The outcomes of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

Pediatric Acute Respiratory Distress Syndrome in South African PICUs: A Multisite Point-Prevalence Study

OBJECTIVES

To describe the prevalence of pediatric acute respiratory distress syndrome (pARDS) and the characteristics of children with pARDS in South African PICUs.

DESIGN

Observational multicenter, cross-sectional point-prevalence study.

SETTING

Eight PICUs in four South African provinces.

PATIENTS

All children beyond the neonatal period and under 18 years of age admitted to participating PICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical and demographic data were prospectively collected on a single day of each month, from February to July 2022, using a centralized database. Cases with or at risk of pARDS were identified using the 2015 Pediatric Acute Lung Injury Consensus Conference criteria. Prevalence was calculated as the number of children meeting pARDS criteria/the total number of children admitted to PICU at the same time points. Three hundred ten patients were present in the PICU on study days: 166 (53.5%) male, median (interquartile range [IQR]) age 9.8 (3.1-32.9) months, and 195 (62.9%) invasively mechanically ventilated. Seventy-one (22.9%) patients were classified as being "at risk" of pARDS and 95 patients (prevalence 30.6%; 95% CI, 24.7-37.5%) fulfilled pARDS case criteria, with severity classified as mild (58.2%), moderate (25.3%), and severe (17.6%). Median (IQR) admission Pediatric Index of Mortality 3 risk of mortality in patients with and without pARDS was 5.6 (3.4-12.1) % versus 3.9 (1.0-8.2) % ( p = 0.002). Diagnostic categories differed between pARDS and non-pARDS groups ( p = 0.002), with no difference in age, sex, or presence of comorbidities. On multivariable logistic regression, increasing admission risk of mortality (adjusted odds ratio [aOR] 1.02; 95% CI, 1.00-1.04; p = 0.04) and being admitted with a respiratory condition (aOR 2.64; 95% CI, 1.27-5.48; p = 0.01) were independently associated with an increased likelihood of having pARDS.

CONCLUSIONS

The 30.6% prevalence of pARDS in South Africa is substantially higher than reports from other sociogeographical regions, highlighting the need for further research in this setting.

Multiple Organ Dysfunction and Critically Ill Children With Acute Myeloid Leukemia: Single-Center Retrospective Cohort Study

OBJECTIVES

To describe the prevalence of multiple organ dysfunction syndrome (MODS) and critical care utilization in children and young adults with acute myeloid leukemia (AML) who have not undergone hematopoietic cell transplantation (HCT).

DESIGN

Retrospective cohort study of MODS (defined as dysfunction of two or more organ systems) occurring any day within the first 72 hours of PICU admission.

SETTING

Large, quaternary-care children's hospital.

PATIENTS

Patients 1 month through 26 years old who were treated for AML from 2011-2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eighty patients with AML were included. These 80 patients had a total of 409 total non-HCT-related hospital and 71 PICU admissions. The majority 53 of 71 of PICU admissions (75%) were associated with MODS within the first 72 hours. MODS was present in 49 of 71 of PICU admissions (69%) on day 1, 29 of 52 (56%) on day 2, and 25 of 32 (78%) on day 3. The organ systems most often involved were hematologic, respiratory, and cardiovascular. There was an increasing proportion of renal failure (8/71 [11%] on day 1 to 8/32 [25%] on day 3; p = 0.02) and respiratory failure (33/71 [47%] to 24/32 [75%]; p = 0.001) as PICU stay progressed. The presence of MODS on day 1 was associated with a longer PICU length of stay (LOS) (β = 5.4 [95% CI, 0.7-10.2]; p = 0.024) and over a six-fold increased risk of an LOS over 2 days (odds ratio, 6.08 [95% CI, 1.59-23.23]; p = 0.008). Respiratory failure on admission was associated with higher risk of increased LOS.

CONCLUSIONS

AML patients frequently require intensive care. In this cohort, MODS occurred in over half of PICU admissions and was associated with longer PICU LOS. Respiratory failure was associated with the development of MODS and progressive MODS, as well as prolonged LOS.

Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome

Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and comorbidities. No specific treatment is available for PARDS and management is largely supportive, but methods to identify patients who would benefit from specific ventilation strategies or ancillary treatments, such as prone positioning, are needed. Understanding of the clinical and biological heterogeneity of PARDS, and of differences in clinical features and clinical course, pathobiology, response to treatment, and outcomes between PARDS and adult ARDS, will be key to the development of novel preventive and therapeutic strategies and a precision medicine approach to care. Studies in which clinical, biomarker, and transcriptomic data, as well as informatics, are used to unpack the biological and phenotypic heterogeneity of PARDS, and implementation of methods to better identify patients with PARDS, including methods to rapidly identify subphenotypes and endotypes at the point of care, will drive progress on the path to precision medicine.

Outcomes of Children Surviving Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To summarize the evidence for the Second Pediatric Acute Lung Injury Consensus Conference-2 (PALICC-2) recommendations for assessment of outcomes among patients surviving pediatric acute respiratory distress syndrome (PARDS).

