Michael Lintner-Rivera
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nadeem I Shafi
- Division of Pediatric Critical Care, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Abdelhafeez H Abdelhafeez
- Department of Surgery, St Jude Children's Research Hospital Memphis, TN, USA; Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Muhammad Ali
- Department of Pediatric Oncology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Halaashuor Ammar
- Department of Paediatrics, School of Medicine, University of Benghazi, Children's Hospital of Benghazi, Benghazi, Libya
| | - Ali I Anwar
- Lincoln Memorial University-DeBusk College of Osteopathic Medicine, Knoxville, TN, USA
| | - John Adabie Appiah
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Jonah E Attebery
- Division of Critical Care, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | | | - Sebastián González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Montevideo, Uruguay; Facultad de Medicina, Universidad de la República, Montevideo, Uruguay; Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | | | - Jan Hau Lee
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore; Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Atnafu M Tekleab
- Department of Pediatrics and Child Health, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jocelyn Rivera
- Pediatric Emergency Department, Hospital Infantil Teletón de Oncología, Querétaro, México
| | - Rebecca Silvers
- Institute for Global Health Sciences and the University of California San Francisco, San Francisco, CA, USA; UCSF School of Nursing, San Francisco, CA, USA; Division of Critical Care, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Mardi Steere
- Royal Flying Doctor Service (South Australia/Northern Territory), SA, Australia; Department of Paediatric Emergency Medicine, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Daniel Tatay
- Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina
| | - Adnan T Bhutta
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Teresa B Kortz
- Institute for Global Health Sciences and the University of California San Francisco, San Francisco, CA, USA; Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Asya Agulnik
- Division of Critical Care and Pulmonary Medicine, Department of Pediatrics, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|
28
|
Yehya N, Zinter MS, Thompson JM, Lim MJ, Hanudel MR, Alkhouli MF, Wong H, Alder MN, McKeone DJ, Halstead ES, Sinha P, Sapru A. Identification of molecular subphenotypes in two cohorts of paediatric ARDS. Thorax 2024; 79:128-134. [PMID: 37813544 PMCID: PMC10850835 DOI: 10.1136/thorax-2023-220130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Two subphenotypes of acute respiratory distress syndrome (ARDS), hypoinflammatory and hyperinflammatory, have been reported in adults and in a single paediatric cohort. The relevance of these subphenotypes in paediatrics requires further investigation. We aimed to identify subphenotypes in two large observational cohorts of paediatric ARDS and assess their congruence with prior descriptions. METHODS We performed latent class analysis (LCA) separately on two cohorts using biomarkers as inputs. Subphenotypes were compared on clinical characteristics and outcomes. Finally, we assessed overlap with adult cohorts using parsimonious classifiers. FINDINGS In two cohorts from the Children's Hospital of Philadelphia (n=333) and from a multicentre study based at the University of California San Francisco (n=293), LCA identified two subphenotypes defined by differential elevation of biomarkers reflecting inflammation and endotheliopathy. In both cohorts, hyperinflammatory subjects had greater illness severity, more sepsis and higher mortality (41% and 28% in hyperinflammatory vs 11% and 7% in hypoinflammatory). Both cohorts demonstrated overlap with adult subphenotypes when assessed using parsimonious classifiers. INTERPRETATION We identified hypoinflammatory and hyperinflammatory subphenotypes of paediatric ARDS from two separate cohorts with utility for prognostic and potentially predictive, enrichment. Future paediatric ARDS trials should identify and leverage biomarker-defined subphenotypes in their analysis.
Collapse
Affiliation(s)
- Nadir Yehya
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Matt S Zinter
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Jill M Thompson
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle J Lim
- Department of Pediatrics, UC Davis, Davis, California, USA
| | - Mark R Hanudel
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Mustafa F Alkhouli
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Hector Wong
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew N Alder
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Daniel J McKeone
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - E Scott Halstead
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Pratik Sinha
- Division of Clinical and Translational Research, Washington University School of Medicine, St. Louis, MO, USA
- Division of Critical Care, Department of Anesthesia, Washington University, St. Louis, MO, USA
| | - Anil Sapru
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
29
|
Chilcote D, Sriram A, Slovis J, Morgan RW, Schaubel DE, Connelly J, Berg RA, Keim G, Yehya N, Kilbaugh T, Himebauch AS. Venovenous Extracorporeal Membrane Oxygenation Initiation for Pediatric Acute Respiratory Distress Syndrome With Cardiovascular Instability is Associated With an Immediate and Sustained Decrease in Vasoactive-Inotropic Scores. Pediatr Crit Care Med 2024; 25:e41-e46. [PMID: 37462429 PMCID: PMC10768839 DOI: 10.1097/pcc.0000000000003325] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To determine the association of venovenous extracorporeal membrane oxygenation (VV-ECMO) initiation with changes in vasoactive-inotropic scores (VISs) in children with pediatric acute respiratory distress syndrome (PARDS) and cardiovascular instability. DESIGN Retrospective cohort study. SETTING Single academic pediatric ECMO center. PATIENTS Children (1 mo to 18 yr) treated with VV-ECMO (2009-2019) for PARDS with need for vasopressor or inotropic support at ECMO initiation. MEASUREMENTS AND MAIN RESULTS Arterial blood gas values, VIS, mean airway pressure (mPaw), and oxygen saturation (Sp o2 ) values were recorded hourly relative to the start of ECMO flow for 24 hours pre-VV-ECMO and post-VV-ECMO cannulation. A sharp kink discontinuity regression analysis clustered by patient tested the difference in VISs and regression line slopes immediately surrounding cannulation. Thirty-two patients met inclusion criteria: median age 6.6 years (interquartile range [IQR] 1.5-11.7), 22% immunocompromised, and 75% had pneumonia or sepsis as the cause of PARDS. Pre-ECMO characteristics included: median oxygenation index 45 (IQR 35-58), mPaw 32 cm H 2o (IQR 30-34), 97% on inhaled nitric oxide, and 81% on an advanced mode of ventilation. Median VIS immediately before VV-ECMO cannulation was 13 (IQR 8-25) with an overall increasing VIS trajectory over the hours before cannulation. VISs decreased and the slope of the regression line reversed immediately surrounding the time of cannulation (robust p < 0.0001). There were pre-ECMO to post-ECMO cannulation decreases in mPaw (32 vs 20 cm H 2o , p < 0.001) and arterial P co2 (64.1 vs 50.1 mm Hg, p = 0.007) and increases in arterial pH (7.26 vs 7.38, p = 0.001), arterial base excess (2.5 vs 5.2, p = 0.013), and SpO 2 (91% vs 95%, p = 0.013). CONCLUSIONS Initiation of VV-ECMO was associated with an immediate and sustained reduction in VIS in PARDS patients with cardiovascular instability. This VIS reduction was associated with decreased mPaw and reduced respiratory and/or metabolic acidosis as well as improved oxygenation.
