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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.
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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
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Rezk AR, Mohamed MA, Elkenawy MH, Bakry N, Omran A. High-frequency oscillatory ventilation versus conventional ventilation in pediatric patients with acute lung injury: outcomes evaluation. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2022. [DOI: 10.1186/s43054-022-00131-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Abstract
Background
With the development of medical technology and advancements of intensive care units, many types of mechanical ventilators are recruited in the management of acute respiratory distress syndrome (ARDS)/acute lung injury (ALI). We evaluated the outcome of the high-frequency oscillatory ventilation (HFOV) compared to conventional mechanical ventilation (CMV) in pediatric patients with critical respiratory situations mainly ALI or ARDS. A prospective cohort study was performed from 2019 to 2020 in the pediatric intensive care unit (PICU). The following data were recorded: demographic and clinical data, length of PICU stay, mechanical ventilation days, and mortality percentages.
Results
Fifty cases who fulfilled the inclusion criteria were divided into two groups, 24 patients on HFOV from the start and the other 26 were admitted on rescue HFOV after the failure of CMV. There was no statistically significant difference between the two groups regarding the age (p = 0.571) and the oxygenation index (OI) (p = 0.651). Early HFOV demonstrated shorter length of PICU stay and fewer days on mechanical ventilation. The mortality rate was less with the application of early HFOV compared to rescue HFOV.
Conclusions
Early admission on HFOV can be a safe option in the management of patients with critical lung situation as ARDS/ALI.
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ROBERT B, GUELLEC I, JEGARD J, JEAN S, GUILBERT J, SOREZE Y, STARCK J, PILOQUET JE, LEGER PL, RAMBAUD J. Extracorporeal membrane oxygenation for immunocompromised children with acute respiratory distress syndrome: a French referral center cohort. Minerva Pediatr (Torino) 2022; 74:537-544. [DOI: 10.23736/s2724-5276.20.05725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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McCrory MC, Woodruff AG, Saha AK, Evans JK, Halvorson EE, Bass AL. Nonadherence to appropriate tidal volume and PEEP in children with pARDS at a single center. Pediatr Pulmonol 2022; 57:2464-2473. [PMID: 35778788 PMCID: PMC9489656 DOI: 10.1002/ppul.26060] [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] [Received: 02/21/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Low tidal volume and adequate positive end-expiratory pressure (PEEP) are evidence-based approaches for pediatric acute respiratory distress syndrome (pARDS), however, data are limited regarding their use since pARDS guidelines were revised in 2015. OBJECTIVE To identify prevalence of, and factors associated with, nonadherence to appropriate tidal volume and PEEP in children with pARDS. METHODS Retrospective cohort study of children 1 month to <18 years with pARDS who received invasive mechanical ventilation from 2016 to 2018 in a single pediatric intensive care unit (PICU). RESULTS At 24 h after meeting pARDS criteria, 48/86 (56%) patients received tidal volume ≤8 ml/kg of ideal body weight and 45/86 (52%) received appropriate PEEP, with 22/86 (26%) receiving both. Among patients ≥2 years of age, a lower proportion of patients with overweight/obesity (9/25, 36%) had appropriate tidal volume versus those in the normal or underweight category (16/22, 73%, p = 0.02). When FIO2 was ≥50%, PEEP was appropriate in 19/60 (32%) cases versus 26/26 (100%) with FIO2 < 50% (p < 0.0001). pARDS was documented in the progress note in 7/86 (8%) patients at 24 h. Severity of pARDS, documentation in the progress note, and other clinical factors were not significantly associated with use of appropriate tidal volume and PEEP, however pARDS was documented more commonly in patients with severe pARDS. CONCLUSIONS In a single PICU in the United States, children with pARDS did not receive appropriate tidal volume for ideal body weight nor PEEP. Targets for improving tidal volume and PEEP adherence may include overweight patients and those receiving FIO2 ≥ 50%, respectively.
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Affiliation(s)
- Michael C. McCrory
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Alan G. Woodruff
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
- Center for Redox in Biology and Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amit K. Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Joni K. Evans
- Department of Biostatistics; Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Andora L Bass
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
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5
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Pujari CG, Lalitha AV, Raj JM, Kavilapurapu A. Epidemiology of Acute Respiratory Distress Syndrome in Pediatric Intensive Care Unit: Single-center Experience. Indian J Crit Care Med 2022; 26:949-955. [PMID: 36042772 PMCID: PMC9363796 DOI: 10.5005/jp-journals-10071-24285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is characterized by dysregulated inflammation resulting in hypoxemia and respiratory failure and causes both morbidity and mortality. Objectives To describe the clinical profile, outcome, and predictors of mortality in ARDS in children admitted to the Pediatric intensive care unit. Materials and methods This is a single-center retrospective study conducted at a tertiary referral hospital in a 12-bed PICU involving children (1 month to 18 years) with ARDS as defined by Pediatric Acute Lung Injury Consensus Conference (PALICC) guidelines, over a period of 5 years (2016–2020). Demographic, clinical, and laboratory details at onset and during PICU stay were collected. Predictors of mortality were compared between survivors and non-survivors. Results We identified 89 patients with ARDS. The median age at presentation was 76 months (12–124 months). The most common precipitating factor was pneumonia (66%). The majority of children (35.9%) had moderate ARDS. Overall mortality was 33% with more than half belonging to severe ARDS group (58%). On Kaplan–Meier survival curve analysis, the mean time to death was shorter in the severe ARDS group as compared to other groups. Multiorgan dysfunction was present in 46 (51.6%) of the cases. Non-survivors had higher mean pediatric logistic organ dysfunction (PELOD2) on day 1. PRISM III at admission, worsening trends of ventilator and oxygenation parameters (OI, P/F, MAP, and PEEP) independently predicted mortality after multivariate analysis. Conclusion High PRISM score predicts poor outcome, and worsening trends of ventilator and oxygenation parameters (OI, P/F, MAP, and PEEP) are associated with mortality. How to cite this article Pujari CG, Lalitha AV, Raj JM, Kavilapurapu A. Epidemiology of Acute Respiratory Distress Syndrome in Pediatric Intensive Care Unit: Single-center Experience. Indian J Crit Care Med 2022;26(8):949–955.
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Affiliation(s)
- Chandrakant G Pujari
- Department of Paediatric Intensive Care Unit, St John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - AV Lalitha
- Department of Paediatric Intensive Care Unit, St John's Medical College and Hospital, Bengaluru, Karnataka, India
- Lalitha AV, Department of Paediatric Intensive Care Unit, St John's Medical College and Hospital, Bengaluru, Karnataka, India, Phone: +91 9448461673, e-mail:
| | - John Michael Raj
- Department of Biostatistics, St John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Ananya Kavilapurapu
- Department of Paediatric Intensive Care Unit, St John's Medical College and Hospital, Bengaluru, Karnataka, India
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Kollisch-Singule M, Ramcharran H, Satalin J, Blair S, Gatto LA, Andrews PL, Habashi NM, Nieman GF, Bougatef A. Mechanical Ventilation in Pediatric and Neonatal Patients. Front Physiol 2022; 12:805620. [PMID: 35369685 PMCID: PMC8969224 DOI: 10.3389/fphys.2021.805620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/15/2021] [Indexed: 11/30/2022] Open
Abstract
Pediatric acute respiratory distress syndrome (PARDS) remains a significant cause of morbidity and mortality, with mortality rates as high as 50% in children with severe PARDS. Despite this, pediatric lung injury and mechanical ventilation has been poorly studied, with the majority of investigations being observational or retrospective and with only a few randomized controlled trials to guide intensivists. The most recent and universally accepted guidelines for pediatric lung injury are based on consensus opinion rather than objective data. Therefore, most neonatal and pediatric mechanical ventilation practices have been arbitrarily adapted from adult protocols, neglecting the differences in lung pathophysiology, response to injury, and co-morbidities among the three groups. Low tidal volume ventilation has been generally accepted for pediatric patients, even in the absence of supporting evidence. No target tidal volume range has consistently been associated with outcomes, and compliance with delivering specific tidal volume ranges has been poor. Similarly, optimal PEEP has not been well-studied, with a general acceptance of higher levels of FiO2 and less aggressive PEEP titration as compared with adults. Other modes of ventilation including airway pressure release ventilation and high frequency ventilation have not been studied in a systematic fashion and there is too little evidence to recommend supporting or refraining from their use. There have been no consistent outcomes among studies in determining optimal modes or methods of setting them. In this review, the studies performed to date on mechanical ventilation strategies in neonatal and pediatric populations will be analyzed. There may not be a single optimal mechanical ventilation approach, where the best method may simply be one that allows for a personalized approach with settings adapted to the individual patient and disease pathophysiology. The challenges and barriers to conducting well-powered and robust multi-institutional studies will also be addressed, as well as reconsidering outcome measures and study design.
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Affiliation(s)
| | - Harry Ramcharran
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
- *Correspondence: Joshua Satalin,
| | - Sarah Blair
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Louis A. Gatto
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Penny L. Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Nader M. Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Adel Bougatef
- Independent Researcher, San Antonio, TX, United States
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7
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Heath C, Hauser N. Is there a role for lung-protective ventilation in healthy children? Paediatr Anaesth 2022; 32:278-285. [PMID: 34839569 DOI: 10.1111/pan.14345] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/27/2022]
Abstract
Lung-protective ventilation (LPV) has been adopted in the theater environment as a strategy to reduce pulmonary complications under anesthesia. Postoperative pulmonary complications are not infrequent and may have significant implications on the postoperative length of stay as well as the morbidity and mortality of pediatric patients. There is evidence in the adult literature to suggest that intraoperative LPV strategies may reduce the risk of such complications. The utility of LPV strategies in healthy children is not well researched, and the data from critical care studies appear to be conflicting. To ascertain the value of intraoperative LPV in pediatric patients, it is important to understand the pathophysiology of pediatric ventilator-induced lung injury and the basis of LPV strategies. The current evidence in adult and pediatric populations, including pediatric intensive care, is reviewed to gain insight into the role and value of intraoperative LPV for pediatric patients.