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

We conducted a scoping review to identify studies evaluating outcomes following PARDS. We included studies of survivors of PARDS, acute respiratory failure with a high proportion of PARDS patients, or other critical illnesses if PARDS-specific outcomes could be extracted.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. Of 8,037 abstracts screened, we identified 20 articles for inclusion. Morbidity following PARDS was common and affected multiple domains of pulmonary and nonpulmonary function. There was insufficient evidence to generate any evidence-based recommendations. We generated eight good practice statements and five research statements. A panel of 52 experts discussed each proposed good practice statement and research statement, and the agreement rate was measured with an online voting process. Good practice statements describe the approach to clinical outcome assessment, assessment of pulmonary outcomes of children surviving PARDS, and assessment of nonpulmonary outcomes of children surviving PARDS including health-related quality of life and physical, neurocognitive, emotional, family, and social functioning. The five research statements relate to assessment of patient preillness status, use of postdischarge endpoints for clinical trials, the association between short-term and longer term outcomes, the trajectory of recovery following PARDS, and practices to optimize follow-up.

CONCLUSIONS

There is increasing evidence that children are at risk for impairments across a range of pulmonary and nonpulmonary health domains following hospitalization for PARDS. The results of this extensive scoping review and consensus conference involving experts in PARDS research, clinical care, and outcomes assessment provide guidance to clinicians and researchers on postdischarge follow-up to optimize the long-term health of patients surviving PARDS.

Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)

OBJECTIVES

We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed.

DESIGN

International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science.

SETTING

Not applicable.

PATIENTS

Patients with or at risk for PARDS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%.

CONCLUSIONS

PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.

Core Outcome Sets in Child Health: A Systematic Review

IMPORTANCE

Developing core outcome sets is essential to ensure that results of clinical trials are comparable and useful. A number of core outcome sets in pediatrics have been published, but a comprehensive in-depth understanding of core outcome sets in this field is lacking.

OBJECTIVE

To systematically identify core outcome sets in child health, collate the diseases to which core outcome sets have been applied, describe the methods used for development and stakeholder participation, and evaluate the methodological quality of existing core outcome sets.

EVIDENCE REVIEW

MEDLINE, SCOPUS, Cochrane Library, and CINAHL were searched using relevant search terms, such as clinical trials, core outcome, and children, along with relevant websites, such as Core Outcome Measures in Effectiveness Trials (COMET). Four researchers worked in teams of 2, performed literature screening and data extraction, and evaluated the methodological quality of core outcome sets using the Core Outcome Set-Standards for Development (COS-STAD).

FINDINGS

A total of 77 pediatric core outcome sets were identified, mainly developed by organizations or researchers in Europe, North America, and Australia and mostly from the UK (22 [29%]) and the US (22 [29%]). A total of 77 conditions were addressed; the most frequent International Classification of Diseases, 11th Revision category was diseases of the digestive system (14 [18%]). Most of the outcomes in pediatric core outcome sets were unordered (34 [44%]) or presented in custom classifications (29 [38%]). Core outcome sets used 1 or more of 8 development methods; the most frequent combination of methods was systematic review/literature review/scoping review, together with the Delphi approach and consensus for decision-making (10 [14%]). Among the 6 main types of stakeholders, clinical experts were the most frequently involved (74 [100%]), while industry representatives were rarely involved (4 [5%]). Only 6 core outcome sets (8%) met the 12 criteria of COS-STAD.

CONCLUSIONS AND RELEVANCE

Future quality of pediatric core outcome sets should be improved based on the standards proposed by the COMET initiative, while core outcome sets methodology and reporting standards should be extended to pediatric populations to help improve the quality of core outcome sets in child health. In addition, the COMET outcome taxonomy should also add items applicable to children.

Oxygenation Severity Categories and Long-Term Quality of Life among Children who Survive Septic Shock

Objectives This study aimed to test whether early oxygenation failure severity categories (absent/mild/moderate/severe) were associated with health-related quality of life (HRQL) deterioration among children who survived sepsis-related acute respiratory failure.

Methods We performed a secondary analysis of a study of community-acquired pediatric septic shock, Life After Pediatric Sepsis Evaluation. The primary outcome was an adjusted decline in HRQL ≥ 25% below baseline as assessed 3 months following admission. Logistic regression models were built to test the association of early oxygenation failure including covariates of age and nonrespiratory Pediatric Logistic Organ Dysfunction-2 score. Secondarily, we tested if there was an adjusted decline in HRQL at 6 and 12 months and functional status at 28 days.

Results We identified 291 children who survived to discharge and underwent invasive ventilation. Of those, that 21% (61/291) had mild oxygenation failure, 20% (58/291) had moderate, and 17% (50/291) had severe oxygenation failure. Fifteen percent of children exhibited a decline in HRQL of at least 25% from their baseline at the 3-month follow-up time point. We did not identify an association between the adjusted severity of oxygenation failure and decline in HRQL ≥ 25% at 3-, 6-, or 12-month follow-up. Children with oxygenation failure were more likely to exhibit a decline in functional status from baseline to hospital discharge, but results were similar across severity categories.

Conclusion Our findings that children of all oxygenation categories are at risk of HRQL decline suggest that those with mild lung injury should not be excluded from comprehensive follow-up, but more work is needed to identify those at the highest risk.

Whole pulmonary assessment 1 year after paediatric acute respiratory distress syndrome: prospective multicentre study

Background

Long-term pulmonary sequelae, including 1-year thoracic computed tomography (CT) sequelae of paediatric acute respiratory distress syndrome (ARDS) remain unknown. The purpose of the study was to determine pulmonary abnormalities in child survivors of pulmonary (p-ARDS) and extra-pulmonary ARDS (ep-ARDS) 1 year after paediatric intensive care unit discharge (PICUD).