Collapse
Affiliation(s)
- Daniel Chilcote
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Anant Sriram
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - James Connelly
- ECMO Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Garrett Keim
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- ECMO Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Adam S. Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- ECMO Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
30
|
Barajas-Romero JS, Vásquez-Hoyos P, Pardo R, Jaramillo-Bustamante JC, Grigolli R, Monteverde-Fernández N, Gonzalez-Dambrauskas S, Jabornisky R, Cruces P, Wegner A, Díaz F, Pietroboni P. Factors associated with prolonged mechanical ventilation in children with pulmonary failure: Cohort study from the LARed Network registry. Med Intensiva 2024; 48:23-36. [PMID: 37481458 DOI: 10.1016/j.medine.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/15/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVES To identify factors associated with prolonged mechanical ventilation (pMV) in pediatric patients in pediatric intensive care units (PICUs). DESIGN Secondary analysis of a prospective cohort. SETTING PICUs in centers that are part of the LARed Network between April 2017 and January 2022. PARTICIPANTS Pediatric patients on mechanical ventilation (IMV) due to respiratory causes. We defined IMV time greater than the 75th percentile of the global cohort. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Demographic data, diagnoses, severity scores, therapies, complications, length of stay, morbidity, and mortality. RESULTS 1698 children with MV of 8±7 days were included, and pIMV was defined as 9 days. Factors related to admission were age under 6 months (OR 1.61, 95% CI 1.17-2.22), bronchopulmonary dysplasia (OR 3.71, 95% CI 1.87-7.36), and fungal infections (OR 6.66, 95% CI 1.87-23.74), while patients with asthma had a lower risk of pIMV (OR 0.30, 95% CI 0.12-0.78). Regarding evolution and length of stay in the PICU, it was related to ventilation-associated pneumonia (OR 4.27, 95% CI 1.79-10.20), need for tracheostomy (OR 2.91, 95% CI 1.89-4.48), transfusions (OR 2.94, 95% CI 2.18-3.96), neuromuscular blockade (OR 2.08, 95% CI 1.48-2.93), high-frequency ventilation (OR 2.91, 95% CI 1.89-4.48), and longer PICU stay (OR 1.13, 95% CI 1.10-1.16). In addition, mean airway pressure greater than 13cmH2O was associated with pIMV (OR 1.57, 95% CI 1.12-2.21). CONCLUSIONS Factors related to IMV duration greater than 9 days in pediatric patients in PICUs were identified in terms of admission, evolution, and length of stay.
Collapse
Affiliation(s)
| | - Pablo Vásquez-Hoyos
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Universidad Nacional de Colombia, Bogotá, Colombia; Sociedad de Cirugía de Bogota Hospital de San José, FUCS, Bogotá, Colombia.
| | - Rosalba Pardo
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Clínica Infantil de Colsubsidio, Bogotá, Colombia
| | - Juan Camilo Jaramillo-Bustamante
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Hospital General de Medellín Luz Castro de Gutiérrez E.S.E., Medellín, Colombia
| | - Regina Grigolli
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Hospital Infantil Sabará, Sao Paulo, Brazil
| | | | - Sebastián Gonzalez-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Roberto Jabornisky
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Hospital Juan Pablo II, Corrientes, Argentina; Hospital Regional Olga Stucky de Rizzi, Reconquista, Argentina
| | - Pablo Cruces
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Universidad Andres Bello, Facultad de Ciencias de la Vida, Santiago, Chile
| | - Adriana Wegner
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Complejo Asistencial Dr. Sotero del Rio, Santiago, Chile
| | - Franco Díaz
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Hospital El Carmen de Maipú, Dr. Luis Valentín Ferrada, Santiago, Chile; Unidad de Investigación y Epidemiología Clínica, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Pietro Pietroboni
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); Hospital Regional de Antofagasta, Antofagasta, Chile
| |
Collapse
|
31
|
Williams JG, Jones RL, Yunger TL, Lahni PM, Yehya N, Varisco BM. Comparison of 16 Pediatric Acute Respiratory Distress Syndrome-Associated Plasma Biomarkers With Changing Lung Injury Severity. Pediatr Crit Care Med 2024; 25:e31-e40. [PMID: 37382480 PMCID: PMC10755079 DOI: 10.1097/pcc.0000000000003311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
OBJECTIVES Pediatric acute respiratory distress syndrome (PARDS) is a source of substantial morbidity and mortality in the PICU, and different plasma biomarkers have identified different PARDS and ARDS subgroups. We have a poor understanding of how these biomarkers change over time and with changing lung injuries. We sought to determine how biomarker levels change over PARDS course, whether they are correlated, and whether they are different in critically ill non-PARDS patients. DESIGN Two-center prospective observational study. SETTING Two quaternary care academic children's hospitals. PATIENTS Subjects under 18 years of age admitted to the PICU who were intubated and met the Second Pediatric Acute Lung Injury Consensus Conference-2 PARDS diagnostic criteria and nonintubated critically ill subjects without apparent lung disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma samples were obtained on study days 1, 3, 7, and 14. The levels of 16 biomarkers were measured using a fluorometric bead-based assay. Compared with non-PARDS subjects, on day 1 PARDS subjects had increased concentrations of tumor necrosis factor-alpha, interleukin (IL)-8, interferon-γ, IL17, granzyme B, soluble intercellular adhesion molecule-1 (sICAM1), surfactant protein D, and IL18 but reduced matrix metalloproteinase 9 (MMP-9) concentrations (all p < 0.05). Day 1 biomarker concentrations and PARDS severity were not correlated. Over PARDS course, changes in 11 of the 16 biomarkers positively correlated with changing lung injury with sICAM1 ( R = 0.69, p = 2.2 × 10 -16 ) having the strongest correlation. By Spearman rank correlation of biomarker concentrations in PARDS subjects, we identified two patterns. One had elevations of plasminogen activator inhibitor-1, MMP-9, and myeloperoxidase, and the other had higher inflammatory cytokines. CONCLUSIONS sICAM1 had the strongest positive correlation with worsening lung injury across all study time points suggesting that it is perhaps the most biologically relevant of the 16 analytes. There was no correlation between biomarker concentration on day 1 and day 1 PARDS severity; however, changes in most biomarkers over time positively correlated with changing lung injury. Finally, in day 1 samples, 7 of the 16 biomarkers were not significantly different between PARDS and critically ill non-PARDS subjects. These data highlight the difficulty of using plasma biomarkers to identify organ-specific pathology in critically ill patients.
Collapse
Affiliation(s)
- James G Williams
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rhonda L Jones
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Toni L Yunger
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Patrick M Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nadir Yehya
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian M Varisco
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
32
|
Morrow BM, Lozano Ray E, McCulloch M, Salie S, Salloo A, Appel IN, Du Plooy E, Cawood S, Moshesh P, Keeling KH, Solomon LJ, Hlophe S, Demopoulos D, Parker N, Khan AB, Naidoo KD, Argent AC. Pediatric Acute Respiratory Distress Syndrome in South African PICUs: A Multisite Point-Prevalence Study. Pediatr Crit Care Med 2023; 24:1063-1071. [PMID: 37523579 DOI: 10.1097/pcc.0000000000003330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVES To describe the prevalence of pediatric acute respiratory distress syndrome (pARDS) and the characteristics of children with pARDS in South African PICUs. DESIGN Observational multicenter, cross-sectional point-prevalence study. SETTING Eight PICUs in four South African provinces. PATIENTS All children beyond the neonatal period and under 18 years of age admitted to participating PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and demographic data were prospectively collected on a single day of each month, from February to July 2022, using a centralized database. Cases with or at risk of pARDS were identified using the 2015 Pediatric Acute Lung Injury Consensus Conference criteria. Prevalence was calculated as the number of children meeting pARDS criteria/the total number of children admitted to PICU at the same time points. Three hundred ten patients were present in the PICU on study days: 166 (53.5%) male, median (interquartile range [IQR]) age 9.8 (3.1-32.9) months, and 195 (62.9%) invasively mechanically ventilated. Seventy-one (22.9%) patients were classified as being "at risk" of pARDS and 95 patients (prevalence 30.6%; 95% CI, 24.7-37.5%) fulfilled pARDS case criteria, with severity classified as mild (58.2%), moderate (25.3%), and severe (17.6%). Median (IQR) admission Pediatric Index of Mortality 3 risk of mortality in patients with and without pARDS was 5.6 (3.4-12.1) % versus 3.9 (1.0-8.2) % ( p = 0.002). Diagnostic categories differed between pARDS and non-pARDS groups ( p = 0.002), with no difference in age, sex, or presence of comorbidities. On multivariable logistic regression, increasing admission risk of mortality (adjusted odds ratio [aOR] 1.02; 95% CI, 1.00-1.04; p = 0.04) and being admitted with a respiratory condition (aOR 2.64; 95% CI, 1.27-5.48; p = 0.01) were independently associated with an increased likelihood of having pARDS. CONCLUSIONS The 30.6% prevalence of pARDS in South Africa is substantially higher than reports from other sociogeographical regions, highlighting the need for further research in this setting.