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Affiliation(s)
- Chloe Heath
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
| | - Neil Hauser
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Nedlands, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, the University of Western Australia, Perth, WA, Australia
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8
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Cui Y, Zhang Y, Dou J, Shi J, Zhao Z, Zhang Z, Chen Y, Cheng C, Zhu D, Quan X, Zhu X, Huang W. Venovenous vs. Venoarterial Extracorporeal Membrane Oxygenation in Infection-Associated Severe Pediatric Acute Respiratory Distress Syndrome: A Prospective Multicenter Cohort Study. Front Pediatr 2022; 10:832776. [PMID: 35391748 PMCID: PMC8982932 DOI: 10.3389/fped.2022.832776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been increasingly used as rescue therapy for severe pediatric acute respiratory distress syndrome (PARDS) over the past decade. However, a contemporary comparison of venovenous (VV) and venoarterial (VA) ECMO in PARDS has yet to be well described. Therefore, the objective of our study was to assess the difference between VV and VA ECMO in efficacy and safety for infection-associated severe PARDS patients. METHODS This prospective multicenter cohort study included patients with infection-associated severe PARDS who received VV or VA ECMO in pediatric intensive care units (PICUs) of eight university hospitals in China between December 2018 to June 2021. The primary outcome was in-hospital mortality. Secondary outcomes included ECMO weaning rate, duration of ECMO and mechanical ventilation (MV), ECMO-related complications, and hospitalization costs. RESULTS A total of 94 patients with 26 (27.66%) VV ECMO and 68 (72.34%) VA ECMO were enrolled. Compared to the VA ECMO patients, VV ECMO patients displayed a significantly lower in-hospital mortality (50 vs. 26.92%, p = 0.044) and proportion of neurologic complications, shorter duration of ECMO and MV, but the rate of successfully weaned from ECMO, bleeding, bloodstream infection complications and pump failure were similar. By contrast, oxygenator failure was more frequent in patients receiving VV ECMO. No significant intergroup difference was observed for the hospitalization costs. CONCLUSION These positive findings showed the conferred survival advantage and safety of VV ECMO compared with VA ECMO, suggesting that VV ECMO may be an effective initial treatment for patients with infection-associated severe PARDS.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaying Dou
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Zhe Zhao
- Pediatric Intensive Care Unit, Senior Department of Pediatrics, The Seventh Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhen Zhang
- Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
| | - Yingfu Chen
- Critical Care Medicine, Children's Hospital Affiliated to Chongqing Medical University, Chongqing, China
| | - Chao Cheng
- Pediatric Intensive Care Unit, Shengjing Hospital Affiliated to China Medical University, Shenyang, China
| | - Desheng Zhu
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, China
| | - Xueli Quan
- Surgical Intensive Care Unit of Henan Children's Hospital, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xuemei Zhu
- Critical Care Medicine, Children's Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenyan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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9
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Oh SB, Aguilan A, Tan HL, Ma YJ, Sultana R, Lee JH, Wong JJM. The Association Between Alveolar Dead Space Fraction and Mortality in Pediatric Acute Respiratory Distress Syndrome: A Prospective Cohort Study. Front Pediatr 2022; 10:814484. [PMID: 35295701 PMCID: PMC8918668 DOI: 10.3389/fped.2022.814484] [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: 11/13/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Alveolar dead-space fraction (AVDSF), the volume of alveolar gas that does not participate in gas exchange, has been reported to predict mortality and morbidity in adults with acute respiratory distress syndrome (ARDS). This study aims to characterize AVDSF in patients with pediatric ARDS (PARDS), to determine its association with clinical outcomes and examine the validity of a previously studied cutoff (AVDSF > 0.25). METHODS This was a prospective cohort study performed in the setting of a lung protective mechanical ventilation protocol. AVDSF was calculated by the equation: AVDSF = [partial pressure of arterial carbon dioxide (PaCO2) - end tidal carbon dioxide (etCO2)]/PaCO2. Receiver operating curve and Youden index were used to identify an AVDSF cutoff associated with mortality, which characterized "high or low AVDSF" groups. Correlation between AVDSF and clinical indices of severity were determined [including daily oxygenation index (OI), admission Pediatric Index of Mortality 2 (PIM 2) and Pediatric Logistic Organ Dysfunction (PELOD) scores]. The primary outcome, mortality in PARDS patients, was compared between the high and low AVDSF groups and analyzed in a multivariable logistic regression adjusting for inotrope use and PIM 2 score. Secondary outcomes included 28-day ventilator-free (VFD) and intensive care unit-free (IFD) days. RESULTS Sixty-nine PARDS patients with a median (interquartile range) age of 4.5 (0.8, 10.6) years were included in this analysis. Daily AVDSF correlated with daily OI (R 2 = 0.10; p < 0.001). Mean AVDSF over the first 7 days of PARDS correlated with PIM 2 (R 2 = 0.10; p = 0.010) and PELOD (R 2 = 0.12; p = 0.004) scores. The greatest area under the curve identified an AVDSF cutoff of 0.22, which was close to the previously suggested 0.25. The high AVDSF group had higher mortality [7/19 (36.8%) vs. 5/50 (10.0%); p = 0.009] and lower VFD [2 (0, 18) vs. 21 (15, 24); p = 0.007] and IFD [0 (0, 16) vs. 16 (5, 21); p = 0.013]. In the multivariable model, being in the high AVDSF group [adjusted odds ratio 4.67 (95% CI: 1.12, 19.39)] was significantly associated with mortality. CONCLUSIONS High AVDSF was independently associated with increased mortality and decreased VFD and IFD. AVDSF may be complementary to oxygenation indices in risk stratifying PARDS and warrant further study.
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Affiliation(s)
- Sheow Boon Oh
- Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Apollo Aguilan
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Herng Lee Tan
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yi-Jyun Ma
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Rehena Sultana
- Center for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Judith Ju Ming Wong
- Lee Kong Chian School of Medicine, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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10
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Rudolph M, van Dijk J, de Jager P, Dijkstra SK, Burgerhof JGM, Blokpoel RGT, Kneyber MCJ. Performance of acute respiratory distress syndrome definitions in a high acuity paediatric intensive care unit. Respir Res 2021; 22:256. [PMID: 34587946 PMCID: PMC8480111 DOI: 10.1186/s12931-021-01848-z] [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] [Received: 10/23/2020] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For years, paediatric critical care practitioners used the adult American European Consensus Conference (AECC) and revised Berlin Definition (BD) for acute respiratory distress syndrome (ARDS) to study the epidemiology of paediatric ARDS (PARDS). In 2015, the paediatric specific definition, Paediatric Acute Lung Injury Consensus Conference (PALICC) was developed. The use of non-invasive metrics of oxygenation to stratify disease severity were introduced in this definition, although this potentially may lead to a confounding effect of disease severity since it is more common to place indwelling arterial lines in sicker patients. We tested the hypothesis that PALICC outperforms AECC/BD in our high acuity PICU, which employs a liberal use of indwelling arterial lines and high-frequency oscillatory ventilation (HFOV). METHODS We retrospectively collected data from children < 18 years mechanically ventilated for at least 24 h in our tertiary care, university-affiliated paediatric intensive care unit. The primary endpoint was the difference in the number of PARDS cases between AECC/BD and PALICC. Secondary endpoints included mortality and ventilator free days. Performance was assessed by the area under the receiver operating characteristics curve (AUC-ROC). RESULTS Data from 909 out of 2433 patients was eligible for analysis. AECC/BD identified 35 (1.4%) patients (mortality 25.7%), whereas PALICC identified 135 (5.5%) patients (mortality 14.1%). All but two patients meeting AECC/Berlin criteria were also identified by PALICC. Almost half of the cohort (45.2%) had mild, 33.3% moderate and 21.5% severe PALICC PARDS at onset. Highest mortality rates were seen in patients with AECC acute lung injury (ALI)/mild Berlin and severe PALICC PARDS. The AUC-ROC for Berlin was the highest 24 h (0.392 [0.124-0.659]) after onset. PALICC showed the highest AUC-ROC at the same moment however higher than Berlin (0.531 [0.345-0.716]). Mortality rates were significantly increased in patients with bilateral consolidations (9.3% unilateral vs 26.3% bilateral, p = 0.025). CONCLUSIONS PALICC identified more new cases PARDS than the AECC/Berlin definition. However, both PALICC and Berlin performed poorly in terms of mortality risk stratification. The presence of bilateral consolidations was associated with a higher mortality rate. Our findings may be considered in future modifications of the PALICC criteria.
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Affiliation(s)
- Michelle Rudolph
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands.
| | - Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Pauline de Jager
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Sandra K Dijkstra
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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11
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Bateman ST, Johnson AC, Tiber D, Gauguet S, Fortier L, Valentine S. Pediatric ECMO Candidates at Non-ECMO Centers: Transfer, Cannulate, or Treat Locally? Hosp Pediatr 2021; 11:1172-1178. [PMID: 34470788 DOI: 10.1542/hpeds.2020-004929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric inpatient and intensive care specialists working outside of tertiary medical centers confront difficult clinical scenarios related to how best to care for extremely ill children who may or may not benefit from advanced medical technology, and these clinicians are often faced with limited local availability. Extracorporeal membrane oxygenation (ECMO) is a technology that is only available at a subset of tertiary care centers, and the decision to risk the transfer of a child for the potential benefit of ECMO is challenging. This article is aimed at addressing the main factors and ethical principles related to this decision-making: (1) whether ECMO is the standard of care, (2) clinical decision analysis of the risks and benefits, (3) informed consent and education of the parents and/or guardians, and (4) institutional leadership decision-making. A decisional framework is proposed that incorporates a thoughtful shared decision-making algorithm.
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Affiliation(s)
- Scot T Bateman
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Amanda C Johnson
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David Tiber
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Stefanie Gauguet
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Lauren Fortier
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
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12
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Hon KL, Leung KKY, Oberender F, Leung AK. Paediatrics: how to manage acute respiratory distress syndrome. Drugs Context 2021; 10:dic-2021-1-9. [PMID: 34122589 PMCID: PMC8177958 DOI: 10.7573/dic.2021-1-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/17/2021] [Indexed: 12/13/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a significant cause of mortality and morbidity amongst critically ill children. The purpose of this narrative review is to provide an up-to-date review on the evaluation and management of paediatric ARDS (PARDS). Methods A PubMed search was performed with Clinical Queries using the key term "acute respiratory distress syndrome". The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. Google, Wikipedia and UpToDate were also searched to enrich the review. The search was restricted to the English literature and children. Discussion Non-invasive positive pressure ventilation, lung-protective ventilation strategies, conservative fluid management and adequate nutritional support all have proven efficacy in the management of PARDS. The Pediatric Acute Lung Injury Consensus Conference recommends the use of corticosteroids, high-frequency oscillation ventilation and inhaled nitric oxide in selected scenarios. Partial liquid ventilation and surfactant are not considered efficacious based on evidence from clinical trials. Conclusion PARDS is a serious but relatively rare cause of admission into the paediatric intensive care unit and is associated with high mortality. Non-invasive positive pressure ventilation, lung-protective ventilation strategies, conservative fluid management and adequate nutrition are advocated. As there has been a lack of progress in the management of PARDS in recent years, further well-designed, large-scale, randomized controlled trials in this field are urgently needed.
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Affiliation(s)
- Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, Australia.,Monash University, School of Clinical Sciences, Department of Paediatrics, Melbourne, Australia
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
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13
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Serazin NA, Edem B, Williams SR, Ortiz JR, Kawade A, Das MK, Šubelj M, Edwards KM, Parida SK, Wartel TA, Munoz FM, Bastero P. Acute respiratory distress syndrome (ARDS) as an adverse event following immunization: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2021; 39:3028-3036. [PMID: 33583673 PMCID: PMC7843093 DOI: 10.1016/j.vaccine.2021.01.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/20/2021] [Indexed: 02/08/2023]
Abstract
This is a Brighton Collaboration Case Definition of the term “Acute Respiratory Distress Syndrome – ARDS” to be utilized in the evaluation of adverse events following immunization. The Case Definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of vaccines for SARS-CoV-2 vaccines and other emerging pathogens. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected Expert Reviewers prior to submission. The comments of the reviewers were taken into consideration and edits incorporated in this final manuscript.
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Affiliation(s)
- Nathan A Serazin
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Bassey Edem
- Department of Vaccines and Immunity, Medical Research Council the Gambia Unit at the London School of Hygiene and Tropical Medicine, UK
| | - Sarah R Williams
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Justin R Ortiz
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anand Kawade
- King Edward Memorial Hospital Research Centre, Vadu Rural Health Program Pune, India
| | | | - Maja Šubelj
- National Institute of Public Health, University of Ljubljana, Slovenia
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - T Anh Wartel
- International Vaccine Institute, Seoul, Republic of Korea
| | - Flor M Munoz
- Departments of Pediatrics, Section of Infectious Diseases, and Molecular Virology and Microbiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Patricia Bastero
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
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14
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Yehya N, Varisco BM, Thomas NJ, Wong HR, Christie JD, Feng R. Peripheral blood transcriptomic sub-phenotypes of pediatric acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:681. [PMID: 33287889 PMCID: PMC7720038 DOI: 10.1186/s13054-020-03410-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/24/2020] [Indexed: 02/18/2023]
Abstract
Background Acute respiratory distress syndrome (ARDS) is heterogeneous and may be amenable to sub-phenotyping to improve enrichment for trials. We aimed to identify subtypes of pediatric ARDS based on whole blood transcriptomics. Methods This was a prospective observational study of children with ARDS at the Children’s Hospital of Philadelphia (CHOP) between January 2018 and June 2019. We collected blood within 24 h of ARDS onset, generated expression profiles, and performed k-means clustering to identify sub-phenotypes. We tested the association between sub-phenotypes and PICU mortality and ventilator-free days at 28 days using multivariable logistic and competing risk regression, respectively. Results We enrolled 106 subjects, of whom 96 had usable samples. We identified three sub-phenotypes, dubbed CHOP ARDS Transcriptomic Subtypes (CATS) 1, 2, and 3. CATS-1 subjects (n = 31) demonstrated persistent hypoxemia, had ten subjects (32%) with immunocompromising conditions, and 32% mortality. CATS-2 subjects (n = 29) had more immunocompromising diagnoses (48%), rapidly resolving hypoxemia, and 24% mortality. CATS-3 subjects (n = 36) had the fewest comorbidities and also had rapidly resolving hypoxemia and 8% mortality. The CATS-3 subtype was associated with lower mortality (OR 0.18, 95% CI 0.04–0.86) and higher probability of extubation (subdistribution HR 2.39, 95% CI 1.32–4.32), relative to CATS-1 after adjustment for confounders. Conclusions We identified three sub-phenotypes of pediatric ARDS using whole blood transcriptomics. The sub-phenotypes had divergent clinical characteristics and prognoses. Further studies should validate these findings and investigate mechanisms underlying differences between sub-phenotypes.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, 6040A Wood Building, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA. .,University of Pennsylvania, Philadelphia, PA, USA.
| | - Brian M Varisco
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Hector R Wong
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jason D Christie
- Critical Care Division, Department of Medicine, Pulmonary, Allergy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rui Feng
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
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15
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Baumann P, Wiegert S, Greco F, Ersch J, Cannizzaro V. Strain-specific differences in lung tissue viscoelasticity of mechanically ventilated infant Sprague-Dawley and Wistar rats. Am J Physiol Lung Cell Mol Physiol 2020; 320:L220-L231. [PMID: 33207919 DOI: 10.1152/ajplung.00100.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Rats are often used in ventilator-induced lung injury (VILI) models. However, strain-specific susceptibility for VILI has not been elucidated yet. The aim of this study was to demonstrate strain-specific differences in VILI in infant Sprague-Dawley and Wistar rats. VILI was compared in 2-wk-old pups after 8 h of protective or injurious ventilation. Pups were ventilated with tidal volumes (VT) of ∼7 mL/kg and positive end-expiratory pressures (PEEP) of 6 cmH2O (VT7 PEEP6) or with VT of ∼21 mL/kg and PEEP 2 cmH2O (VT21 PEEP2). Interleukin-6, macrophage inflammatory protein-2 (MIP-2), inflammatory cells, and albumin in bronchoalveolar lavage fluid (BALF); histology; and low-frequency forced oscillation technique (LFOT) and pressure-volume (PV) maneuvers were assessed. Alveolar macrophages, neutrophils, and MIP-2 derived from BALF revealed more pronounced VILI after VT21 PEEP2 in both strains. LFOT and PV analyses demonstrated rat strain-specific differences both at baseline and particularly in response to VT21 PEEP2 ventilation. Sprague-Dawley rats showed higher airway and tissue resistance and elastance values with no difference in hysteresivity between ventilation strategies. Wister rats challenged by VT21 PEEP2 experienced significantly more energy dissipation when compared with VT7 PEEP6 ventilation. In conclusion, both rat strains are useful for VILI models. The degree of VILI severity depends on ventilation strategy and selected strain. However, fundamental and time-dependent differences in respiratory system mechanics exist and reflect different lung tissue viscoelasticity. Hence, strain-specific characteristics of the respiratory system need to be considered when planning and interpreting VILI studies with infant rats.