Methods

Prospective multicentre study in four paediatric academic centres between 2005 and 2014. Patients with ARDS were assessed 1 year after PICUD with respiratory symptom questionnaire, thoracic CT and pulmonary function tests (PFT).

Results

39 patients (31 p-ARDS) aged 1.1–16.2 years were assessed. Respiratory symptoms at rest or exercise and/or respiratory maintenance treatment were reported in 23 (74%) of children with p-ARDS but in 1 (13%) of those with ep-ARDS. Thoracic CT abnormalities were observed in 18 (60%) of children with p-ARDS and 4 (50%) of those with ep-ARDS. Diffuse and more important CT abnormalities, such as ground glass opacities or mosaic perfusion patterns, were observed in 5 (13%) of children, all with p-ARDS. PFT abnormalities were observed in 30 (86%) of patients: lung hyperinflation and/or obstructive pattern in 12 (34%) children, restrictive abnormalities in 6 (50%), mild decrease in diffusing capacity in 2 (38%) and 6-min walking distance decrease in 11 (73%). Important PFT abnormalities were observed in 7 (20%) children, all with p-ARDS. Increasing driving pressure (max plateau pressure—max positive end-expiratory pressure) was correlated with increasing CT-scan abnormalities and increasing functional residual capacity (more hyperinflation) (p < 0.005).

Conclusions

Children surviving ARDS requiring mechanical ventilation present frequent respiratory symptoms, significant CT-scan and PFT abnormalities 1 year after PICUD. This highlights the need for a systematic pulmonary assessment of these children.

Trial registration The study was registered on Clinical Trials.gov PRS (ID NCT01435889)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01050-4.

Assessment of Patient Health-Related Quality of Life and Functional Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

To describe health-related quality of life (HRQL) and functional outcomes in pediatric acute respiratory distress syndrome (ARDS) and to determine risk factors associated with poor outcome defined as death or severe reduction in HRQL at 28 days or ICU discharge.

DESIGN

Prospective multisite cohort-outcome study conducted between 2019 and 2020.

SETTING

Eight academic PICUs in the United States.

PATIENTS

Children with ARDS based on standard criteria.

INTERVENTIONS

Patient characteristics and illness severity were collected during PICU admission. Parent proxy-report measurements were obtained at baseline, day 28/ICU discharge, month 3, and month 9, utilizing Pediatric Quality of Life Inventory and Functional Status Scale (FSS). A composite outcome evaluated using univariate and multivariate analysis was death or severe reduction in HRQL (>25% reduction in the Pediatric Quality of Life Inventory at day 28/ICU discharge.

MEASUREMENTS AND MAIN RESULTS

This study enrolled 122 patients with a median age of 3 years (interquartile range, 1-12 yr). Common etiologies of ARDS included pneumonia ( n = 63; 52%) and sepsis ( n = 27; 22%). At day 28/ICU discharge, half (50/95; 53%) of surviving patients with follow-up data reported a greater than 10% decrease in HRQL from baseline, and approximately one-third of participants ( n = 19/61; 31%) reported a greater than 10% decrease in HRQL at 9 months. Trends in FSS were similar. Of 104 patients with data, 47 patients (45%) died or reported a severe decrease of greater than 25% in HRQL at day 28/ICU discharge. Older age was associated with an increased risk of death or severe reduction in HRQL (odds ratio, 1.08; CI, 1.01-1.16).

CONCLUSIONS

Children with ARDS are at risk for deterioration in HRQL and FSS that persists up to 9 months after ARDS. Almost half of children with ARDS experience a poor outcome including death or severe reduction in HRQL at day 28/ICU discharge.

Nutritional practices & outcomes in patients with pediatric acute respiratory distress syndrome

BACKGROUND

Pediatric acute respiratory distress syndrome (PARDS) remains a significant cause of morbidity and mortality. Evidence suggests enteral nutrition (EN) may be protective in critically ill children. This study was designed to determine if an association exists between early enteral nutrition (EEN) and PARDS outcomes.

METHODS

Retrospective cohort study comparing intubated patients with PARDS who received EEN and those who did not. We included intubated patients with PARDS aged 2 weeks to 18 years who could receive full nutrition enterally prior to their disease and excluded patients with cyanotic heart disease. Disease severity captured with oxygenation index (OI), oxygen saturation index (OSI), and pediatric logistic organ dysfunction (PELOD-2) scores. EEN defined as having received at least 25% of calculated caloric goal enterally within the first 48 hours of PARDS diagnosis. We compared PICU mortality, PICU length of stay (LOS), and 28-day ventilator-free days between EEN and non-EEN groups.

RESULTS

We included 151 patients. Adjusted for age, OI, and OSI, the EEN group had a lower PICU mortality rate (aOR=0.071, 95% CI 0.009-0.542, p=0.011), higher likelihood of PICU discharge (aRR=1.79, 95% CI 1.25-2.55, p=0.001) and was more likely to have at least one ventilator-free day (aOR=3.96, 95% CI 1.28-12.22, p=0.017). Adjusted for age and PELOD-2, a statistically significant association between the EEN group and lower PICU mortality (p=0.033), shorter PICU LOS (p<0.001), and more ventilator-free days (p=0.037) persisted.