Collapse
Affiliation(s)
- Brenda M Morrow
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Eleonora Lozano Ray
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Mignon McCulloch
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Shamiel Salie
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Asma Salloo
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Ilse N Appel
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Elri Du Plooy
- Department of Pediatrics, Tygerberg Children's Hospital, Stellenbosch University, Cape Town, South Africa
| | - Shannon Cawood
- Pediatric Intensive Care Unit, Nelson Mandela Children's Hospital, Johannesburg, South Africa
| | - Porai Moshesh
- Pediatric Intensive Care Unit, Nelson Mandela Children's Hospital, Johannesburg, South Africa
| | - Kathryn H Keeling
- Pediatric Intensive Care Unit, Nelson Mandela Children's Hospital, Johannesburg, South Africa
| | - Lincoln J Solomon
- Department of Pediatrics and Child Health, University of the Free State, Bloemfontein, South Africa
- Department of Paediatrics, Universitas Academic and Pelonomi Tertiary Hospitals, Bloemfontein, South Africa
| | - Sbekezelo Hlophe
- Department of Paediatrics, Greys Hospital, Pietermaritzburg, South Africa
| | - Despina Demopoulos
- Department of Paediatrics, WITS Donald Gordon Medical Centre, Johannesburg, South Africa
| | - Noor Parker
- Department of Pediatrics, Tygerberg Children's Hospital, Stellenbosch University, Cape Town, South Africa
| | - Ayesha Bibi Khan
- Department of Paediatrics, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
- Division of Critical Care, University of the Witwatersrand, Johannesburg, South Africa
| | - Kuban D Naidoo
- Department of Paediatrics, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
- Division of Critical Care, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew C Argent
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| |
Collapse
|
33
|
Leland SB, Staffa SJ, Newhams MM, Khemani RG, Marshall JC, Young CC, Maddux AB, Hall MW, Weiss SL, Schwarz AJ, Coates BM, Sanders RC, Kong M, Thomas NJ, Nofziger RA, Cullimore ML, Halasa NB, Loftis LL, Cvijanovich NZ, Schuster JE, Flori H, Gertz SJ, Hume JR, Olson SM, Patel MM, Zurakowski D, Randolph AG. The Modified Clinical Progression Scale for Pediatric Patients: Evaluation as a Severity Metric and Outcome Measure in Severe Acute Viral Respiratory Illness. Pediatr Crit Care Med 2023; 24:998-1009. [PMID: 37539964 PMCID: PMC10688559 DOI: 10.1097/pcc.0000000000003331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To develop, evaluate, and explore the use of a pediatric ordinal score as a potential clinical trial outcome metric in children hospitalized with acute hypoxic respiratory failure caused by viral respiratory infections. DESIGN We modified the World Health Organization Clinical Progression Scale for pediatric patients (CPS-Ped) and assigned CPS-Ped at admission, days 2-4, 7, and 14. We identified predictors of clinical improvement (day 14 CPS-Ped ≤ 2 or a three-point decrease) using competing risks regression and compared clinical improvement to hospital length of stay (LOS) and ventilator-free days. We estimated sample sizes (80% power) to detect a 15% clinical improvement. SETTING North American pediatric hospitals. PATIENTS Three cohorts of pediatric patients with acute hypoxic respiratory failure receiving intensive care: two influenza (pediatric intensive care influenza [PICFLU], n = 263, 31 sites; PICFLU vaccine effectiveness [PICFLU-VE], n = 143, 17 sites) and one COVID-19 ( n = 237, 47 sites). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive mechanical ventilation rates were 71.4%, 32.9%, and 37.1% for PICFLU, PICFLU-VE, and COVID-19 with less than 5% mortality for all three cohorts. Maximum CPS-Ped (0 = home at respiratory baseline to 8 = death) was positively associated with hospital LOS ( p < 0.001, all cohorts). Across the three cohorts, many patients' CPS-Ped worsened after admission (39%, 18%, and 49%), with some patients progressing to invasive mechanical ventilation or death (19%, 11%, and 17%). Despite this, greater than 76% of patients across cohorts clinically improved by day 14. Estimated sample sizes per group using CPS-Ped to detect a percentage increase in clinical improvement were feasible (influenza 15%, n = 142; 10%, n = 225; COVID-19, 15% n = 208) compared with mortality ( n > 21,000, all), and ventilator-free days (influenza 15%, n = 167). CONCLUSIONS The CPS-Ped can be used to describe the time course of illness and threshold for clinical improvement in hospitalized children and adolescents with acute respiratory failure from viral infections. This outcome measure could feasibly be used in clinical trials to evaluate in-hospital recovery.
Collapse
Affiliation(s)
- Shannon B Leland
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - John C Marshall
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Scott L Weiss
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Hospital Orange County (CHOC), Orange, CA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Heidi Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, MI
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Samantha M Olson
- Influenza Division and CDC COVID-19 Response Team, Centers for Disease Control of Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Atlanta, GA
| | - Manish M Patel
- Influenza Division and CDC COVID-19 Response Team, Centers for Disease Control of Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Atlanta, GA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| |
Collapse
|
34
|
Felling RJ, Kamerkar A, Friedman ML, Said AS, LaRovere KL, Bell MJ, Bembea MM. Neuromonitoring During ECMO Support in Children. Neurocrit Care 2023; 39:701-713. [PMID: 36720837 DOI: 10.1007/s12028-023-01675-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
Extracorporeal membrane oxygenation is a potentially lifesaving intervention for children with severe cardiac or respiratory failure. It is used with increasing frequency and in increasingly more complex and severe diseases. Neurological injuries are important causes of morbidity and mortality in children treated with extracorporeal membrane oxygenation and include ischemic stroke, intracranial hemorrhage, hypoxic-ischemic injury, and seizures. In this review, we discuss the epidemiology and pathophysiology of neurological injury in patients supported with extracorporeal membrane oxygenation, and we review the current state of knowledge for available modalities of monitoring neurological function in these children. These include structural imaging with computed tomography and ultrasound, cerebral blood flow monitoring with near-infrared spectroscopy and transcranial Doppler ultrasound, and physiological monitoring with electroencephalography and plasma biomarkers. We highlight areas of need and emerging advances that will improve our understanding of neurological injury related to extracorporeal membrane oxygenation and help to reduce the burden of neurological sequelae in these children.