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Affiliation(s)
- Philipp Baumann
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Susanne Wiegert
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland
| | - Francesco Greco
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland
| | - Joerg Ersch
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland
| | - Vincenzo Cannizzaro
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland.,Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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16
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Fremuth J, Kobr J, Sasek L, Pizingerova K, Zamboryova J, Sykora J. Ultrasound cardiac output monitoring in mechanically ventilated children. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:428-434. [PMID: 33087939 DOI: 10.5507/bp.2020.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022] Open
Abstract
AIM To non-invasively identify the hemodynamic changes in critically ill children during the first 48 h following initiation of mechanical ventilation by the ultrasound cardiac output monitor (USCOM) method and compare the data in children with pulmonary and non-pulmonary pathology. MATERIALS AND METHODS This was a prospective observational study to evaluate the influence of mechanical ventilation on hemodynamic changes and to describe hemodynamic profiles of mechanically ventilated children. A total of 56 children with respiratory failure were included in the present study. Ventilated patients are divided into two groups. Group A (n=36) includes patients with pulmonary pathology. Group B (n=20) consists of patients with extra pulmonary etiology of respiratory failure. Hemodynamic parameters (cardiac index and systemic vascular resistance index) were evaluated using ultrasound cardiac output monitoring (USCOM 1A) immediately following initiation of mechanical ventilation and again at 6, 12, and 48 h. Pharmacological circulatory support (inotropes, vasopressors, levosimendan and phosphodiesterase III inhibitors) was individually and continuously modified based on real-time hemodynamic parameters and optimal fluid balance. RESULTS No significant differences in hemodynamic profiles were found between Group A and Group B. CONCLUSION The protective strategy of mechanical ventilation was not associated with significant differences in hemodynamic profiles between children ventilated for pulmonary and non-pulmonary pathologies. CLINICAL SIGNIFICANCE Hemodynamically unstable children ventilated for pulmonary pathology with the protective strategy of mechanical ventilation had a greater requirement for inotropic and combined inotropic and vasoactive circulatory support than children ventilated for non-pulmonary causes of respiratory failure.
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Affiliation(s)
- Jiri Fremuth
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Jiri Kobr
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Lumir Sasek
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Katerina Pizingerova
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Jana Zamboryova
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Josef Sykora
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
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17
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Kneyber MCJ, Ilia S, Koopman AA, van Schelven P, van Dijk J, Burgerhof JGM, Markhorst DG, Blokpoel RGT. Energy transmission in mechanically ventilated children: a translational study. Crit Care 2020; 24:601. [PMID: 33028370 PMCID: PMC7539278 DOI: 10.1186/s13054-020-03313-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Recurrent delivery of tidal mechanical energy (ME) inflicts ventilator-induced lung injury (VILI) when stress and strain exceed the limits of tissue tolerance. Mechanical power (MP) is the mathematical description of the ME delivered to the respiratory system over time. It is unknown how ME relates to underlying lung pathology and outcome in mechanically ventilated children. We therefore tested the hypothesis that ME per breath with tidal volume (Vt) normalized to bodyweight correlates with underlying lung pathology and to study the effect of resistance on the ME dissipated to the lung. Methods We analyzed routinely collected demographic, physiological, and laboratory data from deeply sedated and/or paralyzed children < 18 years with and without lung injury. Patients were stratified into respiratory system mechanic subgroups according to the Pediatric Mechanical Ventilation Consensus Conference (PEMVECC) definition. The association between MP, ME, lung pathology, and duration of mechanical ventilation as a primary outcome measure was analyzed adjusting for confounding variables and effect modifiers. The effect of endotracheal tube diameter (ETT) and airway resistance on energy dissipation to the lung was analyzed in a bench model with different lung compliance settings. Results Data of 312 patients with a median age of 7.8 (1.7–44.2) months was analyzed. Age (p < 0.001), RR p < 0.001), and Vt < 0.001) were independently associated with MPrs. ME but not MP correlated significantly (p < 0.001) better with lung pathology. Competing risk regression analysis adjusting for PRISM III 24 h score and PEMVECC stratification showed that ME on day 1 or day 2 of MV but not MP was independently associated with the duration of mechanical ventilation. About 33% of all energy generated by the ventilator was transferred to the lung and highly dependent on lung compliance and airway resistance but not on endotracheal tube size (ETT) during pressure control (PC) ventilation. Conclusions ME better related to underlying lung pathology and patient outcome than MP. The delivery of generated energy to the lung was not dependent on ETT size during PC ventilation. Further studies are needed to identify injurious MErs thresholds in ventilated children.
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Affiliation(s)
- Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands. .,Critical Care, Anesthesia, Peri-operative Medicine & Emergency Medicine (CAPE), The University of Groningen, Groningen, the Netherlands.
| | - Stavroula Ilia
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands.,Pediatric Intensive Care Unit, University Hospital Heraklion, University of Crete, Crete, Greece
| | - Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Patrick van Schelven
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, The University of Groningen, Groningen, the Netherlands
| | - Dick G Markhorst
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
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18
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Ward SL, Dahmer MK, Weeks HM, Sapru A, Quasney MW, Curley MAQ, Liu KD, Matthay MA, Flori HR. Association of patient weight status with plasma surfactant protein D, a biomarker of alveolar epithelial injury, in children with acute respiratory failure. Pediatr Pulmonol 2020; 55:2730-2736. [PMID: 32725941 PMCID: PMC8087214 DOI: 10.1002/ppul.24990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 01/01/2023]
Abstract
AIMS AND OBJECTIVES Alveolar epithelial injury is a key determinant of acute respiratory failure (ARF) severity. Plasma surfactant protein D (SP-D), a biomarker of alveolar epithelial injury, is lower in obese adults with ARF compared to their lean peers. We aimed to determine if children with ARF have similar variance in plasma SP-D associated with their weight status on admission. METHODS Plasma SP-D was measured on days 0, 1, or 2 in children (1-18 years) with ARF enrolled in the genetic variation and biomarkers in children with acute lung injury and RESTORE studies. Weight classification (underweight, normal, overweight, and obese) was based on body mass index or weight-for-height z-scores. Associations between weight group and SP-D on each day were tested. RESULTS Inclusion criteria were met in 212 subjects, 24% were obese. There were no differences among weight groups in SP-D levels on days 0 and 1. However, on day 2, there was a statistically significant linear trend for lower SP-D levels as weight increased in both the univariate analysis (P = .02) and when adjusting for age, ethnicity, and diagnosis of pediatric acute respiratory distress syndrome (P = .05). CONCLUSIONS Obesity was associated with lower plasma SP-D levels on day 2 of ARF. This finding may be explained by altered ARF pathogenesis in obese individuals or a reduced incidence of ventilator-induced lung injury.
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Affiliation(s)
- Shan L Ward
- Division of Critical Care, Department of Pediatrics, UCSF Benioff Children's Hospitals, San Francisco and Oakland, California
| | - Mary K Dahmer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Heidi M Weeks
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Anil Sapru
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, California
| | - Michael W Quasney
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Martha A Q Curley
- Division of Anesthesia and Critical Care Medicine, Department of Family and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
| | - Kathleen D Liu
- Department of Medicine, UCSF Medical Center, San Francisco, California
| | - Michael A Matthay
- Department of Anesthesia, UCSF Medical Center, San Francisco, California.,UCSF Medical Center, Cardiovascular Research Institute, San Francisco, California
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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19
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Chacón MA, Calderon A, Fernández-Sarmiento J, Rios B. Clinical Course of Pediatric Acute Respiratory Distress Syndrome at Moderate Altitude. Cureus 2020; 12:e10651. [PMID: 33133821 PMCID: PMC7586349 DOI: 10.7759/cureus.10651] [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: 11/25/2022] Open
Abstract
Background This is a retrospective case series, and the main objective is to describe the epidemiology, clinical features, and outcomes of pediatric acute respiratory distress syndrome in patients at moderate altitude. Methods Children from the Pediatric Intensive Care Unit (PICU) at the Fundación Cardioinfantil, hospitalized with acute respiratory distress syndrome, were prospectively enrolled from March 2009 to March 2014. We evaluated the demographic data, mechanical ventilation, gas exchange, hemodynamics, and multiorgan dysfunction. Results During the study period, 88 patients met the inclusion criteria. Bronchiolitis and pneumonia were the most common causes of acute respiratory distress syndrome. The overall mortality rate was 19.5%. At the beginning of the study, the average relation between blood pressure and the fraction of inspired oxygen (Pa/Fi) was 130.3 ± 52.2; tidal volume was 7.94 ± 1.7 ml/kg, the plateau pressure 25.3 ± 5.09 cmH2O, and positive end-expiratory pressure was 7.2 ± 3.2 cmH2O. After 24 hours, the mortality rate in the group with severe acute respiratory distress syndrome (Pa/Fi <100) was 46.7%, in the moderate acute respiratory distress syndrome group (Pa/Fi 100-200) it was 11.9%, and finally in the mild acute respiratory distress syndrome group (Pa/Fi 200-300) the mortality was 25%. This study found a relation between serum lactate value and positive end-expiratory pressure and mortality (p = 0.02 and 0.0013). Conclusions This study shows that pediatric acute respiratory distress syndrome patients at moderate altitudes have similar clinical behavior, including mortality rate, to those at low altitudes. However, Pa/Fi is not a good predictor of mortality for patients with mild and moderate acute respiratory distress syndrome.
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Affiliation(s)
- María A Chacón
- Pediatric Critical Care, Universidad de La Sabana, Bogotá, COL
| | | | | | - Blanca Rios
- Pediatric Critical Care, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, COL
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20
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Rowan CM, Klein MJ, Hsing DD, Dahmer MK, Spinella PC, Emeriaud G, Hassinger AB, Piñeres-Olave BE, Flori HR, Haileselassie B, Lopez-Fernandez YM, Chima RS, Shein SL, Maddux AB, Lillie J, Izquierdo L, Kneyber MCJ, Smith LS, Khemani RG, Thomas NJ, Yehya N. Early Use of Adjunctive Therapies for Pediatric Acute Respiratory Distress Syndrome: A PARDIE Study. Am J Respir Crit Care Med 2020; 201:1389-1397. [PMID: 32130867 DOI: 10.1164/rccm.201909-1807oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rationale: Few data exist to guide early adjunctive therapy use in pediatric acute respiratory distress syndrome (PARDS).Objectives: To describe contemporary use of adjunctive therapies for early PARDS as a framework for future investigations.Methods: This was a preplanned substudy of a prospective, international, cross-sectional observational study of children with PARDS from 100 centers over 10 study weeks.Measurements and Main Results: We investigated six adjunctive therapies for PARDS: continuous neuromuscular blockade, corticosteroids, inhaled nitric oxide (iNO), prone positioning, high-frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation. Almost half (45%) of children with PARDS received at least one therapy. Variability was noted in the median starting oxygenation index of each therapy; corticosteroids started at the lowest oxygenation index (13.0; interquartile range, 7.6-22.0) and HFOV at the highest (25.7; interquartile range, 16.7-37.3). Continuous neuromuscular blockade was the most common, used in 31%, followed by iNO (13%), corticosteroids (10%), prone positioning (10%), HFOV (9%), and extracorporeal membrane oxygenation (3%). Steroids, iNO, and HFOV were associated with comorbidities. Prone positioning and HFOV were more common in middle-income countries and less frequently used in North America. The use of multiple ancillary therapies increased over the first 3 days of PARDS, but there was not an easily identifiable pattern of combination or order of use.Conclusions: The contemporary description of prevalence, combinations of therapies, and oxygenation threshold for which the therapies are applied is important for design of future studies. Region of the world, income, and comorbidities influence adjunctive therapy use and are important variables to include in PARDS investigations.