CONCLUSIONS

Our study found EEN was associated with superior mortality rates, PICU LOS, and ventilator-free days in patients with PARDS. This article is protected by copyright. All rights reserved.

Potential therapeutics in pediatric acute respiratory distress syndrome: what does the immune system have to offer? A narrative review

Since first described, acute respiratory distress syndrome (ARDS) has been understood to be an inflammatory disease with a dysregulated hyperinflammatory response. While fewer investigations have studied these phenomena in pediatric ARDS (PARDS), similar pathways are believed to be involved. Significant attention has been paid to the innate immune system, particularly neutrophils and neutrophil-related signaling, more recent studies have provided additional nuance regarding the role of upstream damage-associated molecular patterns (DAMPs) and subsequent neutrophil-mediated inflammation, lung permeability, and alveolar epithelial damage. For example, neutrophil extracellular traps (NETs) and inflammasome signaling have been identified as critical mediators existing at the junction of DAMPs and downstream inflammation. We demonstrate how the conclusions obtained from pre-clinical studies of lung injury are highly dependent upon the model chosen, and how this can lead us astray when developing therapies. More recently the adaptive immune system, specifically select T cell subpopulations, have also been implicated in ARDS. This raises the possibility of antigen-specific immunomodulation as a potential therapeutic avenue in ARDS. Finally, we briefly review randomized controlled trials attempting to manipulate the immune dysregulation in ARDS, including pleiotropic immunomodulators like corticosteroids and interferon-β, and what these studies can teach us about the design of novel therapeutics and the design of future trials.

Thrombomodulin is associated with increased mortality and organ failure in mechanically ventilated children with acute respiratory failure: biomarker analysis from a multicenter randomized controlled trial

BACKGROUND

Acute respiratory failure (ARF) can progress to acute respiratory distress syndrome and death. Biomarkers may allow for risk stratification and prognostic enrichment in ARF. Thrombomodulin (TM) is a transmembrane antithrombotic mediator expressed in endothelial cells. It is cleaved into its soluble form (sTM) during inflammation and vascular injury. Levels of sTM correlate with inflammation and end organ dysfunction.

METHODS

This was a prospective observational study of 432 patients aged 2 weeks-17 years requiring invasive mechanical ventilation. It was ancillary to the multicenter clinical trial, Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE). After consent, patients had up to 3 plasma samples collected at 24-h intervals within 5 days after intubation. sTM was assayed by ELISA. The Hazard ratio (HR) for 90-day mortality was determined by Cox regression. Mixed effect models (MEM) were used to test for association with extrapulmonary multiorgan failure (MOF) and oxygenation index (OI). Age, race, sex and PRISM-III scores were used as confounding variables for multivariable analyses.

RESULTS

sTM values ranged from 16.6 to 670.9 ng/ml within 5 days after intubation. Higher sTM was associated with increased 90-day mortality (n = 432, adjusted HR = 1.003, p = 0.02) and worse OI in the first 5 days after intubation (n = 252, Estimate = 0.02, p < 0.01). Both initial and slope of sTM were associated with increased extrapulmonary MOF in unadjusted and adjusted analyses (Intercept, Estimate = 0.003, p < 0.0001; and slope, Estimate = 0.01, p = 0.0009, n = 386).

CONCLUSIONS

Plasma sTM is associated with mortality, severity of hypoxic respiratory failure and worsening extrapulmonary MOF in children with ARF. This suggests a role of vascular injury in the pathogenesis of ARF and provides potential applicability towards targeted therapies.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT00814099 . In healthy lung endothelium, thrombomodulin (TM) recruits thrombin to activate Protein-C (PC/APC), that inhibits plasminogen activator-1 (PAI-1) and thrombosis. In inflamed and damaged endothelium, TM is cleaved into its soluble form (sTM), precluding its usual regulation of thrombosis. In this study, we measured plasma sTM levels in pediatric patients with respiratory failure and found that sTM correlated with mortality and other clinical markers of poor outcomes.

High burden of acquired morbidity in survivors of pediatric acute respiratory distress syndrome

INTRODUCTION

With improving mortality rates in pediatric acute respiratory distress syndrome (PARDS), functional outcomes in survivors are increasingly important. We aim to describe the change in functional status score (FSS) from baseline to discharge and to identify risk factors associated with poor functional outcomes.

METHODS

We examined clinical records of patients with PARDS admitted to our pediatric intensive care unit (PICU) from 2009 to 2016. Our primary outcome was acquired morbidity at PICU and hospital discharge (defined by an increase in FSS ≥3 points above baseline). We included severity of illness scores and severity of PARDS in our bivariate analysis for risk factors for acquired morbidity.

RESULTS

There were 181 patients with PARDS, of which 90 (49.7%) survived. Median pediatric index of mortality 2 score was 4.05 (1.22, 8.70) and 21 (23.3%) survivors had severe PARDS. A total of 59 (65.6%) and 14 (15.6%) patients had acquired morbidity at PICU and hospital discharge, respectively. Median baseline FSS was 6.00 (6.00, 6.25), which increased to 11.00 (8.75, 12.00) at PICU discharge before decreasing to 7.50 (6.00, 9.25) at hospital discharge. All patients had significantly higher FSS at both PICU and hospital discharge median compared to baseline. Feeding and respiratory were the most affected domains. After adjusting for severity of illness, severity categories of PARDS were not a risk factor for acquired morbidity.