Collapse
Affiliation(s)
- Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Suite 2158, Baltimore, MD, USA.
| | - Asavari Kamerkar
- Department of Anesthesia Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care, Indiana School of Medicine, Indianapolis, IN, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
35
|
Liu Y, Zhao Q, Ning J, Wang Y, Niu F, Liu B. Opportunity for invasive mechanical ventilation in NRDS: a retrospective cohort study in China. J Matern Fetal Neonatal Med 2023; 36:2165061. [PMID: 36617661 DOI: 10.1080/14767058.2023.2165061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE Mechanical ventilation, as a critical breathing support, plays a critical role in the treatment of neonatal respiratory distress syndrome (NRDS). We aim to describe the clinical characteristics of NRDS and give suggestions about when to start mechanical ventilation. METHODS We conducted a retrospective cohort study, enrolling 95 neonates between December 2016 and October 2021. Diagnosis of NRDS was according to the Berlin definition. Spearman's and ROC analysis was used to determine the variables correlated with hospital stay and optimal opportunity for mechanical ventilation. RESULTS Ninety-five subjects with NRDS were included. Lower PaO2 and higher PaCO2 in arterial blood gas prompt longer discharge time after mechanical ventilation and total in-hospital stay (p < .05), in which significant correlations were identified in Spearman's analysis. ROC analysis illustrated that mechanical ventilation starting when PaO2 was 52.5 mmHg contributed to the shortest discharge time and in-hospital stay. PaCO2 of 45.4 mmHg was another optimal cut-off value for the initiation of mechanical ventilation with an AUC of 0.636 (sensitivity 91.5%, specificity 29.2%, p = .022). CONCLUSION PaO2 and PaCO2 were significantly correlated with discharge time and in-hospital stays. When PaO2 was reduced to 52.5 mmHg or PaCO2 increased to 45.5 mmHg, mechanical ventilation was strongly recommended.
Collapse
Affiliation(s)
- Yan Liu
- Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, China
| | - Qing Zhao
- Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, China
| | - Jun Ning
- Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, China
| | - Yu Wang
- Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, China
| | - Fenghai Niu
- Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, China
| | - Bo Liu
- Department of Critical Care Medicine, Affiliated Hospital of Jining Medical University, Jining, China
| |
Collapse
|
36
|
Zinter MS, Dvorak CC, Mayday MY, Reyes G, Simon MR, Pearce EM, Kim H, Shaw PJ, Rowan CM, Auletta JJ, Martin PL, Godder K, Duncan CN, Lalefar NR, Kreml EM, Hume JR, Abdel-Azim H, Hurley C, Cuvelier GDE, Keating AK, Qayed M, Killinger JS, Fitzgerald JC, Hanna R, Mahadeo KM, Quigg TC, Satwani P, Castillo P, Gertz SJ, Moore TB, Hanisch B, Abdel-Mageed A, Phelan R, Davis DB, Hudspeth MP, Yanik GA, Pulsipher MA, Sulaiman I, Segal LN, Versluys BA, Lindemans CA, Boelens JJ, DeRisi JL. Pulmonary microbiome and transcriptome signatures reveal distinct pathobiologic states associated with mortality in two cohorts of pediatric stem cell transplant patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.29.23299130. [PMID: 38077035 PMCID: PMC10705623 DOI: 10.1101/2023.11.29.23299130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Lung injury is a major determinant of survival after pediatric hematopoietic cell transplantation (HCT). A deeper understanding of the relationship between pulmonary microbes, immunity, and the lung epithelium is needed to improve outcomes. In this multicenter study, we collected 278 bronchoalveolar lavage (BAL) samples from 229 patients treated at 32 children's hospitals between 2014-2022. Using paired metatranscriptomes and human gene expression data, we identified 4 patient clusters with varying BAL composition. Among those requiring respiratory support prior to sampling, in-hospital mortality varied from 22-60% depending on the cluster (p=0.007). The most common patient subtype, Cluster 1, showed a moderate quantity and high diversity of commensal microbes with robust metabolic activity, low rates of infection, gene expression indicating alveolar macrophage predominance, and low mortality. The second most common cluster showed a very high burden of airway microbes, gene expression enriched for neutrophil signaling, frequent bacterial infections, and moderate mortality. Cluster 3 showed significant depletion of commensal microbes, a loss of biodiversity, gene expression indicative of fibroproliferative pathways, increased viral and fungal pathogens, and high mortality. Finally, Cluster 4 showed profound microbiome depletion with enrichment of Staphylococci and viruses, gene expression driven by lymphocyte activation and cellular injury, and the highest mortality. BAL clusters were modeled with a random forest classifier and reproduced in a geographically distinct validation cohort of 57 patients from The Netherlands, recapitulating similar cluster-based mortality differences (p=0.022). Degree of antibiotic exposure was strongly associated with depletion of BAL microbes and enrichment of fungi. Potential pathogens were parsed from all detected microbes by analyzing each BAL microbe relative to the overall microbiome composition, which yielded increased sensitivity for numerous previously occult pathogens. These findings support personalized interpretation of the pulmonary microenvironment in pediatric HCT, which may facilitate biology-targeted interventions to improve outcomes.
Collapse
Affiliation(s)
- Matt S Zinter
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher C Dvorak
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Madeline Y Mayday
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Departments of Laboratory Medicine and Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Gustavo Reyes
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Miriam R Simon
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Emma M Pearce
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Hanna Kim
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Peter J Shaw
- The Children`s Hospital at Westmead, Sydney, Australia
| | - Courtney M Rowan
- Indiana University, Department of Pediatrics, Division of Critical Care Medicine, Indianapolis, IN, USA
| | - Jeffrey J Auletta
- Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
| | - Paul L Martin
- Division of Pediatric and Cellular Therapy, Duke University Medical Center, Durham, NC, USA
| | - Kamar Godder
- Cancer and Blood Disorders Center, Nicklaus Children's Hospital, Miami, FL, USA
| | - Christine N Duncan
- Harvard Medical School, Boston, Massachusetts; Division of Pediatric Oncology, Department of Pediatrics, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, USA
| | - Nahal R Lalefar
- Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, University of California San Francisco, Oakland, CA, USA
| | - Erin M Kreml
- Department of Child Health, Division of Critical Care Medicine, University of Arizona, Phoenix, AZ, USA
| | - Janet R Hume
- University of Minnesota, Department of Pediatrics, Division of Critical Care Medicine, Minneapolis, MN, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Division of Hematology/Oncology and Transplant and Cell Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Loma Linda University School of Medicine, Cancer Center, Children Hospital and Medical Center, Loma Linda, CA, USA
| | - Caitlin Hurley
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Geoffrey D E Cuvelier
- CancerCare Manitoba, Manitoba Blood and Marrow Transplant Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amy K Keating
- Center for Cancer and Blood Disorders, Children's Hospital Colorado and University of Colorado, Aurora, CO, USA
- Harvard Medical School, Boston, Massachusetts; Division of Pediatric Oncology, Department of Pediatrics, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, USA
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - James S Killinger
- Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Rabi Hanna
- Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kris M Mahadeo
- Department of Pediatrics, Division of Hematology/Oncology, MD Anderson Cancer Center, Houston, TX, USA
- Division of Pediatric and Cellular Therapy, Duke University Medical Center, Durham, NC, USA
| | - Troy C Quigg
- Pediatric Blood and Marrow Transplantation Program, Texas Transplant Institute, Methodist Children's Hospital, San Antonio, TX, USA
- Section of Pediatric BMT and Cellular Therapy, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, NY, USA
| | - Paul Castillo
- University of Florida, Gainesville, UF Health Shands Children's Hospital, Gainesville, FL, USA
| | - Shira J Gertz
- Department of Pediatrics, Division of Critical Care Medicine, Joseph M Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, NJ, USA
- Department of Pediatrics, St. Barnabas Medical Center, Livingston, NJ, USA
| | - Theodore B Moore
- Department of Pediatric Hematology-Oncology, Mattel Children's Hospital, University of California, Los Angeles, CA, USA
| | - Benjamin Hanisch
- Children's National Hospital, Washington, District of Columbia, USA
| | - Aly Abdel-Mageed
- Section of Pediatric BMT and Cellular Therapy, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Rachel Phelan
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dereck B Davis
- Department of Pediatrics, Hematology/Oncology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michelle P Hudspeth
- Adult and Pediatric Blood & Marrow Transplantation, Pediatric Hematology/Oncology, Medical University of South Carolina Children's Hospital/Hollings Cancer Center, Charleston, SC, USA
| | - Greg A Yanik
- Pediatric Blood and Bone Marrow Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael A Pulsipher