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Affiliation(s)
- Courtney M Rowan
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, Indiana
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles and University of Southern California, Los Angeles, California
| | - Deyin Doreen Hsing
- Department of Pediatrics, New York Presbyterian Hospital and Weill Cornell Medical College, New York, New York
| | - Mary K Dahmer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Guillaume Emeriaud
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montreal, Quebec, Canada
| | - Amanda B Hassinger
- Division of Pediatric Critical Care, Department of Pediatrics, Oishei Children's Hospital and University of Buffalo, Buffalo, New York
| | | | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Bereketeab Haileselassie
- Division of Pediatric Critical Care, Department of Pediatrics, Stanford University, Palo Alto, California
| | | | - Ranjit S Chima
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Aline B Maddux
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado, Aurora, Colorado
| | - Jon Lillie
- Evelina London Children's Hospital, London, United Kingdom
| | - Ledys Izquierdo
- Department of Pediatrics, Hospital Militar Central, Bogotá, Colombia
| | - Martin C J Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital and University of Groningen, Groningen, the Netherlands
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles and University of Southern California, Los Angeles, California
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, Pennsylvania and
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Wiegert S, Greco F, Baumann P, Wellmann S, Grest P, Hetzel U, Cannizzaro V. Impact of high tidal volume ventilation on surfactant metabolism and lung injury in infant rats. Am J Physiol Lung Cell Mol Physiol 2020; 319:L562-L575. [PMID: 32579393 DOI: 10.1152/ajplung.00043.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The poorly understood tolerance toward high tidal volume (VT) ventilation observed in critically ill children and age-equivalent animal models may be explained by surfactant homeostasis. The aim of our prospective animal study was to test whether high VT with adequate positive end-expiratory pressure (PEEP) is associated with surfactant de novo synthesis and secretion, leading to improved lung function, and whether extreme mechanical ventilation affects intracellular lamellar body formation and exocytosis. Rats (14 days old) were allocated to five groups: nonventilated controls, PEEP 5 cmH2O with VT of 8, 16, and 24 mL/kg, and PEEP 1 cmH2O with VT 24 mL/kg. Following 6 h of ventilation, lung function, surfactant proteins and phospholipids, and lamellar bodies were assessed by forced oscillation technique, quantitative real-time polymerase chain reaction, mass spectrometry, immunohistochemistry, and transmission electron microscopy. High VT (24 mL/kg) with PEEP of 5 cmH2O improved respiratory system mechanics and was not associated with lung injury, elevated surfactant protein expression, or surfactant phospholipid content. Extreme ventilation with VT 24 mL/kg and PEEP 1 cmH2O produced a mild inflammatory response and correlated with higher surfactant phospholipid concentrations in bronchoalveolar lavage fluid without affecting lamellar body count and morphology. Elevated phospholipid concentrations in the potentially most injurious strategy (VT 24 mL/kg, PEEP 1 cmH2O) need further evaluation and might reflect accumulation of biophysically inactive small aggregates. In conclusion, our data confirm the resilience of infant rats toward high VT-induced lung injury and challenge the relevance of surfactant synthesis, storage, and secretion as protective factors.
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Affiliation(s)
- Susanne Wiegert
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Centre for Integrative Human Physiology, Zurich, Switzerland
| | - Francesco Greco
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Centre for Integrative Human Physiology, Zurich, Switzerland
| | - Philipp Baumann
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Sven Wellmann
- Zurich Centre for Integrative Human Physiology, Zurich, Switzerland.,Department of Neonatology, University Children's Hospital Basel, Basel, Switzerland.,Department of Neonatology, University Children's Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Paula Grest
- Vetsuisse Faculty, Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, University of Zurich, Zurich, Switzerland
| | - Udo Hetzel
- Vetsuisse Faculty, Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, University of Zurich, Zurich, Switzerland
| | - Vincenzo Cannizzaro
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Centre for Integrative Human Physiology, Zurich, Switzerland
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22
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Killien EY, Mills B, Vavilala MS, Watson RS, OʼKeefe GE, Rivara FP. Association between age and acute respiratory distress syndrome development and mortality following trauma. J Trauma Acute Care Surg 2020; 86:844-852. [PMID: 30633097 DOI: 10.1097/ta.0000000000002202] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Improved understanding of the relationship between patient age and acute respiratory distress syndrome (ARDS) development and mortality following traumatic injury may help facilitate generation of new hypotheses about ARDS pathophysiology and the role of novel treatments to improve outcomes across the age spectrum. METHODS We conducted a retrospective cohort study of trauma patients included in the National Trauma Data Bank who were admitted to an intensive care unit from 2007 to 2016. We determined ARDS incidence and mortality across eight age groups for the entire 10-year study period and by year. We used generalized linear Poisson regression models adjusted for underlying mortality risk (injury mechanism, Injury Severity Score, admission Glasgow Coma Scale score, admission heart rate, and admission hypotension). RESULTS Acute respiratory distress syndrome occurred in 3.1% of 1,297,190 trauma encounters. Acute respiratory distress syndrome incidence was lowest among pediatric patients and highest among adults aged 35 to 64 years. Acute respiratory distress syndrome mortality was highest among patients 80 years or older (43.9%), followed by 65 to 79 years (30.6%) and 4 years or younger (25.3%). The relative risk of mortality associated with ARDS was highest among the pediatric age groups, with an adjusted relative risk (aRR) of 2.06 (95% confidence interval [CI], 1.72-2.70) among patients 4 years or younger compared with an aRR of 1.51 (95% CI, 1.42-1.62) for the entire cohort. Acute respiratory distress syndrome mortality increased over the 10-year study period (aRR, 1.03 per year; 95% CI, 1.02-1.05 per year), whereas all-cause mortality decreased (aRR, 0.98 per year; 95% CI, 0.98-0.99 per year). CONCLUSIONS While ARDS development following traumatic injury was most common in middle-aged adults, patients 4 years or younger and 65 years or older with ARDS experienced the highest burden of mortality. Children 4 years or younger were disproportionately affected by ARDS relative to their low underlying mortality following trauma that was not complicated by ARDS. Acute respiratory distress syndrome-associated mortality following trauma has worsened over the past decade, emphasizing the need for new prevention and treatment strategies. LEVEL OF EVIDENCE Prognostic/epidemiological study, level III.
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Affiliation(s)
- Elizabeth Y Killien
- From the Harborview Injury Prevention and Research Center (E.Y.K., B.M., M.S.V., G.E.O., F.P.R.), University of Washington, Seattle, Washington; Division of Pediatric Critical Care Medicine, Department of Pediatrics (E.Y.K., R.S.W.), University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine (M.S.V.), University of Washington, Seattle, Washington; Center for Child Health, Behavior, and Development (R.S.W., F.P.R.), Seattle Children's Research Institute, Seattle, Washington; Department of Surgery (G.E.O.), University of Washington, Seattle, Washington; Division of General Pediatrics, Department of Pediatrics (F.P.R.), University of Washington, Seattle, Washington
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23
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Lim JKB, Qadri SK, Toh TSW, Lin CB, Mok YH, Lee JH. Extracorporeal Membrane Oxygenation for Severe Respiratory Failure During Respiratory Epidemics and Pandemics: A Narrative Review. ANNALS ACADEMY OF MEDICINE SINGAPORE 2020. [DOI: 10.47102/annals-acadmed.sg.202046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Epidemics and pandemics from zoonotic respiratory viruses, such as the 2019 novel coronavirus, can lead to significant global intensive care burden as patients progress to acute respiratory distress syndrome (ARDS). A subset of these patients develops refractory hypoxaemia despite maximal conventional mechanical ventilation and require extracorporeal membrane oxygenation (ECMO). This review focuses on considerations for ventilatory strategies, infection control and patient selection related to ECMO for ARDS in a pandemic. We also summarise the experiences with ECMO in previous respiratory pandemics. Materials and Methods: A review of pertinent studies was conducted via a search using MEDLINE, EMBASE and Google Scholar. References of articles were also examined to identify other relevant publications. Results: Since the H1N1 Influenza pandemic in 2009, the use of ECMO for ARDS continues to grow despite limitations in evidence for survival benefit. There is emerging evidence to suggest that lung protective ventilation for ARDS can be further optimised while receiving ECMO so as to minimise ventilator-induced lung injury and subsequent contributions to multi-organ failure. Efforts to improve outcomes should also encompass appropriate infection control measures to reduce co-infections and prevent nosocomial transmission of novel respiratory viruses. Patient selection for ECMO in a pandemic can be challenging. We discuss important ethical considerations and predictive scoring systems that may assist clinical decision-making to optimise resource allocation. Conclusion: The role of ECMO in managing ARDS during respiratory pandemics continues to grow. This is supported by efforts to redefine optimal ventilatory strategies, reinforce infection control measures and enhance patient selection. Ann Acad Med Singapore 2020;49:199–214 Key words: Acute Respiratory Distress Syndrome, Coronavirus disease 2019, ECMO, Infection control, Mechanical ventilation
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Affiliation(s)
- Joel KB Lim
- KK Women’s and Children’s Hospital, Singapore
| | | | | | | | - Yee Hui Mok
- KK Women’s and Children’s Hospital, Singapore
| | - Jan Hau Lee
- KK Women’s and Children’s Hospital, Singapore
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24
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Ahmed R, Azim A, Nangialay A, Haque A, Jurair H. Frequency of Pediatric Acute Respiratory Distress Syndrome Based on Oxygen Saturation Index in Pediatric Intensive Care Unit of a Developing Country. Cureus 2019; 11:e6444. [PMID: 31998572 PMCID: PMC6973537 DOI: 10.7759/cureus.6444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives To determine the frequency of pediatric acute respiratory distress syndrome based on oxygen saturation index in pediatric intensive care unit of a developing country. Methods We conducted a retrospective study of all children admitted in pediatric intensive care unit (PICU) of Aga Khan University Hospital, Karachi from July 2017 to June 2018 with respiratory rate >40 breaths/minute, shortness of breath, and bluish discoloration of skin and mucous membranes. The diagnosis of acute respiratory distress syndrome (ARDS) was made on the basis of standard operational definitions as mentioned (fulfilling criteria for ARDS). Results During the one-year study period 150 patients with age range of one month to 16 years were admitted fulfilling the inclusion criteria. Mean age was 38.27 ± 53.13 months, and 92 (61.33%) were male with male to female ratio of 1.6:1. Mean duration of symptoms was 1.23 ± 0.42 days. Frequency of pediatric acute respiratory distress syndrome using oxygen saturation index admitted in a pediatric ICU was 23 (15.33%) patients. Conclusion This study has shown that the frequency of pediatric acute respiratory distress syndrome is quite high.
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Affiliation(s)
- Rahim Ahmed
- Pediatric Intensive Care Unit (PICU), The Indus Hospital, Karachi, PAK
| | - Asim Azim
- Pediatric Intensive Care Unit (PICU), The Indus Hospital, Karachi, PAK
| | | | - Anwar Haque
- Pediatrics, The Indus Hospital, Karachi, PAK
| | - Humaira Jurair
- Pediatric Intensive Care Unit (PICU), Aga Khan University Hospital, Karachi, PAK
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25
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Morbidity and Mortality Among Critically Injured Children With Acute Respiratory Distress Syndrome. Crit Care Med 2019; 47:e112-e119. [PMID: 30379667 DOI: 10.1097/ccm.0000000000003525] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate morbidity and mortality among critically injured children with acute respiratory distress syndrome. DESIGN Retrospective cohort study. SETTING Four-hundred sixty Level I/II adult or pediatric trauma centers contributing to the National Trauma Data Bank. PATIENTS One hundred forty-six thousand fifty-eight patients less than 18 years old admitted to an ICU with traumatic injury from 2007 to 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We assessed in-hospital mortality and need for postdischarge care among patients with and without acute respiratory distress syndrome and hospital resource utilization and discharge disposition among survivors. Analyses were adjusted for underlying mortality risk (age, Injury Severity Score, serious brain or chest injury, and admission heart rate and hypotension) and year, transfer status, and facility trauma level designation. Acute respiratory distress syndrome occurred in 2,590 patients (1.8%). Mortality was 20.0% among acute respiratory distress syndrome patients versus 4.3% among nonacute respiratory distress syndrome patients, with an adjusted relative risk of 1.76 (95% CI, 1.52-2.04). Postdischarge care was required in an additional 44.8% of acute respiratory distress syndrome patients versus 16.0% of patients without acute respiratory distress syndrome (adjusted relative risk, 3.59; 2.87-4.49), with only 35.1% of acute respiratory distress syndrome patients discharging to home versus 79.8% of patients without acute respiratory distress syndrome. Acute respiratory distress syndrome mortality did not change over the 10-year study period (adjusted relative risk, 1.01/yr; 0.96-1.06) nor did the proportion of acute respiratory distress syndrome patients requiring postdischarge care (adjusted relative risk, 1.04/yr; 0.97-1.11). Duration of ventilation, ICU stay, and hospital stay were all significantly longer among acute respiratory distress syndrome survivors. Tracheostomy placement occurred in 18.4% of acute respiratory distress syndrome survivors versus 2.1% of patients without acute respiratory distress syndrome (adjusted relative risk, 3.10; 2.59-3.70). CONCLUSIONS Acute respiratory distress syndrome development following traumatic injury in children is associated with significantly increased risk of morbidity and mortality, even after adjustment for injury severity and hemodynamic abnormalities. Outcomes have not improved over the past decade, emphasizing the need for new therapeutic interventions, and prevention strategies for acute respiratory distress syndrome among severely injured children.