CONCLUSION

Acquired morbidity in respiratory and feeding domains was common in PARDS survivors. Specific attention should be given to these two domains of functional outcomes in these children.

Ventilator-Weaning Pathway Associated With Decreased Ventilator Days in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

There is limited evidence on the impact of protocolized ventilator weaning in pediatric acute respiratory distress syndrome, despite utilization in clinical trials and clinical care. We aimed to determine whether protocolized ventilator weaning shortens mechanical ventilation duration and PICU length of stay in pediatric acute respiratory distress syndrome survivors.

DESIGN

Secondary analysis of a prospective pediatric acute respiratory distress syndrome (Berlin definition) cohort from July 2011 to June 2019 analyzed using interrupted time series analysis pre- and postimplementations of a ventilator-weaning pathway. We compared duration of invasive ventilation and PICU length of stay in survivors before and after implementation of a ventilator-weaning pathway. We excluded PICU nonsurvivors and subjects with greater than 100 ventilator days.

SETTING

Large academic tertiary-care PICU.

PATIENTS

Children with acute respiratory distress syndrome who survived to PICU discharge with less than or equal to 100 days of invasive mechanical ventilation.

INTERVENTIONS

Implementation of a ventilator-weaning pathway on May 2016.

MEASUREMENTS AND MAIN RESULTS

Of 723 children with acute respiratory distress syndrome, 132 subjects died and six subjects with ventilation greater than 100 days were excluded. Of the remaining 585 subjects, 375 subjects had acute respiratory distress syndrome prior to pathway intervention and 210 after. Patients in the preintervention epoch were younger, more likely to have infectious acute respiratory distress syndrome, and had increased use of alternative ventilator modes. Pathway adoption was rapid and sustained. Controlling for temporality, pathway implementation was associated with a decrease of a median 3.6 ventilator days (95% CI, -5.4 to -1.7; p < 0.001). There was no change in the reintubation rates. Results were robust to multiple sensitivity analyses adjusting for confounders.

CONCLUSIONS

Ventilator-weaning pathway implementation shortened invasive ventilation duration in pediatric acute respiratory distress syndrome survivors with no change in reintubation. The effect size of this intervention was comparable with those targeted in acute respiratory distress syndrome trials.

The value of oxygen index and base excess in predicting the outcome of neonatal acute respiratory distress syndrome

OBJECTIVE

This study aimed to identify the predictors and threshold of failure in neonatal acute respiratory distress syndrome.

METHODS

Newborns with severe acute respiratory distress syndrome aged 0-28 days and gestational age ≥36 weeks were included in the study if their cases were managed with non-extra corporal membrane oxygenation treatments. Patients were divided into two groups according to whether they died before discharge. Predictors of non-extra corporal membrane oxygenation treatment failure were sought, and the threshold of predictors was calculated.

RESULTS

A total of 103 patients were included in the study. A total of 77 (74.8%) survived hospitalization and were discharged, whereas 26 (25.2%) died. Receiver operating characteristic analysis of oxygen index, pH, base excess, and combinations of these indicators demonstrated the advantage of the combination of oxygen index and base excess over the others variables regarding their predictive ability. The area under the curve for the combination of oxygen index and base excess was 0.865. When the cut-off values of oxygen index and base excess were 30.0 and -7.4, respectively, the sensitivity and specificity for predicting death were 77.0% and 84.0%, respectively. The model with base excess added a net reclassification improvement of 0.090 to the model without base excess.

CONCLUSION

The combination of oxygen index and base excess can be used as a predictor of outcomes in neonates receiving non-extra corporal membrane oxygenation treatment for acute respiratory distress syndrome. In neonates with acute respiratory distress syndrome, if oxygen index >30 and base excess <-7.4, non-extra corporal membrane oxygenation therapy is likely to lead to death.

Postdischarge Outcome Domains in Pediatric Critical Care and the Instruments Used to Evaluate Them: A Scoping Review

OBJECTIVES

Assessing outcomes after pediatric critical illness is imperative to evaluate practice and improve recovery of patients and their families. We conducted a scoping review of the literature to identify domains and instruments previously used to evaluate these outcomes.

DESIGN

Scoping review.

SETTING

We queried PubMed, EMBASE, PsycINFO, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials Registry for studies evaluating pediatric critical care survivors or their families published between 1970 and 2017. We identified articles using key words related to pediatric critical illness and outcome domains. We excluded articles if the majority of patients were greater than 18 years old or less than 1 month old, mortality was the sole outcome, or only instrument psychometrics or procedural outcomes were reported. We used dual review for article selection and data extraction and categorized outcomes by domain (overall health, emotional, physical, cognitive, health-related quality of life, social, family).

SUBJECTS

Manuscripts evaluating outcomes after pediatric critical illness.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 60,349 citations, 407 articles met inclusion criteria; 87% were published after 2000. Study designs included observational (85%), interventional (7%), qualitative (5%), and mixed methods (3%). Populations most frequently evaluated were traumatic brain injury (n = 96), general pediatric critical illness (n = 87), and congenital heart disease (n = 72). Family members were evaluated in 74 studies (18%). Studies used a median of 2 instruments (interquartile range 1-4 instruments) and evaluated a median of 2 domains (interquartile range 2-3 domains). Social (n = 223), cognitive (n = 183), and overall health (n = 161) domains were most frequently studied. Across studies, 366 unique instruments were used, most frequently the Wechsler and Glasgow Outcome Scales. Individual domains were evaluated using a median of 77 instruments (interquartile range 39-87 instruments).