- Division of Hematology, Oncology, Transplantation, and Immunology, Primary Children's Hospital, Huntsman Cancer Institute, Spense Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
| | - Imran Sulaiman
- Departments of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
| | - Leopoldo N Segal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
| | - Birgitta A Versluys
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Caroline A Lindemans
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Jaap J Boelens
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
- Transplantation and Cellular Therapy, MSK Kids, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| |
Collapse
|
37
|
Kahveci F, Karaçoban G, Çelik NA, Gurbanov A, Uçmak H, Özen H, Balaban B, Botan E, Dikmen N, Havan M, Gökhan Ramoğlu M, Eyileten Z, Uçar T, Kendirli T. Venovenous Versus Venoarterial Extracorporeal Membrane Oxygenation: Pediatric Acute Respiratory Distress Syndrome. Turk Arch Pediatr 2023; 58:600-606. [PMID: 37818844 PMCID: PMC10724726 DOI: 10.5152/turkarchpediatr.2023.23025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 08/16/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE This study aimed to compare the efficacy, complication, and mortality of patients who were supported by venovenous (VV) extracorporeal membrane oxygenation (ECMO) and venoarterial (VA) ECMO for pediatric acute respiratory distress syndrome (PARDS). MATERIALS AND METHODS This study is a single-center, retrospective cohort study between 2014 and 2022. We evaluated to indication of ECMO support, ECMO type, patients' demographic features, complications, and children's outcomes supported by ECMO for PARDS. RESULTS Twenty-two patients with PARDS, 12 (54%) with VV, and 10 (46%) with VA ECMO were selected. The median number of days to be intubated before ECMO cannulation was 5 (0-16) days. The distribution of intubated days before the patients underwent ECMO was as follows: 0-1 days, 7 (31.8%) patients; 2-3 days, 2 (9.1%) patients; 4-7 days, 7 (31.8%) patients; 8-14 days, 5 (22.8%) patients; >14 days, 1 (4.5%) patient. The median ECMO cannulation day after admission to the pediatric intensive care unit was 3 (range, 1-9) days in the VV ECMO patient group, whereas it was 8 (range, 0-19) days in the VA ECMO group (P = .02). Considering hospital survival, 4 (45%) patients who underwent double-lumen VV ECMO, 1 (33%) patient who underwent VV ECMO, and 3 (30%) patients who supported by VAECMO survived. There was no difference between the groups in terms of hospital discharge rates. CONCLUSION The highest survival rate was found in the VV ECMO patient group established with double-lumen cannulas, similar to the literature. There was no difference in mortality between the groups whose intubation time before ECMO was 14 days or less.
Collapse
Affiliation(s)
- Fevzi Kahveci
- Division of Pediatrics, Department of Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gülçin Karaçoban
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Nur Ayça Çelik
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Anar Gurbanov
- Division of Pediatrics, Department of Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hacer Uçmak
- Division of Pediatrics, Department of Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hasan Özen
- Division of Pediatrics, Department of Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Burak Balaban
- Division of Pediatrics, Department of Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Edin Botan
- Division of Pediatrics, Department of Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Nur Dikmen
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Merve Havan
- Division of Pediatrics, Department of Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Gökhan Ramoğlu
- Division of Pediatrics, Department of Pediatric Cardiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Eyileten
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tayfun Uçar
- Division of Pediatrics, Department of Pediatric Cardiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tanıl Kendirli
- Division of Pediatrics, Department of Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
38
|
Rambaud J, Broman LM, Chevret S, Visconti F, Leger PL, Guner Y, Butragueño-Laiseca L, Piloquet JE, Di Nardo M. Association between pediatric intensive care mortality and mechanical ventilation settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome. Eur J Pediatr 2023; 182:4487-4497. [PMID: 37491617 DOI: 10.1007/s00431-023-05119-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/11/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
Abstract
The main objective of this study was to describe the current mechanical ventilation (MV) settings during extracorporeal membrane oxygenation (ECMO) for pediatric acute respiratory distress syndrome (P-ARDS) in six European centers. This is a retrospective observational cohort study performed in six European centers from January 2009 to December 2019. Children > 1 month to 18 years supported with ECMO for refractory P-ARDS were included. Collected data were as follows: patients' pre-ECMO medical condition, pre-ECMO adjunctive therapies for P-ARDS, pre-ECMO and during ECMO MV settings on day (D) 1, D3, D7, and D14 of ECMO, use of adjunctive therapies during ECMO, duration of ECMO, pediatric intensive care unit length of stay, and survival. A total of 255 patients with P-ARDS were included. The multivariate analysis showed that PEEP on D1 (OR = 1.13, 95% CI [1.03-1.24], p = 0.01); D3 (OR = 1.17, 95% CI [1.06-1.29], p = 0.001); and D14 (OR = 1.21, 95% CI [1.05-1.43], p = 0.02) and DP on D7 were significantly associated with higher odds of mortality (OR = 0.82, 95% CI [0.71-0.92], p = 0.001). Moreover, DP on D1 above 15 cmH2O (OR 2.23, 95% CI (1.09-4.71), p = 0.03) and native lung FiO2 above 60% on D14 (OR 10.36, 95% CI (1.51-116.15), p = 0.03) were significantly associated with higher odds of mortality. Conclusion: MV settings during ECMO for P-ARDS varied among centers; however, use of high PEEP levels during ECMO was associated with higher odds of mortality as well as a DP above 15 cmH2O and a native lung FiO2 above 60% on D14 of ECMO. What is Known: • Invasive ventilation settings are well defined for pediatric acute respiratory distress syndrome; however, once the children required an extracorporeal respiratory support, there is no recommendation how to set the mechanical ventilator. • Impact of invasive ventilator during extracorporeal respiratory support ad only been during the first days of this support but the effects of these settings later in the assistance are not described. What is New: • It seems to be essential to early decrease FiO2 on native lung once the ECMO flow allows an efficient oxygenation. • Tight control to limit the driving pressure at 15 cmH20 during ECMO run seems to be associated with better survival rate.
Collapse
Affiliation(s)
- Jerome Rambaud
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, Sorbonne University, Paris, France.
| | - Lars M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | | | - Federico Visconti
- Anaesthesia and Intensive Care, Padova University Hospital, Padua, Italy
| | - Pierre-Louis Leger
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, Sorbonne University, Paris, France
| | - Yigit Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Laura Butragueño-Laiseca
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jean-Eudes Piloquet
- Pediatric and Neonatal Intensive Care Unit, Nantes Universitary Hospital, Nantes, France
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| |
Collapse
|
39
|
Emeriaud G, Pons-Òdena M, Bhalla AK, Shein SL, Killien EY, Alapont VMI, Rowan C, Baudin F, Lin JC, Grégoire G, Napolitano N, Mayordomo-Colunga J, Diaz F, Cruces P, Medina A, Smith L, Khemani RG. Noninvasive Ventilation for Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study. Pediatr Crit Care Med 2023; 24:715-726. [PMID: 37255352 PMCID: PMC10524424 DOI: 10.1097/pcc.0000000000003281] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The worldwide practice and impact of noninvasive ventilation (NIV) in pediatric acute respiratory distress syndrome (PARDS) is unknown. We sought to describe NIV use and associated clinical outcomes in PARDS. DESIGN Planned ancillary study to the 2016/2017 prospective Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study. SETTING One hundred five international PICUs. PATIENTS Patients with newly diagnosed PARDS admitted during 10 study weeks. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children were categorized by their respiratory support at PARDS diagnosis into NIV or invasive mechanical ventilation (IMV) groups. Of 708 subjects with PARDS, 160 patients (23%) received NIV at PARDS diagnosis (NIV group). NIV failure rate (defined as tracheal intubation or death) was 84 of 160 patients (53%). Higher nonrespiratory pediatric logistic organ dysfunction (PELOD-2) score, Pa o2 /F io2 was less than 100 at PARDS diagnosis, immunosuppression, and male sex were independently associated with NIV failure. NIV failure was 100% among patients with nonrespiratory PELOD-2 score greater than 2, Pa o2 /F io2 less than 100, and immunosuppression all present. Among patients with Pa o2 /F io2 greater than 100, children in the NIV group had shorter total duration of NIV and IMV, than the IMV at initial diagnosis group. We failed to identify associations between NIV use and PICU survival in a multivariable Cox regression analysis (hazard ratio 1.04 [95% CI, 0.61-1.80]) or mortality in a propensity score matched analysis ( p = 0.369). CONCLUSIONS Use of NIV at PARDS diagnosis was associated with shorter exposure to IMV in children with mild to moderate hypoxemia. Even though risk of NIV failure was high in some children, we failed to identify greater hazard of mortality in these patients.