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26
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Moskowitzova K, Orfany A, Liu K, Ramirez-Barbieri G, Thedsanamoorthy JK, Yao R, Guariento A, Doulamis IP, Blitzer D, Shin B, Snay ER, Inkster JAH, Iken K, Packard AB, Cowan DB, Visner GA, Del Nido PJ, McCully JD. Mitochondrial transplantation enhances murine lung viability and recovery after ischemia-reperfusion injury. Am J Physiol Lung Cell Mol Physiol 2019; 318:L78-L88. [PMID: 31693391 PMCID: PMC6985877 DOI: 10.1152/ajplung.00221.2019] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The most common cause of acute lung injury is ischemia-reperfusion injury (IRI), during which mitochondrial damage occurs. We have previously demonstrated that mitochondrial transplantation is an efficacious therapy to replace or augment mitochondria damaged by IRI, allowing for enhanced muscle viability and function in cardiac tissue. Here, we investigate the efficacy of mitochondrial transplantation in a murine lung IRI model using male C57BL/6J mice. Transient ischemia was induced by applying a microvascular clamp on the left hilum for 2 h. Upon reperfusion mice received either vehicle or vehicle-containing mitochondria either by vascular delivery (Mito V) through the pulmonary artery or by aerosol delivery (Mito Neb) via the trachea (nebulization). Sham control mice underwent thoracotomy without hilar clamping and were ventilated for 2 h before returning to the cage. After 24 h recovery, lung mechanics were assessed and lungs were collected for analysis. Our results demonstrated that at 24 h of reperfusion, dynamic compliance and inspiratory capacity were significantly increased and resistance, tissue damping, elastance, and peak inspiratory pressure (Mito V only) were significantly decreased (P < 0.05) in Mito groups as compared with their respective vehicle groups. Neutrophil infiltration, interstitial edema, and apoptosis were significantly decreased (P < 0.05) in Mito groups as compared with vehicles. No significant differences in cytokines and chemokines between groups were shown. All lung mechanics results in Mito groups except peak inspiratory pressure in Mito Neb showed no significant differences (P > 0.05) as compared with Sham. These results conclude that mitochondrial transplantation by vascular delivery or nebulization improves lung mechanics and decreases lung tissue injury.
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Affiliation(s)
- Kamila Moskowitzova
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Arzoo Orfany
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Kaifeng Liu
- Department of Pulmonary and Respiratory Diseases, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Giovanna Ramirez-Barbieri
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jerusha K Thedsanamoorthy
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts
| | - Rouan Yao
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts
| | - Alvise Guariento
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ilias P Doulamis
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - David Blitzer
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Borami Shin
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Erin R Snay
- Department of Radiology, Division of Nuclear Medicine and Molecular imaging, Boston Children's Hospital, Boston, Massachusetts
| | - James A H Inkster
- Department of Radiology, Division of Nuclear Medicine and Molecular imaging, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Khadija Iken
- Department of Pulmonary and Respiratory Diseases, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Alan B Packard
- Department of Radiology, Division of Nuclear Medicine and Molecular imaging, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Douglas B Cowan
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Gary A Visner
- Department of Pulmonary and Respiratory Diseases, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - James D McCully
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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27
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Koopman AA, de Jager P, Blokpoel RGT, Kneyber MCJ. Ventilator-induced lung injury in children: a reality? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:506. [PMID: 31728359 DOI: 10.21037/atm.2019.09.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Mechanical ventilation (MV) is inextricably linked to the care of critically ill patients admitted to the paediatric intensive care unit (PICU). Even today, little evidence supports best MV practices for life-threatening acute respiratory failure in children. However, careful attention must be paid because this life-saving technique induces pulmonary inflammation that aggravates pre-existing lung injury, a concept that is known as ventilator-induced lung injury (VILI). The delivery of too large tidal volumes (Vt) (i.e., volutrauma) and repetitive opening and closure of alveoli (i.e., atelectrauma) are two key mechanisms underlying VILI. Despite the knowledge of these mechanisms, the clinical relevance of VILI in critically ill children is poorly understood as almost all of our knowledge has been obtained from studies in adults or experimental studies mimicking the adult critical care situation. This leaves the question if VILI is relevant in the paediatric context. In fact, limited paediatric experimental data showed that the use of large, supraphysiologic Vt resulted in less inflammation and injury in paediatric animal models compared to adult models. Furthermore, the association between large Vt and adverse outcome has not been confirmed and the issue of setting positive end-expiratory pressure (PEEP) to prevent atelectrauma has hardly been studied in paediatric clinical studies. Hence, even today, the question whether or not there VILI is relevant in pediatric critical remains to be answered. Consequently, how MV is used remains thus based on institutional preferences, personal beliefs and clinical data extrapolated from adults. This signifies the need for clinical and experimental studies in order to better understand the use and effects of MV in paediatric patients with or without lung injury.
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Affiliation(s)
- Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Pauline de Jager
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
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28
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Monteverde-Fernández N, Cristiani F, McArthur J, González-Dambrauskas S. Steroids in pediatric acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:508. [PMID: 31728361 PMCID: PMC6828791 DOI: 10.21037/atm.2019.07.77] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a complex entity with high potential for harm and healthcare resource utilization. Despite multiple clinical advances in its ventilatory management, ARDS continues to be one of the most challenging disease processes for intensivists. It continues to lack a direct, proven and desperately needed effective therapeutic intervention. Given their biologic rationale, corticosteroids have been widely used by clinicians and considered useful by many in the management of ARDS since its first description. Adult data is abundant, yet contradictory. Controversy remains regarding the routine use of corticosteroids in ARDS. Therefore, widespread evidence-based recommendations for this heterogeneous disease process have not been made. In this article, our aim was to provide a summary of available evidence for the role of steroids in the treatment of ARDS, while giving special focus on pediatric ARDS (PARDS).
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Affiliation(s)
- Nicolás Monteverde-Fernández
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Uruguay
- Medica Uruguaya Corporación Asistencia Médica (MUCAM). Cuidados Intensivos Neonatales y Pediatricos (CINP), Uruguay
| | - Federico Cristiani
- Department of Anesthesiology, Centro Hospitalario Pereira Rossell, Cátedra de Anestesiología, Universidad de la República, Montevideo, Uruguay
| | - Jenniffer McArthur
- Division of Critical Care, Department of Pediatrics, St. Jude’s Children’s Research Hospital, Memphis, TN, USA
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Uruguay
- Cuidados Intensivos Pediátricos Especializados (CIPe) Casa de Galicia, Montevideo, Uruguay
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29
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Iyer R, Bansal A. What do we know about optimal nutritional strategies in children with pediatric acute respiratory distress syndrome? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:510. [PMID: 31728363 DOI: 10.21037/atm.2019.08.25] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Nutrition in pediatric acute respiratory distress syndrome (PARDS) is an essential aspect of therapy, with potential to modify outcomes. The gut is slowly establishing its place as the motor of critical illness, and the 'gut-lung' axis has been shown to be in play in the systemic inflammatory response. Thus, utilizing the gut to modify outcomes in PARDS is an exciting prospect. PARDS is associated with high mortality in low- and middle-income countries (LMIC), where malnutrition is also prevalent and may worsen during hospital stay. Mortality may be higher in this subgroup of patients. At present, the gold standard to estimate resting energy expenditure (REE) in critically ill children is indirect calorimetry. However, it is a cumbersome and expensive procedure, as a result of which its routine practice is limited to very few units across the world. Therefore, predictive equations, which may under- or over-estimate REE, are relied upon to approximate calorie and protein needs of children with PARDS. Despite having target calorie and protein requirements, studies have found that a large proportion of critically ill children do not achieve these levels even at the end of a week in pediatric intensive care unit (PICU). The preferred mode of nutrition delivery is enteral, and if possible, early enteral nutrition (EEN). Immunonutrition has been a lucrative subject of research, and while there have been some strides, no therapy has yet conclusively demonstrated benefit in terms of mortality or reduced length of stay in PICU or the hospital. Probable immunonutrients in PARDS include omega-3 fatty acids, arginine, glutamine and vitamin D, though none are a part of any recommendations yet.
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Affiliation(s)
- Rajalakshmi Iyer
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Bansal
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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30
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Erickson S. Extra-corporeal membrane oxygenation in paediatric acute respiratory distress syndrome: overrated or underutilized? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:512. [PMID: 31728365 DOI: 10.21037/atm.2019.09.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a modified form of cardiopulmonary bypass which may provide support for severe cardiorespiratory failure including paediatric acute respiratory distress syndrome (PARDS). While ECMO was initially demonstrated to successfully support neonates with severe respiratory failure, the use of ECMO has expanded rapidly to support both paediatric and adult respiratory failure. Extracorporeal Life Support Organization (ELSO) registry data shows that the use of ECMO for paediatric respiratory failure has expanded rapidly over the past decades with increasing use of venovenous ECMO. Despite the increasing complexity of children supported by ECMO for ARDS, outcomes have remained consistent with survival to hospital discharge greater than 50%. ECMO complications are still common and potentially devastating, especially neurological complications. There is grade 1 evidence to support the use of ECMO in both neonatal and adult respiratory failure but evidence in paediatric respiratory failure is confined to case series and case-control studies. While there are no published guidelines for use of ECMO in PARDS, in particular no clearly defined inclusion and exclusion criteria, current evidence suggests that children with severe ARDS may benefit from ECMO support, with survival to hospital discharge equivalent or better than conventional management in children with severe ARDS.
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Affiliation(s)
- Simon Erickson
- Paediatric Critical Care, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Senior Lecturer, University of Western Australia, Hackett Drive, Nedlands, Western Australia, Australia
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31
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Beltramo F, Khemani RG. Definition and global epidemiology of pediatric acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:502. [PMID: 31728355 DOI: 10.21037/atm.2019.09.31] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute respiratory distress syndrome (ARDS) has been known to occur in children since early descriptions of the disease, but pediatric specific diagnostic criteria were first established in 2015 with the Pediatric Acute Lung Injury Consensus Conference (PALICC) definition of pediatric ARDS (PARDS). There were substantial changes proposed with the PALICC definition, including simplification of radiographic criteria, use of pulse oximetry based metrics to define PARDS, specific criteria for non-invasive ventilation, and the use of oxygenation index (OI) instead of PaO2/FiO2 ratio for those on invasive ventilation. While these changes could potentially result in major changes in the reported incidence and outcome of PARDS, review of the recent literature since publication of the PALICC definitions highlight that major elements regarding the contemporary epidemiology of PARDS have remained stable over the past 20 years. This highlights that the PARDS definition is likely catching up to changes in clinical practice, and suggests that this new definition should be used moving forward as it is more reflective of current practice than historical definitions. However, it is also clear that PARDS severity alone (as measured by the PALICC) criteria insufficiently characterizes the risk for mortality or other important clinical outcomes amongst PARDS patients, although there appears to be some association between PARDS severity and outcome, particularly when hypoxemia is severe.