CONCLUSIONS

A comprehensive, generalizable understanding of outcomes after pediatric critical illness is limited by heterogeneity in methodology, populations, domains, and instruments. Developing assessment standards may improve understanding of postdischarge outcomes and support development of interventions after pediatric critical illness.

Acute Respiratory Distress Syndrome Following Pediatric Trauma: Application of Pediatric Acute Lung Injury Consensus Conference Criteria

OBJECTIVES

To assess the incidence, severity, and outcomes of pediatric acute respiratory distress syndrome following trauma using Pediatric Acute Lung Injury Consensus Conference criteria.

DESIGN

Retrospective cohort study.

SETTING

Level 1 pediatric trauma center.

PATIENTS

Trauma patients less than or equal to 17 years admitted to the ICU from 2009 to 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We queried electronic health records to identify patients meeting pediatric acute respiratory distress syndrome oxygenation criteria for greater than or equal to 6 hours and determined whether patients met complete pediatric acute respiratory distress syndrome criteria via chart review. We estimated associations between pediatric acute respiratory distress syndrome and outcome using generalized linear Poisson regression adjusted for age, injury mechanism, Injury Severity Score, and serious brain and chest injuries. Of 2,470 critically injured children, 103 (4.2%) met pediatric acute respiratory distress syndrome criteria. Mortality was 34.0% among pediatric acute respiratory distress syndrome patients versus 1.7% among patients without pediatric acute respiratory distress syndrome (adjusted relative risk, 3.7; 95% CI, 2.0-6.9). Mortality was 50.0% for severe pediatric acute respiratory distress syndrome at onset, 33.3% for moderate, and 30.5% for mild. Cause of death was neurologic in 60.0% and multiple organ failure in 34.3% of pediatric acute respiratory distress syndrome nonsurvivors versus neurologic in 85.4% of nonsurvivors without pediatric acute respiratory distress syndrome (p = 0.001). Among survivors, 77.1% of pediatric acute respiratory distress syndrome patients had functional disability at discharge versus 30.7% of patients without pediatric acute respiratory distress syndrome patients (p < 0.001), and only 17.5% of pediatric acute respiratory distress syndrome patients discharged home without ongoing care versus 86.4% of patients without pediatric acute respiratory distress syndrome (adjusted relative risk, 1.5; 1.1-2.1).

CONCLUSIONS

Incidence and mortality associated with pediatric acute respiratory distress syndrome following traumatic injury are substantially higher than previously recognized, and pediatric acute respiratory distress syndrome development is associated with high risk of poor outcome even after adjustment for underlying injury type and severity.

Understanding the age divide in COVID-19: why are children overwhelmingly spared?

The rapid emergence and subsequent global dissemination of SARS-CoV-2 disease (COVID-19) has resulted in over 4 million cases worldwide. The disease has a marked predilection for adults, and children are relatively spared. Understanding the age-based differences in pathophysiological pathways and processes relevant to the onset and progression of disease both in the clinical course and in experimental disease models may hold the key to the identification of therapeutic targets. The differences in the clinical course are highlighted by the lack of progression of the SARS-CoV-2 infection beyond mild symptoms in a majority of children, whereas in adults the disease progresses to acute lung injury and an acute respiratory distress syndrome (ARDS)-like phenotype with high mortality. The pathophysiological mechanisms leading to decreased lung injury in children may involve the decreased expression of the mediators necessary for viral entry into the respiratory epithelium and differences in the immune system responses in children. Specifically, decreased expression of proteins, including angiotensin-converting enzyme 2 (ACE2) and Transmembrane Serine Protease 2 (TMPRSS2) in the airway epithelium in children may prevent viral entry. The immune system differences may include a relative preponderance of CD4+ T cells, decreased neutrophil infiltration, decreased production of proinflammatory cytokines, and increased production of immunomodulatory cytokines in children compared with adults. Notably, the developing lung in children may have a greater capacity to recover and repair after viral infection. Understanding the relative contributions of the above processes to the protective phenotype in the developing lung can guide the trial of the appropriate therapies in adults.

Ethical decision-making for children with neuromuscular disorders in the COVID-19 crisis

The sudden appearance and proliferation of coronavirus disease 2019 has forced societies and governmental authorities across the world to confront the possibility of resource constraints when critical care facilities are overwhelmed by the sheer numbers of grievously ill patients. As governments and health care systems develop and update policies and guidelines regarding the allocation of resources, patients and families affected by chronic disabilities, including many neuromuscular disorders that affect children and young adults, have become alarmed at the possibility that they may be determined to have less favorable prognoses due to their underlying diagnoses and thus be assigned to lower priority groups. It is important for health care workers, policymakers, and government officials to be aware that the long-term prognoses for children and young adults with neuromuscular disorders are often more promising than previously believed due to a better understanding of the natural history of these diseases, benefits of multidisciplinary supportive care, and novel molecular therapies that can dramatically improve the disease course. Although the realities of a global pandemic have the potential to require a shift from our usual, highly individualistic standards of care to crisis standards of care, shifting priorities should nonetheless be informed by good facts. Resource allocation guidelines with the potential to affect children and young adults with neuromuscular disorders should take into account the known trajectory of acute respiratory illness in this population and rely primarily on contemporary long-term outcome data.