Collapse
Affiliation(s)
- Guillaume Emeriaud
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Marti Pons-Òdena
- Inmune and Respiratory dysfunction in the child research group. Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950 Esplugues de Llobregat, Spain
- Pediatric Intensive Care and Intermediate care Department, Sant Joan de Déu University Hospital, Universitat de Barcelona, Esplugues de Llobregat, Spain
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, USA
| | - Steven L Shein
- Rainbow Babies and Children’s Hospital, Division of Pediatric Critical Care Medicine, Cleveland Ohio USA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, USA
| | | | - Courtney Rowan
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Florent Baudin
- Réanimation Pédiatrique, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
| | - John C Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, USA
| | - Gabrielle Grégoire
- Applied Clinical Research Unit, CHU Sainte-Justine, Montreal, QC, Canada
| | - Natalie Napolitano
- Respiratory Therapy Department, Children’s Hospital of Philadelphia, USA
| | - Juan Mayordomo-Colunga
- Pediatric Intensive Care Unit. Hospital Universitario Central de Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Franco Diaz
- Instituto de Ciencias e innovación en medicina (ICIM), Universidad del Desarrollo, Santiago de Chile
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago de Chile
| | - Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago de Chile
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Alberto Medina
- Pediatric Intensive Care Unit. Hospital Universitario Central de Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain
| | - Lincoln Smith
- Department of Pediatrics, University of Washington, Seattle Children’s Hospital, USA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, USA
| | | | | |
Collapse
|
40
|
Silver L, Kaplan D, Asencio J, Mandell I, Fishbein J, Shah S. Interrater Reliability of the 2015 Pediatric Acute Lung Injury Consensus Conference Criteria for Pediatric ARDS. Chest 2023; 164:650-655. [PMID: 37062351 PMCID: PMC10104599 DOI: 10.1016/j.chest.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Diagnostic guidelines for pediatric ARDS (PARDS) were developed at the 2015 Pediatric Acute Lung Injury Consensus Conference (PALICC). Although this was an improvement in creating pediatric-specific diagnostic criteria, there remains potential for variability in identification of PARDS. RESEARCH QUESTION What is the interrater reliability of the 2015 PALICC criteria for diagnosing moderate to severe PARDS? What clinical criteria and patient factors are associated with diagnostic disagreements? STUDY DESIGN AND METHODS Patients with acute hypoxic respiratory failure admitted from 2016 to 2021 who received invasive mechanical ventilation were retrospectively reviewed by two pediatric ICU physicians. Reviewers evaluated whether the patient met the 2015 PALICC definition of moderate to severe PARDS and rated their diagnostic confidence. Interrater reliability was measured using Gwet's agreement coefficient. RESULTS Thirty-seven of 191 encounters had a diagnostic disagreement. Interrater reliability was substantial (Gwet's agreement coefficient, 0.74; 95% CI, 0.65-0.83). Disagreements were caused by different interpretations of chest radiographs (56.8%), ambiguity in origin of pulmonary edema (37.8%), or lack of clarity if patient's current condition was significantly different from baseline (27.0%). Disagreement was more likely in patients who were chronically ventilated (OR, 4.66; 95% CI, 2.16-10.08; P < .001), had a primary cardiac admission diagnosis (OR, 3.36; 95% CI, 1.18-9.53; P = .02), or underwent cardiothoracic surgery during the admission (OR, 4.90; 95% CI, 1.60-15.00; P = .005). Reviewers were at least moderately confident in their decision 73% of the time; however, they were less likely to be confident if the patient had cardiac disease or chronic respiratory failure. INTERPRETATION The interrater reliability of the 2015 PALICC criteria for diagnosing moderate to severe PARDS in this cohort was substantial, with diagnostic disagreements commonly caused by differences in chest radiograph interpretations. Patients with cardiac disease or chronic respiratory failure were more vulnerable to diagnostic disagreements. More guidance is needed on interpreting chest radiographs and diagnosing PARDS in these subgroups.
Collapse
Affiliation(s)
- Layne Silver
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY.
| | - Daniel Kaplan
- Division of Pediatric Critical Care, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jessica Asencio
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
| | - Iris Mandell
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
| | - Joanna Fishbein
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY
| | - Sareen Shah
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
| |
Collapse
|
41
|
Baker AK, Beardsley AL, Leland BD, Moser EA, Lutfi RL, Cristea AI, Rowan CM. Predictors of Failure of Noninvasive Ventilation in Critically Ill Children. J Pediatr Intensive Care 2023; 12:196-202. [PMID: 37565011 PMCID: PMC10411242 DOI: 10.1055/s-0041-1731433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022] Open
Abstract
Noninvasive ventilation (NIV) is a common modality employed to treat acute respiratory failure. Most data guiding its use is extrapolated from adult studies. We sought to identify clinical predictors associated with failure of NIV, defined as requiring intubation. This single-center retrospective observational study included children admitted to pediatric intensive care unit (PICU) between July 2014 and June 2016 treated with NIV, excluding postextubation. A total of 148 patients was included. Twenty-seven (18%) failed NIV. There was no difference between the two groups with regard to age, gender, comorbidities, or etiology of acute respiratory failure. Those that failed had higher admission pediatric risk of mortality ( p = 0.01) and pediatric logistic organ dysfunction ( p = 0.002) scores and higher fraction of inspired oxygen (FiO 2 ; p = 0.009) at NIV initiation. Failure was associated with lack of improvement in tachypnea. At 6 hours of NIV, the failure group had worsening tachypnea with a median increase in respiratory rate of 8%, while the success group had a median reduction of 18% ( p = 0.06). Multivariable Cox's proportional hazard models revealed FiO 2 at initiation and worsening respiratory rate at 1- and 6-hour significant risks for failure of NIV. Failure was associated with a significantly longer PICU length of stay (success [2.8 days interquartile range (IQR): 1.7, 5.5] vs. failure [10.6 days IQR: 5.6, 13.2], p < 0.001). NIV can be successfully employed to treat acute respiratory failure in pediatric patients. There should be heightened concern for NIV failure in hypoxemic patients whose tachypnea is unresponsive to NIV. A trend toward improvement should be closely monitored.