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Affiliation(s)
- Fernando Beltramo
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Robinder G Khemani
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Risk Factors on Hospital Arrival for Acute Respiratory Distress Syndrome Following Pediatric Trauma. Crit Care Med 2019; 46:e1088-e1096. [PMID: 30119074 DOI: 10.1097/ccm.0000000000003379] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To determine risk factors identifiable at hospital arrival associated with acute respiratory distress syndrome development among critically injured children. DESIGN Retrospective cohort study. SETTING Level I or II adult or pediatric trauma centers contributing to the National Trauma Data Bank from 2007 to 2016. PATIENTS Patients less than 18 years admitted to an ICU with traumatic injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We determined associations between patient, injury, and clinical characteristics present at hospital arrival with development of acute respiratory distress syndrome recorded as a hospital complication. Acute respiratory distress syndrome occurred in 1.8% of 146,058 critically injured children (n = 2,590). The only demographic factor associated with higher risk of developing acute respiratory distress syndrome on multivariable analysis was African American race (relative risk, 1.42 vs white; 95% CI, 1.13-1.78). Injury characteristics included firearm injuries (relative risk 1.93; 1.50-2.48) and motor vehicle crashes (relative risk, 1.91; 1.57-2.31) relative to falls; spine (relative risk, 1.39; 1.20-1.60), chest (relative risk, 1.36; 1.22-1.52), or lower extremity injuries (relative risk, 1.26; 1.10-1.44); amputations (relative risk, 2.10; 1.51-2.91); and more severe injury (relative risk, 3.69 for Injury Severity Score 40-75 vs 1-8; 2.50-5.44). Clinical variables included abnormal respiratory status (intubated relative risk, 1.67; 1.23-2.26 and hypopnea relative risk, 1.23; 1.05-1.45 and tachypnea relative risk, 1.26; 1.10-1.44) and lower Glasgow Coma Scale score (relative risk, 5.61 for Glasgow Coma Scale score 3 vs 15; 4.44-7.07). CONCLUSIONS We provide the first description of the incidence of and risk factors for acute respiratory distress syndrome among pediatric trauma patients. Improved understanding of the risk factors associated with acute respiratory distress syndrome following pediatric trauma may help providers anticipate its development and intervene early to improve outcomes for severely injured children.
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Early Right Ventricular Systolic Dysfunction and Pulmonary Hypertension Are Associated With Worse Outcomes in Pediatric Acute Respiratory Distress Syndrome. Crit Care Med 2019; 46:e1055-e1062. [PMID: 30095502 DOI: 10.1097/ccm.0000000000003358] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The prevalence and importance of early right ventricular dysfunction and pulmonary hypertension in pediatric acute respiratory distress syndrome are unknown. We aimed to describe the prevalence of right ventricular dysfunction and pulmonary hypertension within 24 hours of pediatric acute respiratory distress syndrome diagnosis and their associations with outcomes. DESIGN Retrospective, single-center cohort study. SETTING Tertiary care, university-affiliated PICU. PATIENTS Children who had echocardiograms performed within 24 hours of pediatric acute respiratory distress syndrome diagnosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between July 1, 2012, and June 30, 2016, 103 children met inclusion criteria. Echocardiograms were analyzed using established indices of right ventricular and left ventricular systolic function and for evidence of pulmonary hypertension. Echocardiographic abnormalities were common: 26% had low right ventricular fractional area change, 65% had low tricuspid annular plane systolic excursion, 30% had low left ventricular fractional shortening, and 21% had evidence of pulmonary hypertension. Abnormal right ventricular global longitudinal strain and abnormal right ventricular free wall strain were present in 35% and 40% of patients, respectively. No echocardiographic variables differed between or across pediatric acute respiratory distress syndrome severity. In multivariable analyses, right ventricular global longitudinal strain was independently associated with PICU mortality (odds ratio, 3.57 [1.33-9.60]; p = 0.01), whereas right ventricular global longitudinal strain, right ventricular free wall strain, and the presence of pulmonary hypertension were independently associated with lower probability of extubation (subdistribution hazard ratio, 0.46 [0.26-0.83], p = 0.01; subdistribution hazard ratio, 0.58 [0.35-0.98], p = 0.04; and subdistribution hazard ratio, 0.49 [0.26-0.92], p = 0.03, respectively). CONCLUSIONS Early ventricular dysfunction and pulmonary hypertension were detectable, prevalent, and independent of lung injury severity in children with pediatric acute respiratory distress syndrome. Right ventricular dysfunction was associated with PICU mortality, whereas right ventricular dysfunction and pulmonary hypertension were associated with lower probability of extubation.
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Abstract
OBJECTIVES Investigations of acute respiratory distress syndrome in adults suggest hypoxemia is an uncommon cause of death. However, the epidemiology of death in pediatric acute respiratory distress syndrome is not well characterized. We aimed to describe the cause, mode, and timing of death in pediatric acute respiratory distress syndrome nonsurvivors. We hypothesized that most deaths would be due to nonpulmonary factors, rather than hypoxemia. DESIGN Retrospective, decedent-only analysis. SETTING Two large, academic PICUs. PATIENTS Nonsurvivors with pediatric acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 798 subjects with pediatric acute respiratory distress syndrome, there were 153 nonsurvivors (19% mortality). Median time to death was 6 days (interquartile range, 3-13 d) after pediatric acute respiratory distress syndrome onset. Patients dying less than 7 days after pediatric acute respiratory distress syndrome onset had greater illness severity and worse oxygenation. Patients dying less than 7 days were more likely to die of a neurologic cause, including brain death. Patients dying greater than or equal to 7 days after pediatric acute respiratory distress syndrome onset were more commonly immunocompromised. Multisystem organ failure predominated in deaths greater than or equal to 7 days. Withdrawal of therapy was the most common mode of death at all timepoints, accounting for 66% of all deaths. Organ dysfunction was common at time of death, irrespective of cause of death. Refractory hypoxemia accounted for only a minority of pediatric acute respiratory distress syndrome deaths (20%). CONCLUSIONS In pediatric acute respiratory distress syndrome, early deaths were due primarily to neurologic failure, whereas later deaths were more commonly due to multisystem organ failure. Deaths from neurologic causes accounted for a substantial portion of nonsurvivors. Refractory hypoxemia accounted for only a minority of deaths. Our study highlights limitations associated with using death as an endpoint in therapeutic pediatric acute respiratory distress syndrome trials.
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Moffet JR, Mahadeo KM, McArthur J, Hsing DD, Gertz SJ, Smith LS, Loomis A, Fitzgerald JC, Nitu ME, Duncan CN, Hall MW, Pinos EL, Tamburro RF, Simmons RA, Troy J, Cheifetz IM, Rowan CM. Acute respiratory failure and the kinetics of neutrophil recovery in pediatric hematopoietic cell transplantation: a multicenter study. Bone Marrow Transplant 2019; 55:341-348. [PMID: 31527817 PMCID: PMC7091821 DOI: 10.1038/s41409-019-0649-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 07/09/2019] [Accepted: 08/10/2019] [Indexed: 11/23/2022]
Abstract
In this multicenter study, we investigated the kinetics of neutrophil recovery in relation to acuity and survival among 125 children undergoing allogeneic hematopoietic cell transplantation (allo-HCT) who required invasive mechanical ventilation (IMV). Recovery of neutrophils, whether prior to or after initiation of IMV, was associated with a significantly decreased risk of death relative to never achieving neutrophil recovery. A transient increase in acuity (by oxygenation index and vasopressor requirements) occurred among a subset of the patients who achieved neutrophil recovery after initiation of IMV; 61.5% of these patients survived to discharge from the intensive care unit (ICU). Improved survival among patients who subsequently achieved neutrophil recovery on IMV was not limited to those with peri-engraftment respiratory distress syndrome. The presence of a respiratory pathogen did not affect the risk of death while on IMV but was associated with an increased length of IMV (p < 0.01). Among patients undergoing HCT who develop respiratory failure and require advanced therapeutic support, neutrophil recovery at time of IMV and/or presence of a respiratory pathogen should not be used as determining factors when counseling families about survival.
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Affiliation(s)
- J R Moffet
- Department of Pediatrics, Division of Blood and Marrow Transplant, Duke Children's Hospital, Duke University, Durham, NC, USA.
| | - K M Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - J McArthur
- Department of Pediatrics, Division of Critical Care, St. Jude's Children's Research Hospital, Memphis, TN, USA
| | - D D Hsing
- Department of Pediatrics, Division of Critical Care, Weil Cornell Medical College, New York Presbyterian Hospital, New York City, NY, USA
| | - S J Gertz
- Department of Pediatrics, St. Barnabas Medical Center, Livingston, NJ, USA
| | - L S Smith
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - A Loomis
- Department of Pediatrics, Division of Critical Care, Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - J C Fitzgerald
- Department of Anesthesiology and Critical Care, Division of Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - M E Nitu
- Department of Pediatrics, Division of Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C N Duncan
- Department of Pediatrics, Pediatric Oncology, Dana-Farber Cancer Institute Harvard University, Boston, MA, USA
| | - M W Hall
- Department of Pediatrics, Division of Critical Care, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - E L Pinos
- Department of Pediatrics, Division of Critical Care, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - R F Tamburro
- Department of Pediatrics, Division of Critical Care, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - R A Simmons
- Duke CTSI Biostatistics, Epidemiology and Research Design (BERD) Methods Core, Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | - J Troy
- Department of Pediatrics, Division of Blood and Marrow Transplant, Duke Children's Hospital, Duke University, Durham, NC, USA
| | - I M Cheifetz
- Department of Pediatrics, Division of Critical Care, Duke Children's Hospital, Duke University, Durham, NC, USA
| | - C M Rowan
- Department of Pediatrics, Division of Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
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Hanudel MR, Zinter MS, Chen L, Gala K, Lim M, Guglielmo M, Deshmukh T, Vangala S, Matthay M, Sapru A. Plasma total fibroblast growth factor 23 levels are associated with acute kidney injury and mortality in children with acute respiratory distress syndrome. PLoS One 2019; 14:e0222065. [PMID: 31487315 PMCID: PMC6728039 DOI: 10.1371/journal.pone.0222065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 08/21/2019] [Indexed: 11/24/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) has high rates of mortality and multisystem morbidity. Pre-clinical data suggest that fibroblast growth factor 23 (FGF23) may contribute to pulmonary pathology, and FGF23 is associated with mortality and morbidity, including acute kidney injury (AKI), in non-ARDS cohorts. Here, we assess whether FGF23 is associated with AKI and/or mortality in a cohort of 161 pediatric ARDS patients. Plasma total (intact + C-terminal) FGF23 and intact FGF23 concentrations were measured within 24 hours of ARDS diagnosis (Day 1), and associations with Day 3 AKI and 60-day mortality were evaluated. 35 patients (22%) developed AKI by 3 days post-ARDS diagnosis, and 25 (16%) died by 60 days post-ARDS diagnosis. In unadjusted models, higher Day 1 total FGF23 was associated with Day 3 AKI (odds ratio (OR) 2.22 [95% confidence interval (CI) 1.62, 3.03], p<0.001), but Day 1 intact FGF23 was not. In a model adjusted for demographics and disease severity, total FGF23 remained associated with AKI (OR 1.52 [95% CI 1.02, 2.26], p = 0.039). In unadjusted models, both higher Day 1 total and intact FGF23 were associated with 60-day mortality (OR 1.43 [95% CI 1.07, 1.91], p = 0.014; and OR 1.44 [95% CI 1.02, 2.05], p = 0.039, respectively). In the adjusted model, only total FGF23 remained associated with 60-day mortality (OR 1.62 [95% CI 1.07, 2.45], p = 0.023). In a subgroup analysis of patients with Day 1 plasma IL-6 concentrations available, inflammation partially mediated the association between total FGF23 and AKI. Our data suggest both inflammation-dependent and inflammation-independent associations between total FGF23 and clinical outcomes in pediatric ARDS patients.
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Affiliation(s)
- Mark R. Hanudel
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- * E-mail:
| | - Matthew S. Zinter
- Department of Pediatrics, UCSF School of Medicine, San Francisco, CA, United States of America
| | - Lucia Chen
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Kinisha Gala
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Michelle Lim
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Mona Guglielmo
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Tanaya Deshmukh
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Sitaram Vangala
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Michael Matthay
- Department of Medicine, UCSF School of Medicine, San Francisco, CA, United States of America
| | - Anil Sapru
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
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Abstract
Acute and chronic respiratory failure are a significant source of pediatric morbidity and mortality. Current respiratory support options used to bridge children to lung recovery or transplantation typically render them bedridden and can worsen long-term patient outcomes. The Pittsburgh Pediatric Ambulatory Lung (P-PAL) is a wearable pediatric blood pump and oxygenator (0.3 m surface area) integrated into a single compact unit that enables patient ambulation. The P-PAL is intended for long-term use and designed to provide up to 90% of respiratory support in children weighing 5-25 kg. Computational fluid dynamics and numerical gas exchange modeling were used to design the P-PAL and predict its performance. A P-PAL prototype was then used to obtain pressure versus flow curves at various impeller rotation rates using a blood analog fluid. In vitro oxygen exchange rates were obtained in blood in accordance with ISO standard 7199. The normalized index of hemolysis (NIH) was measured over a 6 hour period at blood flow rates of 1 and 2.5 L/min. The P-PAL provided blood flows of 1-2.5 L/min against the pressure drop associated with its intended-use pediatric cannulas. The oxygen exchange rate reached a maximum of 108 ml/min at a blood flow rate of 2.5 L/min and met our respiratory support design target. Device-induced hemolysis was low with NIH values of 0.022-0.027 g/100 L in the intended blood flow rate range. In conclusion, the current P-PAL design met our pumping, oxygenation, and hemolysis specifications and has the potential to improve treatment for pediatric respiratory failure.