Airway pressure release ventilation in children

PURPOSE OF REVIEW

In patients with acute respiratory distress syndrome (ARDS), airway pressure release ventilation (APRV) has been purported to have several physiological benefits. This review synthesizes recent research evaluating APRV mode and provides perspectives on the utility of this mode in children with ARDS.

RECENT FINDINGS

Two single-center clinical trials on APRV, one adult and one pediatric, have been published this year. These two trials have not only elicited editorials and letters that highlight some of their strengths and weaknesses but also rekindled debate on several aspects of APRV. Despite their contradicting results, both trials provide significant insights into APRV strategies that work and those that may not. This review places the newer evidence in the context of existing literature and provides a comprehensive analysis of APRV use in children.

SUMMARY

There have been significant recent advancements in our understanding of the clinical utility of APRV in children with ARDS. The recent trial highlights the urgent need to evolve a consensus on definition of APRV and identify strategies that work. Pending further research, clinicians should avoid the use of a zero-PLOW Personalized-APRV strategy as a primary ventilation modality in children with moderate-severe ARDS.

Improved oxygenation following methylprednisolone therapy and survival in paediatric acute respiratory distress syndrome

Background

Methylprednisolone remains a commonly used ancillary therapy for paediatric acute respiratory distress syndrome (PARDS), despite a lack of level 1 evidence to justify its use. When planning prospective trials it is useful to define response to therapy and to identify if there is differential response in certain patients, i.e. existence of ‘responders’ and ‘non responders’ to therapy. This retrospective, observational study carried out in 2 tertiary referral paediatric intensive care units aims to characterize the change in Oxygen Saturation Index, following the administration of low dose methylprednisolone in a cohort of patients with PARDS, to identify what proportion of children treated demonstrated response, whether any particular characteristics predict response to therapy, and to determine if a positive response to corticosteroids is associated with reduced Paediatric Intensive Care Unit mortality.

Methods

All patients who received prolonged, low dose, IV methylprednisolone for the specific indication of PARDS over a 5-year period (2011–2016) who met the PALICC criteria for PARDS at the time of commencement of steroid were included (n = 78).OSI was calculated four times per day from admission until discharge from PICU (or death). Patients with ≥20% improvement in their mean daily OSI within 72 hours of commencement of methylprednisolone were classified as ‘responders’. Primary outcome measure was survival to PICU discharge.

Results

Mean OSI of the cohort increased until the day of steroid commencement then improved thereafter. 59% of patients demonstrated a response to steroids. Baseline characteristics were similar between responders and non-responders. Survival to PICU discharge was significantly higher in ‘responders’ (74% vs 41% OR 4.14(1.57–10.87) p = 0.004). On multivariable analysis using likely confounders, response to steroid was an independent predictor of survival to PICU discharge (p = 0.002). Non-responders died earlier after steroid administration than responders (p = 0.003).

Conclusions

An improvement in OSI was observed in 60% of patients following initiation of low dose methylprednisolone therapy in this cohort of patients with PARDS. Baseline characteristics fail to demonstrate a difference between responders and non-responders. A 20% improvement in OSI after commencement of methylprednisolone was independently predictive of survival, Prospective trials are needed to establish if there is a benefit from this therapy.

Pertinent clinical outcomes in pediatric survivors of pediatric acute respiratory distress syndrome (PARDS): a narrative review

The objectives of this review are to describe the limitations of commonly used clinical outcomes [e.g., mortality, ventilation parameters, need for extracorporeal membrane oxygenation (ECMO), pediatric intensive care unit (PICU) and hospital length of stay (LOS)] in pediatric acute respiratory distress syndrome (PARDS) studies; and to explore other pertinent clinical outcomes that pediatric critical care practitioners should consider in future clinical practice and research studies. These include long-term pulmonary function, risk of pulmonary hypertension (PHT), nutrition status and growth, PICU-acquired weakness, neurological outcomes and neurocognitive development, functional status, health-related quality of life (HRQOL)], health-care costs, caregiver and family stress. PubMed was searched using the following keywords or medical subject headings (MESH): "acute lung injury (ALI)", "acute respiratory distress syndrome (ARDS)", "pediatric acute respiratory distress syndrome (PARDS)", "acute hypoxemia respiratory failure", "outcomes", "pediatric intensive care unit (PICU)", "lung function", "pulmonary hypertension", "growth", "nutrition', "steroid", "PICU-acquired weakness", "functional status scale", "neurocognitive", "psychology", "health-care expenditure", and "HRQOL". The concept of contemporary measure outcomes was adapted from adult ARDS long-term outcome studies. Articles were initially searched from existing PARDS articles pool. If the relevant measure outcomes were not found, where appropriate, we considered studies from non-ARDS patients within the PICU in whom these outcomes were studied. Long-term outcomes in survivors of PARDS were not follow-up in majority of pediatric studies regardless of whether the new or old definitions of ARDS in children were used. Relevant studies were scarce, and the number of participants was small. As such, available studies were not able to provide conclusive answers to most of our clinical queries. There remains a paucity of data on contemporary clinical outcomes in PARDS studies. In addition to the current commonly used outcomes, clinical researchers and investigators should consider examining these contemporary outcome measures in PARDS studies in the future.