Collapse
Affiliation(s)
- Alyson K. Baker
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, United States
| | - Andrew L. Beardsley
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, United States
| | - Brian D. Leland
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, United States
| | - Elizabeth A. Moser
- Department of Biostatistics, Indiana University, Indianapolis, Indiana, United States
| | - Riad L. Lutfi
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, United States
| | - A. Ioana Cristea
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, United States
| | - Courtney M. Rowan
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, United States
| |
Collapse
|
42
|
Milesi C, Baleine J, Mortamet G, Apert J, Gavotto A, Cambonie G. Noninvasive Ventilation in Pediatric Acute Respiratory Distress Syndrome: "Another Dogma Bites the Dust". Pediatr Crit Care Med 2023; 24:783-785. [PMID: 37668500 DOI: 10.1097/pcc.0000000000003299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Christophe Milesi
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Julien Baleine
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alps University Hospital, Grenoble, France
| | - Juliette Apert
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Arthur Gavotto
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France
| | - Gilles Cambonie
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
- Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France
| |
Collapse
|
43
|
Hamill GS, Remy KE, Slain KN, Sallee CJ, Khemani R, Smith L, Shein SL. Association of Interventions With Outcomes in Children At-Risk for Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study. Pediatr Crit Care Med 2023; 24:574-583. [PMID: 37409896 DOI: 10.1097/pcc.0000000000003217] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES Describe the frequency with which transfusion and medications that modulate lung injury are administered to children meeting at-risk for pediatric acute respiratory distress syndrome (ARF-PARDS) criteria and evaluate for associations of transfusion, fluid balance, nutrition, and medications with unfavorable clinical outcomes. DESIGN Secondary analysis of the Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study, a prospective point prevalence study. All enrolled ARF-PARDS patients were included unless they developed subsequent pediatric acute respiratory distress syndrome (PARDS) within 24 hours of PICU admission or PICU length of stay was less than 24 hours. Univariate and multivariable analyses were used to identify associations between therapies given during the first 2 calendar days after ARF-PARDS diagnosis and subsequent PARDS diagnosis (primary outcome), 28-day PICU-free days (PFDs), and 28-day ventilator-free days (VFDs). SETTING Thirty-seven international PICUs. PATIENTS Two hundred sixty-seven children meeting Pediatric Acute Lung Injury Consensus Conference ARF-PARDS criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the first 2 days after meeting ARF-PARDS criteria, 55% of subjects received beta-agonists, 42% received corticosteroids, 28% received diuretics, and 9% were transfused. Subsequent PARDS (15%) was associated with platelet transfusion (n = 11; adjusted odds ratio: 4.75 [95% CI 1.03-21.92]) and diuretics (n = 74; 2.55 [1.19-5.46]) in multivariable analyses that adjusted for comorbidities, PARDS risk factor, initial oxygen saturation by pulse oximetry:Fio2 ratio, and initial type of ventilation. Beta-agonists were associated with lower adjusted odds of subsequent PARDS (0.43 [0.19-0.98]). Platelets and diuretics were also associated with fewer PFDs and fewer VFDs in the multivariable models, and TPN was associated with fewer PFDs. Corticosteroids, net fluid balance, and volume of enteral feeding were not associated with the primary or secondary outcomes. CONCLUSIONS There is an independent association between platelet transfusion, diuretic administration, and unfavorable outcomes in children at risk for PARDS, although this may be related to treatment bias and unmeasured confounders. Nevertheless, prospective evaluation of the role of these management strategies on outcomes in children with ARF-PARDS is needed.
Collapse
Affiliation(s)
- Grant S Hamill
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Katherine N Slain
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Colin J Sallee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, CA
| | - Robinder Khemani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lincoln Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| |
Collapse
|
44
|
Lozano Ray EI, Argent AC, Lupton-Smith A, Salie S, Morrow BM. Prevalence and Incidence of Pediatric Acute Respiratory Distress Syndrome in a Tertiary Academic PICU in South Africa. Pediatr Crit Care Med 2023; 24:594-601. [PMID: 37092843 DOI: 10.1097/pcc.0000000000003245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES To determine the prevalence and incidence of pediatric acute respiratory distress syndrome (pARDS) among infants and children admitted to the PICU. DESIGN A single-center descriptive point prevalence study with twice weekly data collection over a 6 months (August 2020 to February 12, 2021). SETTING Red Cross War Memorial Children's Hospital, Cape Town, South Africa. PATIENTS All infants and children admitted to the PICU on study days were included. INTERVENTIONS Data were captured electronically on a standardized case record form using a Research Electronic Data Capture electronic database. MEASUREMENTS AND MAIN RESULTS The Pediatric Acute Lung Injury Consensus Conference criteria were used to define pARDS cases. Prevalence was calculated as the total number of pARDS cases/1,000 PICU bed days. The study included 354 patients (median [interquartile range]) 10.1 months old (1.5-61.3 mo old), with 204 males (57.6%), who occupied 879 bed days. Of these 879 bed days, 266 (30.3%; 95% CI, 27.2-33.3%) were occupied by pARDS cases, with a calculated prevalence and incidence of 302.6 of 1,000 bed days (30.3%) and 29.7% (95% CI, 26.7-32.7%), respectively. Three cases from the cohort were defined using the oxygen saturation index calculation. In cases receiving invasive ventilation ( n = 494; 56.2%), pARDS severity was classified as mild ( n = 143; 16.3%), moderate ( n = 44; 5.0%), and severe ( n = 29, 3.3%). A further 205 beds (23.3%) were occupied by patients classified as being at risk of pARDS. CONCLUSIONS The prevalence and incidence of pARDS in a South African PICU appears substantially higher than findings described in international reports. Further investigation of risk factors and outcomes is warranted.
Collapse
Affiliation(s)
- Eleonora I Lozano Ray
- Department of Paediatrics, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Andrew C Argent
- Department of Paediatrics, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | | | - Shamiel Salie
- Department of Paediatrics, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Brenda M Morrow
- Department of Paediatrics, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
45
|
Ohman RT, Killien EY. Prevention of Pediatric Acute Respiratory Distress Syndrome: The Holy Grail Remains Elusive. Pediatr Crit Care Med 2023; 24:622-624. [PMID: 37409900 PMCID: PMC10328550 DOI: 10.1097/pcc.0000000000003231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Robert T. Ohman
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention & Research Center, Seattle, WA, USA
| |
Collapse
|
46
|
Ripple MJ, Huang M, Stephenson ST, Mohammad AF, Tidwell M, Fitzpatrick AM, Kamaleswaran R, Grunwell JR. RNA Sequencing Analysis of CD4 + T Cells Exposed to Airway Fluid From Children With Pediatric Acute Respiratory Distress Syndrome. Crit Care Explor 2023; 5:e0935. [PMID: 37378084 PMCID: PMC10292738 DOI: 10.1097/cce.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
CD4+ T cells contribute to lung inflammation in acute respiratory distress syndrome. The CD4+ T-cell response in pediatric acute respiratory distress syndrome (PARDS) is unknown. OBJECTIVES To identify differentially expressed genes and networks using a novel transcriptomic reporter assay with donor CD4+ T cells exposed to the airway fluid of intubated children with mild versus severe PARDS. DESIGN In vitro pilot study. SETTING Laboratory-based study using human airway fluid samples admitted to a 36-bed university-affiliated pediatric intensive care unit. PATIENTS/SUBJECTS Seven children with severe PARDS, nine children with mild PARDS, and four intubated children without lung injury as controls. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed bulk RNA sequencing using a transcriptomic reporter assay of CD4+ T cells exposed to airway fluid from intubated children to discover gene networks differentiating severe from mild PARDS. We found that innate immunity pathways, type I (α and β), and type II (γ) interferon response and cytokine/chemokine signaling are downregulated in CD4+ T cells exposed to airway fluid from intubated children with severe PARDS compared with those with mild PARDS. CONCLUSIONS We identified gene networks important to the PARDS airway immune response using bulk RNA sequencing from a novel CD4+ T-cell reporter assay that exposed CD4+ T cells to airway fluid from intubated children with severe and mild PARDS. These pathways will help drive mechanistic investigations into PARDS. Validation of our findings using this transcriptomic reporter assay strategy is needed.