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Risk Stratification Using Oxygenation in the First 24 Hours of Pediatric Acute Respiratory Distress Syndrome. Crit Care Med 2019; 46:619-624. [PMID: 29293150 DOI: 10.1097/ccm.0000000000002958] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Oxygenation measured 24 hours after acute respiratory distress syndrome onset more accurately stratifies risk, relative to oxygenation at onset, in both children and adults. However, waiting 24 hours is problematic, especially for interventions that are more efficacious early in the disease course. We aimed to delineate whether oxygenation measured at timepoints earlier than 24 hours would retain predictive validity in pediatric acute respiratory distress syndrome. DESIGN Observational cohort study. SETTING Two large, academic PICUs. PATIENTS Invasively ventilated children with acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PaO2/FIO2 and oxygenation index (mean airway pressure × FIO2 × 100)/PaO2) were measured at acute respiratory distress syndrome onset, at 6, 12, 18, and 24 hours after in 459 children at the Children's Hospital of Philadelphia. Neither PaO2/FIO2 nor oxygenation index at acute respiratory distress syndrome onset discriminated outcome. Between 6 and 24 hours, both PaO2/FIO2 (area under receiver operating curve for mortality between 0.57 and 0.62; p = 0.049-0.002) and oxygenation index (area under receiver operating curve, 0.60-0.62; p = 0.006-0.001) showed good discrimination and calibration across multiple outcomes, including mortality, ventilator-free days at 28 days, ventilator days in survivors, and probability of extubation, given competing risk of death. The utility of oxygenation at 12 hours was confirmed in an independent cohort from the Children's Hospital of Los Angeles. CONCLUSION Oxygenation measured between 6 and 12 hours of acute respiratory distress syndrome onset accurately stratified outcomes in children. Our results have critical implications for the design of trials, especially for interventions with greater impact in early acute respiratory distress syndrome.
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Khemani RG, Parvathaneni K, Yehya N, Bhalla AK, Thomas NJ, Newth CJL. Positive End-Expiratory Pressure Lower Than the ARDS Network Protocol Is Associated with Higher Pediatric Acute Respiratory Distress Syndrome Mortality. Am J Respir Crit Care Med 2019; 198:77-89. [PMID: 29373802 DOI: 10.1164/rccm.201707-1404oc] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE The ARDS Network (ARDSNet) used a positive end-expiratory pressure (PEEP)/FiO2 model in many studies. In general, pediatric intensivists use less PEEP and higher FiO2 than this model. OBJECTIVES To evaluate whether children managed with PEEP lower than recommended by the ARDSNet PEEP/FiO2 model had higher mortality. METHODS This was a multicenter, retrospective analysis of patients with pediatric acute respiratory distress syndrome (PARDS) managed without a formal PEEP/FiO2 protocol. Four distinct datasets were combined for analysis. We extracted time-matched PEEP/FiO2 values, calculating the difference between PEEP level and the ARDSNet-recommended PEEP level for a given FiO2. We analyzed the median difference over the first 24 hours of PARDS diagnosis against ICU mortality and adjusted for confounding variables, effect modifiers, or factors that may have affected the propensity to use lower PEEP. MEASUREMENTS AND MAIN RESULTS Of the 1,134 patients with PARDS, 26.6% were managed with lower PEEP relative to the amount of FiO2 recommended by the ARDSNet protocol. Patients managed with lower PEEP experienced higher mortality than those who were managed with PEEP levels in line with or higher than recommended by the protocol (P < 0.001). After adjustment for hypoxemia, inotropes, comorbidities, severity of illness, ventilator settings, nitric oxide, and dataset, PEEP lower than recommended by the protocol remained independently associated with higher mortality (odds ratio, 2.05; 95% confidence interval, 1.32-3.17). Findings were similar after propensity-based covariate adjustment (odds ratio, 2.00; 95% confidence interval, 1.24-3.22). CONCLUSIONS Patients with PARDS managed with lower PEEP relative to FiO2 than recommended by the ARDSNet model had higher mortality. Clinical trials targeting PEEP management in PARDS are needed.
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Affiliation(s)
- Robinder G Khemani
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,2 Department of Pediatrics, Keck School of Medicine, and
| | - Kaushik Parvathaneni
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,3 Department of Biological Sciences, Dana and David Dornsife College of Letters Arts and Sciences, University of Southern California, Los Angeles, California
| | - Nadir Yehya
- 4 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Anoopindar K Bhalla
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,2 Department of Pediatrics, Keck School of Medicine, and
| | - Neal J Thomas
- 5 Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Christopher J L Newth
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,2 Department of Pediatrics, Keck School of Medicine, and
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Orloff KE, Turner DA, Rehder KJ. The Current State of Pediatric Acute Respiratory Distress Syndrome. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2019; 32:35-44. [PMID: 31236307 PMCID: PMC6589490 DOI: 10.1089/ped.2019.0999] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/24/2019] [Indexed: 12/16/2022]
Abstract
Pediatric acute respiratory distress syndrome (PARDS) is a significant cause of morbidity and mortality in children. Children with PARDS often require intensive care admission and mechanical ventilation. Unfortunately, beyond lung protective ventilation, there are limited data to support our management strategies in PARDS. The Pediatric Acute Lung Injury Consensus Conference (PALICC) offered a new definition of PARDS in 2015 that has improved our understanding of the true epidemiology and heterogeneity of the disease as well as risk stratification. Further studies will be crucial to determine optimal management for varying disease severity. This review will present the physiologic basis of PARDS, describe the unique pediatric definition and risk stratification, and summarize the current evidence for current standards of care as well as adjunctive therapies.
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Affiliation(s)
- Kirsten E Orloff
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - David A Turner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
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Association Between Tidal Volumes Adjusted for Ideal Body Weight and Outcomes in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2019; 20:e145-e153. [PMID: 30640889 PMCID: PMC6399049 DOI: 10.1097/pcc.0000000000001846] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The impact of tidal volume on outcomes in mechanically ventilated children with pediatric acute respiratory distress syndrome remains unclear. To date, observational investigations have failed to calculate tidal volume based on standardized corrections of weight. We investigated the impact of tidal volume on mortality and probability of extubation in pediatric acute respiratory distress syndrome using ideal body weight-adjusted tidal volume. DESIGN Retrospective analysis of an ongoing prospective cohort of pediatric acute respiratory distress syndrome patients. Tidal volume was calculated based on actual body weight and two different formulations of ideal body weight. SETTING PICU at a large, tertiary care children's hospital. PATIENTS Pediatric acute respiratory distress syndrome patients on conventional ventilation with a documented height or length. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 483 patients with a measured height or length at pediatric acute respiratory distress syndrome onset included in the final analysis, with 73 nonsurvivors (15%). At 24 hours, there remained 400 patients on conventional ventilation. When calculating tidal volume based on ideal body weight by either method, volumes were larger both at onset and at 24 hours compared with tidal volume based on actual body weight (all p < 0.001), and the proportion of patients being ventilated with tidal volumes greater than 10 mL/kg based on ideal body weight was larger both at onset (12.4% and 15.5%) and 24 hours (10.3% and 11.5%) compared with actual body weight at onset (3.5%) and 24 hours (4.0%) (all p < 0.001). Tidal volume, based on both actual body weight and ideal body weight, was not associated with either increased mortality or decreased probability of extubation after adjusting for oxygenation index in the whole cohort, whereas associations between higher tidal volume and poor outcomes were seen in subgroup analyses in overweight children and in severe pediatric acute respiratory distress syndrome. CONCLUSIONS Our retrospective analysis of a cohort of pediatric acute respiratory distress syndrome patients did not find a consistent association between tidal volume adjusted for ideal body weight and outcomes, although an association may exist in certain subgroups. Although it remains to be shown in a prospective trial whether high volumes or pressures are injurious in pediatric acute respiratory distress syndrome, tidal volume is likely an imprecise parameter for titrating lung-protective ventilation.
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Zhang Z. Prediction model for patients with acute respiratory distress syndrome: use of a genetic algorithm to develop a neural network model. PeerJ 2019; 7:e7719. [PMID: 31576250 PMCID: PMC6752189 DOI: 10.7717/peerj.7719] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/21/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is associated with significantly increased risk of death, and early risk stratification may help to choose the appropriate treatment. The study aimed to develop a neural network model by using a genetic algorithm (GA) for the prediction of mortality in patients with ARDS. METHODS This was a secondary analysis of two multicenter randomized controlled trials conducted in forty-four hospitals that are members of the National Heart, Lung, and Blood Institute, founded to create an acute respiratory distress syndrome Clinical Trials Network. Model training and validation were performed using the SAILS and OMEGA studies, respectively. A GA was employed to screen variables in order to predict 90-day mortality, and a neural network model was trained for the prediction. This machine learning model was compared to the logistic regression model and APACHE III score in the validation cohort. RESULTS A total number of 1,071 ARDS patients were included for analysis. The GA search identified seven important variables, which were age, AIDS, leukemia, metastatic tumor, hepatic failure, lowest albumin, and FiO2. A representative neural network model was constructed using the forward selection procedure. The area under the curve (AUC) of the neural network model evaluated with the validation cohort was 0.821 (95% CI [0.753-0.888]), which was greater than the APACHE III score (0.665; 95% CI [0.590-0.739]; p = 0.002 by Delong's test) and logistic regression model, albeit not statistically significant (0.743; 95% CI [0.669-0.817], p = 0.130 by Delong's test). CONCLUSIONS The study developed a neural network model using a GA, which outperformed conventional scoring systems for the prediction of mortality in ARDS patients.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Gan T, Yang Y, Hu F, Chen X, Zhou J, Li Y, Xu Y, Wang H, Chen Y, Zhang M. TLR3 Regulated Poly I:C-Induced Neutrophil Extracellular Traps and Acute Lung Injury Partly Through p38 MAP Kinase. Front Microbiol 2018; 9:3174. [PMID: 30622526 PMCID: PMC6308186 DOI: 10.3389/fmicb.2018.03174] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 12/07/2018] [Indexed: 12/12/2022] Open
Abstract
Acute lung injury (ALI) is the leading cause of morbidity and mortality in critically ill patients. Neutrophil extracellular traps (NETs) have been well documented in the ALI model of bacterial infection. In the present study, we demonstrated that poly I:C could induce pulmonary NETs. Upon poly I:C intratracheal inoculation, neutrophil infiltration in the bronchoalveolar lavage fluid (BALF) was significantly increased. Furthermore, the inflammatory cytokines IL-1β, IL-6, and TNF-α in the lung were also significantly elevated. Neutrophil depletion abolished NETs and decreased both neutrophil infiltration and IL-1β in the lung. As expected, DNase I, an inhibitor of MPO and NADPH, decreased pulmonary inflammation and NETs. Blocking of the poly I:C receptor TLR3 reduced lung inflammation and NETs. The MAPK kinase inhibitor p38 diminished the formation of NETs and restored the expression of the tight junction protein claudin-5 in the mouse lung when challenged with poly I:C. In summary, poly I:C induced the formation of pulmonary NETs and ALI, which may be associated with the activation of p38 MAPK and the decreased expression of claudin-5.