Collapse
Affiliation(s)
- Michael J Ripple
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, GA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Min Huang
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
| | - Susan T Stephenson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ahmad F Mohammad
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Mallory Tidwell
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, GA
| | - Anne M Fitzpatrick
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, GA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Rishikesan Kamaleswaran
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Jocelyn R Grunwell
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, GA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
47
|
Flerlage T, Crawford JC, Allen EK, Severns D, Tan S, Surman S, Ridout G, Novak T, Randolph A, West AN, Thomas PG. Single cell transcriptomics identifies distinct profiles in pediatric acute respiratory distress syndrome. Nat Commun 2023; 14:3870. [PMID: 37391405 PMCID: PMC10313703 DOI: 10.1038/s41467-023-39593-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 06/21/2023] [Indexed: 07/02/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS), termed pediatric ARDS (pARDS) in children, is a severe form of acute respiratory failure (ARF). Pathologic immune responses are implicated in pARDS pathogenesis. Here, we present a description of microbial sequencing and single cell gene expression in tracheal aspirates (TAs) obtained longitudinally from infants with ARF. We show reduced interferon stimulated gene (ISG) expression, altered mononuclear phagocyte (MNP) transcriptional programs, and progressive airway neutrophilia associated with unique transcriptional profiles in patients with moderate to severe pARDS compared to those with no or mild pARDS. We additionally show that an innate immune cell product, Folate Receptor 3 (FOLR3), is enriched in moderate or severe pARDS. Our findings demonstrate distinct inflammatory responses in pARDS that are dependent upon etiology and severity and specifically implicate reduced ISG expression, altered macrophage repair-associated transcriptional programs, and accumulation of aged neutrophils in the pathogenesis of moderate to severe pARDS caused by RSV.
Collapse
Affiliation(s)
- Tim Flerlage
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - E Kaitlynn Allen
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Danielle Severns
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaoyuan Tan
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sherri Surman
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Granger Ridout
- Hartwell Center for Biotechnology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Tanya Novak
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Adrienne Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Alina N West
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paul G Thomas
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA.
| |
Collapse
|
48
|
Li M, Wang J, Yao Z, Liao H, Su S, Yang X, Xie M, Zheng Y. Metagenomic-based pathogen surveillance for children with severe pneumonia in pediatric intensive care unit. Front Public Health 2023; 11:1177069. [PMID: 37397737 PMCID: PMC10309210 DOI: 10.3389/fpubh.2023.1177069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/26/2023] [Indexed: 07/04/2023] Open
Abstract
Background Pneumonia is a significant cause of morbidity and mortality in children. Metagenomic next-generation sequencing (mNGS) has the potential to assess the landscape of pathogens responsible for severe pulmonary infection. Methods Bronchoalveolar lavage fluid (BALF) samples of 262 children with suspected pulmonary infections were collected from April 2019 to October 2021 in the Pediatric Intensive Care Unit (PICU) of Guangdong Women and Children Hospital. Both mNGS and conventional tests were utilized for pathogen detection. Results A total of 80 underlying pathogens were identified using both mNGS and conventional tests. Respiratory syncytial virus (RSV), Staphylococcus aureus and rhinovirus were the most frequently detected pathogens in this cohort. The incidence rate of co-infection was high (58.96%, 148/251), with bacterial-viral agents most co-detected. RSV was the main pathogen in children younger than 6 months of age, and was also commonly found in older pediatric patients. Rhinovirus was prevalent in children older than 6 months. Adenovirus and Mycoplasma pneumoniae were more prevalent in children older than 3 years than in other age groups. Pneumocystis jirovecii was detected in nearly 15% of children younger than 6 months. Besides, influenza virus and adenovirus were rarely found in 2020 and 2021. Conclusions Our study highlights the importance of using advanced diagnostic techniques like mNGS to improve our understanding of the microbial epidemiology of severe pneumonia in pediatric patients.
Collapse
Affiliation(s)
- Meijin Li
- Department of Pediatric Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, China
| | - Jing Wang
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Zhongwei Yao
- Department of Pediatric Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, China
| | - Hailing Liao
- Department of Pediatric Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, China
| | - Shufen Su
- Department of Pediatric Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xuying Yang
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Mingzhou Xie
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Yinan Zheng
- Department of Pediatric Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, China
| |
Collapse
|
49
|
Dixon CG, Thadani S, Fitzgerald JC, Akcan-Arikan A, Yehya N. Fluid Overload Precedes and Masks Cryptic Kidney Injury in Pediatric Acute Respiratory Distress Syndrome. Crit Care Med 2023; 51:765-774. [PMID: 36939256 PMCID: PMC10214878 DOI: 10.1097/ccm.0000000000005836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
OBJECTIVES Given the complex interrelatedness of fluid overload (FO), creatinine, acute kidney injury (AKI), and clinical outcomes, the association of AKI with poor outcomes in critically ill children may be underestimated due to definitions used. We aimed to disentangle these temporal relationships in a large cohort of children with acute respiratory distress syndrome (ARDS). DESIGN Retrospective cohort study. SETTING Quaternary care PICU. PATIENTS Seven hundred twenty intubated children with ARDS between 2011 and 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily fluid balance, urine output (UOP), and creatinine for days 1-7 of ARDS were retrospectively abstracted. A subset of patients had angiopoietin 2 (ANGPT2) quantified on days 1, 3, and 7. Patients were classified as AKI by Kidney Disease Improving Global Outcomes (KDIGO) stage 2/3 then grouped by timing of AKI onset (early if days 1-3 of ARDS, late if days 4-7 of ARDS, persistent if both) for comparison of PICU mortality and ventilator-free days (VFDs). A final category of "Cryptic AKI" was used to identify subjects who met KDIGO stage 2/3 criteria only when creatinine was adjusted for FO. Outcomes were compared between those who had Cryptic AKI identified by FO-adjusted creatinine versus those who had no AKI. Conventionally defined AKI occurred in 26% of patients (early 10%, late 3%, persistent 13%). AKI was associated with higher mortality and fewer VFDs, with no differences according to timing of onset. The Cryptic AKI group (6% of those labeled no AKI) had higher mortality and fewer VFDs than patients who did not meet AKI with FO-adjusted creatinine. FO, FO-adjusted creatinine, and ANGPT2 increased 1 day prior to meeting AKI criteria in the late AKI group. CONCLUSIONS AKI was associated with higher mortality and fewer VFDs in pediatric ARDS, irrespective of timing. FO-adjusted creatinine captures a group of patients with Cryptic AKI with outcomes approaching those who meet AKI by traditional criteria. Increases in FO, FO-adjusted creatinine, and ANGPT2 occur prior to meeting conventional AKI criteria.
Collapse
Affiliation(s)
- Celeste G. Dixon
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - Sameer Thadani
- Divisions of Critical Care Medicine and Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Julie C. Fitzgerald
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ayse Akcan-Arikan
- Divisions of Critical Care Medicine and Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
50
|
Miranda M, Nadel S. Pediatric Sepsis: a Summary of Current Definitions and Management Recommendations. CURRENT PEDIATRICS REPORTS 2023; 11:29-39. [PMID: 37252329 PMCID: PMC10169116 DOI: 10.1007/s40124-023-00286-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/31/2023]
Abstract
Purpose of Review Pediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, the current evidence base for interventions discuss some controversial themes and point towards possible areas of improvement. Recent Findings Controversy remains regarding the accurate definition, resuscitation fluid volume and type, choice of vasoactive/inotropic agents, and antibiotic depending upon specific infection risks. Many adjunctive therapies have been suggested with theoretical benefits, although definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices. Summary Early diagnosis and timely intervention with antibiotics, fluid resuscitation, and vasoactive medications are the most important interventions in sepsis. The implementation of protocols, resource-adjusted sepsis bundles, and advanced technologies will have an impact on reducing sepsis mortality.
Collapse
Affiliation(s)
- Mariana Miranda
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Simon Nadel
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|