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Affiliation(s)
- Tingting Gan
- Department of Anesthesiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yonglin Yang
- Department of Infectious Diseases, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.,NHC Key Laboratory of Antibody Technique, Nanjing Medical University, Nanjing, China
| | - Fan Hu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, China
| | - Xichen Chen
- Analysis Center, Nanjing Medical University, Nanjing, China
| | - Jiawei Zhou
- Department of Anesthesiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Li
- Department of Anesthesiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Xu
- Nanjing University Medical School, The Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Huijuan Wang
- Department of Immunology, Nanjing Medical University, Nanjing, China
| | - Yu Chen
- Department of Anesthesiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingshun Zhang
- NHC Key Laboratory of Antibody Technique, Nanjing Medical University, Nanjing, China.,Department of Immunology, Nanjing Medical University, Nanjing, China
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44
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Yehya N, Thomas NJ. Sepsis and Pediatric Acute Respiratory Distress Syndrome. J Pediatr Intensive Care 2018; 8:32-41. [PMID: 31073506 DOI: 10.1055/s-0038-1676133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/17/2018] [Indexed: 12/13/2022] Open
Abstract
The epidemiology of the acute respiratory distress syndrome (ARDS) in pediatric sepsis is poorly defined. With significant data extrapolated from adult studies in sepsis and ARDS, sometimes with uncertain applicability, better pediatric-specific guidelines and dedicated investigations are warranted. The recent publication of a consensus definition for pediatric ARDS (PARDS) is the first step in addressing this knowledge gap. The aim of this review is to frame our current understanding of PARDS as it relates to pediatric sepsis, encompassing epidemiology, pathophysiology, and management. We argue that addressing the role of PARDS in pediatric sepsis requires significant attention to details with respect to how PARDS and sepsis are defined to accurately describe their epidemiology, natural history, and outcomes. Finally, we highlight certain aspects of PARDS management as they relate to the septic child and offer suggestion for future directions in this field.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, United States
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45
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Patry C, Kranig S, Rafat N, Schaible T, Toenshoff B, Hoffmann GF, Ries M. Cross-sectional analysis on publication status and age representation of clinical studies addressing mechanical ventilation and ventilator-induced lung injury in infants and children. BMJ Open 2018; 8:e023524. [PMID: 30455388 PMCID: PMC6252714 DOI: 10.1136/bmjopen-2018-023524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES We determined the number and time-to-public availability of study results of published and unpublished clinical studies in paediatric mechanical ventilation (MV) and ventilator-induced lung injury (VILI), which were registered as completed on ClinicalTrials.gov. Furthermore, we explored the pattern of represented research study subtopics and the corresponding study populations. SETTING Literature search based on ClinicalTrials.gov, PubMed and Google Scholar from 9 July 2017 to 27 September 2017. PRIMARY AND SECONDARY OUTCOME MEASURES Assessment, if studies included in our analysis had been published. Assessment of primary research focus, patient enrolment and age representation of the analysed studies. RESULTS We identified n=109 registered and completed clinical studies on paediatric MV and VILI (enrolment: 22 233 participants). 71% were published, including data from 18 647 subjects. 29% of studies were unpublished, containing data from 3586 subjects. Median time-to-public availability of study results was 22 (IQR, 12.8-41.5) months. The most important study subtopics were biophysical and technical aspects of MV (32 studies), administration of drugs to mitigate VILI through various mechanisms (40 studies) and diagnostic procedures (16 studies). n=66/109 (61%) studies exclusively focused on children below 1 year of age and n=2/109 (2%) exclusively on children between 1 and 14 years. CONCLUSIONS One-third of clinical studies in paediatric MV and VILI registered as completed on ClinicalTrials.gov remained unpublished and contained data on 3586 study participants. The overall median time-to-public availability of study results was longer than the deadline of 12 months mandated by the Food and Drug Administration Amendment Act of 2007. Important and clinically relevant research study subtopics were represented in the research questions investigated in paediatric MV and VILI. The study population was skewed towards children younger than 1 year which indicates, that there is a substantial need for clinical VILI research in older children.
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Affiliation(s)
- Christian Patry
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
- Institute for Physiology and Pathophysiology, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Simon Kranig
- Department of Neonatology, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Neysan Rafat
- Clinic for Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Thomas Schaible
- Clinic for Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Burkhard Toenshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Markus Ries
- Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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46
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Keim G, Watson RS, Thomas NJ, Yehya N. New Morbidity and Discharge Disposition of Pediatric Acute Respiratory Distress Syndrome Survivors. Crit Care Med 2018; 46:1731-1738. [PMID: 30024428 PMCID: PMC6185805 DOI: 10.1097/ccm.0000000000003341] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Much of the research related to pediatric acute respiratory distress syndrome has focused on inhospital mortality and interventions affecting this outcome. Limited data exist on survivors' morbidity, hospital disposition, and 1-year survival. The aim of this study was to determine new morbidity rate, discharge disposition, and 1-year mortality for survivors of pediatric acute respiratory distress syndrome. DESIGN Secondary analysis of prospective cohort study. SETTING Quaternary children's hospital. PATIENTS Three-hundred sixteen mechanically ventilated children with pediatric acute respiratory distress syndrome (Berlin and Pediatric Acute Lung Injury Consensus Conference criteria) between July 2011 and December 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed secondary analysis of a prospectively recruited cohort of 316 mechanically ventilated children with pediatric acute respiratory distress syndrome between July 2011, and December 2014. Preillness and hospital discharge Functional Status Scale score were determined via chart review, and factors associated with new morbidity, defined as an increase of Functional Status Scale score of 3 or more, were analyzed. Demographic variables, pediatric acute respiratory distress syndrome characteristics, and ventilator management were tested for association with development of new morbidity, discharge disposition, and 1-year mortality. Inhospital mortality of pediatric acute respiratory distress syndrome was 13.3% (42/316). Of 274 survivors to hospital discharge, new morbidity was seen in 63 patients (23%). Discharge to rehabilitation rate was 24.5% (67/274) and associated with development of new morbidity. One- and 3-year mortality of survivors was 5.5% (15 deaths) and 8% (22 deaths) and was associated with baseline Functional Status Scale, immunocompromised status, Pediatric Risk of Mortality III, and organ failures at pediatric acute respiratory distress syndrome onset, but not with pediatric acute respiratory distress syndrome severity. CONCLUSIONS New morbidity was common after pediatric acute respiratory distress syndrome and appears to be intermediate phenotype between survival without morbidity and death, making it a useful metric in future interventional and outcome studies in pediatric acute respiratory distress syndrome.
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Affiliation(s)
- Garrett Keim
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Neal J. Thomas
- Pennsylvania State University College of Medicine, Hershey, PA
| | - Nadir Yehya
- Children’s Hospital of Philadelphia, Philadelphia, PA
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47
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Muttath A, Annayappa Venkatesh L, Jose J, Vasudevan A, Ghosh S. Adverse Outcomes due to Aggressive Fluid Resuscitation in Children: A Prospective Observational Study. J Pediatr Intensive Care 2018; 8:64-70. [PMID: 31093457 DOI: 10.1055/s-0038-1667009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/03/2018] [Indexed: 12/28/2022] Open
Abstract
Fluid management has a major impact on the duration, severity, and outcome of critically ill children. The aim of this study was to examine the relationship between cumulative fluid overload (CFO) with mortality and morbidity in critically ill children. This was a prospective observational study wherein children (1 month-16 years) who were critically ill (with shock requiring inotropes and/or mechanically ventilated) were enrolled. CFO was defined as the sum of daily fluid balances. Daily fluid balance was calculated as a difference between fluid intake (oral and intravenous) and output (urine output, discharge from nasogastric tube) in 24 hours. Percentage of fluid overload (FO) (PFO) was calculated as the ratio of CFO with weight at admission in kilogram. The CFO and PFO at 24, 48, 72 hours and at 7 days or end of PICU stay were calculated. A total of 291 children (244 survivors and 47 non-survivors; 47% males) were included in the final analysis. A higher mortality was observed in children with higher PFO (>20% FO: 45.8% mortality vs. 14.5% < 10% FO, p < 0.01) and CFO (10.97 ± 6.4 mL/kg in survivors vs. 13.95 ± 9.6 mL/kg in non-survivors; p = 0.022) at 72 hours. A 1% increase in fluid overload was associated with 6% and 4% increase in mortality at 72 hours and 7 days, respectively. Similarly, the impact of every 1% increase in fluid overload on both ventilation (yes/no) and acute kidney injury (AKI; yes/no) were found to be significant for both parameters at 72 hours, but only AKI had significant correlation on seventh day. In the multivariate stepwise Cox's proportional hazard model for PICU stay and hospital stay, 3% ( p < 0.05) and 2% ( p > 0.05) increase were found for every 1% increase in fluid overload, respectively. Oxygenation index is also associated with fluid overload with the adjusted model estimated 0.27 units (95% confidence interval: 0.18-0.36) increase per 1% increase in fluid overload. FO was associated with increased mortality and morbidity in critically ill children.
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Affiliation(s)
- Anand Muttath
- Department of Paediatrics, St John's Medical College and Hospital, Bangalore, Karnataka, India
| | | | - Joe Jose
- Department of Paediatrics, St John's Medical College and Hospital, Bangalore, Karnataka, India
| | - Anil Vasudevan
- Department of Paediatric Nephrology, St John's Medical College and Hospital, Bangalore, Karnataka, India
| | - Santu Ghosh
- Department of Biostatistics, St John's Medical College, Bangalore, Karnataka, India
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48
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Yehya N, Keim G, Thomas NJ. Subtypes of pediatric acute respiratory distress syndrome have different predictors of mortality. Intensive Care Med 2018; 44:1230-1239. [PMID: 29971591 DOI: 10.1007/s00134-018-5286-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/20/2018] [Indexed: 01/06/2023]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is heterogeneous in etiology, which may affect outcomes. Stratification into biologically-defined subtypes may reduce heterogeneity. However, it is unknown whether pediatric ARDS has clinically relevant subtypes. We aimed to determine whether clinical characteristics and predictors of mortality differed between direct and indirect ARDS, and separately between infectious and non-infectious ARDS. METHODS This was a single center, prospective cohort study of 544 children with ARDS (Berlin) between July 2011 and June 2017, stratified into direct versus indirect ARDS, and separately into infectious versus non-infectious ARDS. Multiple logistic regression was used to test for predictors of mortality in the entire cohort, and separately within subtypes. Effect modification by subtype was assessed using interaction tests. RESULTS Direct ARDS had lower severity of illness (p < 0.001) but worse oxygenation (p < 0.001), relative to indirect. Predictors of mortality were similar for direct and indirect ARDS. When comparing infectious and non-infectious ARDS, infectious ARDS had lower severity of illness (p < 0.001), worse oxygenation (p = 0.014), and lower mortality (p = 0.013). In multivariable analysis, immunocompromised status demonstrated effect modification between infectious and non-infectious ARDS (p = 0.005 for interaction), with no association with mortality in non-infectious ARDS. CONCLUSIONS In children, direct and indirect ARDS have distinct clinical characteristics, but similar outcomes and similar predictors of mortality. In contrast, infectious and non-infectious ARDS demonstrate heterogeneity of clinical characteristics, mortality, and predictors of mortality, with traditional predictors of ARDS mortality only applicable to infectious ARDS.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, 6040A Wood Building, 34th Street and 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Garrett Keim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, 6040A Wood Building, 34th Street and 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
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Abstract
This article reviews the definition, pathophysiology, etiology, assessment, and management of acute respiratory failure in children. Acute respiratory failure is the inability of the respiratory system to maintain oxygenation or eliminate carbon dioxide. Acute respiratory failure is a common cause for admission to a pediatric intensive care unit. Most causes of acute respiratory failure can be grouped into one of three categories: lung parenchymal disease, airway obstruction, or neuromuscular dysfunction. Many patients with acute respiratory failure are managed successfully with noninvasive respiratory support; however, in severe cases, patients may require intubation and mechanical ventilation. [Pediatr Ann. 2018;47(7):e268-e273.].
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50
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Amigoni A, Pettenazzo A, Stritoni V, Circelli M. Surfactants in Acute Respiratory Distress Syndrome in Infants and Children: Past, Present and Future. Clin Drug Investig 2018; 37:729-736. [PMID: 28510235 PMCID: PMC5509808 DOI: 10.1007/s40261-017-0532-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There is a lack of definitive data on the effective management of acute respiratory distress syndrome (ARDS) in infants and children. The development and validation of the Berlin definition (BD) for ARDS and the Pediatric Acute Lung Injury Consensus Conference (PALICC) recommendations in children represented a major advance in optimizing research and treatment, mainly due to the introduction of a severe ARDS category. Proposed reasons for the lack of consistent results with surfactants in children and infants compared with neonates include different causes, type of lung damage (direct or indirect), timing and mode of administration as well as the type of surfactant used. Secretory phospholipase A2 plays an important role in inflammation and possible dysfunction of surfactants in ARDS. Bronchoalveolar lavage (BAL) with normal saline and surfactant allows the removal of inhaled material, the recruitment of non-ventilating areas and the maintenance of the surfactant pool size. BAL with diluted surfactant allows rapid absorption of the surfactant at the air/liquid interface, which blocks the progression of pathological lung disease and in turn disrupts the inflammatory cycle. Importantly, it is now recognized that the type of surfactant, the time of administration and the method of administration could all play an important role in the management of ARDS, and there is evidence that surfactant is effective and well tolerated in children and infants with ARDS.
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Affiliation(s)
- Angela Amigoni
- Paediatric Intensive Care Unit, Department of Women's and Child's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy.
| | - Andrea Pettenazzo
- Paediatric Intensive Care Unit, Department of Women's and Child's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy
| | - Valentina Stritoni
- Paediatric Intensive Care Unit, Department of Women's and Child's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy
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