Airway Pressure Release Ventilation in Pediatric Acute Respiratory Distress Syndrome. A Randomized Controlled Trial

RATIONALE

Although case series describe benefits of airway pressure release ventilation (APRV), this mode of ventilation has not been evaluated against the conventional low-tidal volume ventilation (LoTV) in children with acute respiratory distress syndrome (ARDS).

OBJECTIVES

To compare the effect of APRV and conventional LoTV on ventilator-free days in children with ARDS.

METHODS

This open-label, parallel-design randomized controlled trial was conducted in a 15-bed ICU. Children aged 1 month to 12 years satisfying the modified Berlin definition were included. We excluded children with air leaks, increased intracranial pressure, poor spontaneous breathing efforts, chronic lung disease, and beyond 24 hours of ARDS diagnosis or 72 hours of ventilation. Children were randomized using unstratified, variable-sized block technique. A priori interim analysis was planned at 50% enrollment. All enrolled children were followed up until 180 days after enrollment or death, whichever was earlier.

MEASUREMENTS AND MAIN RESULTS

The trial was terminated after 50% enrollment (52 children) when analysis revealed higher mortality in the intervention arm. Ventilator-free days were statistically similar in both arms (P = 0.23). The 28-day all-cause mortality was 53.8% in APRV as compared with 26.9% among control subjects (risk ratio, 2.0; 95% confidence interval, 0.97-4.1; Fisher exact P = 0.089). The multivariate-adjusted risk ratio of death for APRV compared with LoTV was 2.02 (95% confidence interval, 0.99-4.12; P = 0.05). Higher mean airway pressures, greater spontaneous breathing, and early improvement in oxygenation were seen in the intervention arm.

CONCLUSIONS

APRV, as a primary ventilation strategy in children with ARDS, was associated with a trend toward higher mortality compared with the conventional LoTV. Limitations should be considered while interpreting these results. Clinical trial registered with www.clinicaltrials.gov (NCT02167698) and Clinical Trials Registry of India (CTRI/2014/06/004677).

The Association Between Inhaled Nitric Oxide Treatment and ICU Mortality and 28-Day Ventilator-Free Days in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

To investigate the association between inhaled nitric oxide treatment and ICU mortality and 28-day ventilator-free days in pediatric acute respiratory distress syndrome.

DESIGN

Retrospective cohort study. A propensity score for inhaled nitric oxide treatment was developed and used in the analysis.

SETTING

Two quaternary care PICUs.

PATIENTS

Children with pediatric acute respiratory distress syndrome.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 499 children enrolled in this study with 143 (28.7%) receiving inhaled nitric oxide treatment. Children treated with inhaled nitric oxide were more likely to have a primary diagnosis of pneumonia (72% vs 54.8%; p < 0.001), had a higher initial oxygenation index (median 16.9 [interquartile range, 10.1-27.3] vs 8.5 [interquartile range, 5.8-12.2]; p < 0.001), and had a higher 72-hour maximal Vasoactive-Inotrope Score (median 15 [interquartile range, 6-25] vs 8 [interquartile range, 0-17.8]; p < 0.001) than those not receiving inhaled nitric oxide. Mortality was higher in the inhaled nitric oxide treatment group (25.2% vs 16.3%; p = 0.02), and children in this group had fewer 28-day ventilator-free days (10 d [interquartile range, 0-18 d] vs 17 d (interquartile range 5.5-22 d]; p < 0.0001). We matched 176 children based on propensity score for inhaled nitric oxide treatment. In the matched cohort, inhaled nitric oxide treatment was not associated with mortality (odds ratio, 1.3 [95% CI, 0.56-3.0]) or 28-day ventilator-free days (incidence rate ratio, 0.91 [95% CI, 0.80-1.04]). These results remained consistent in the entire study cohort when the propensity score for inhaled nitric oxide treatment was used for either inverse probability weighting or stratification in regression modeling with the exception that subjects treated with inhaled nitric oxide were more likely to have 0 ventilator-free days (p ≤ 0.02). In secondary analysis stratified by oxygenation response, inhaled nitric oxide treatment was not associated with mortality or 28-day ventilator-free days in children with a positive oxygenation response (all p > 0.2) CONCLUSIONS:: Treatment with inhaled nitric oxide in pediatric acute respiratory distress syndrome is not associated with improvement in either mortality or ventilator-free days and may be associated with harm. Further prospective trials are required to define the role of inhaled nitric oxide treatment in pediatric acute respiratory distress syndrome.

Equilibration Time Required for Respiratory System Compliance and Oxygenation Response Following Changes in Positive End-Expiratory Pressure in Mechanically Ventilated Children

OBJECTIVES

Increases in positive end-expiratory pressure are implemented to improve oxygenation through the recruitment and stabilization of collapsed alveoli. However, the time it takes for a positive end-expiratory pressure change to have maximum effect upon oxygenation and pulmonary compliance has not been adequately described in children. Therefore, we sought to quantify the time required for oxygenation and pulmonary system compliance changes in children requiring mechanical ventilation.

DESIGN

Retrospective analysis of continuous data.

SETTINGS

Multidisciplinary ICU of a pediatric university hospital.

PATIENTS

Mechanically ventilated pediatric subjects.

INTERVENTIONS

A case was eligible for analysis if during a 90-minute window following an increase in positive end-expiratory pressure, no other changes to the ventilator were made, ventilator and physiologic data were continuously available and a positive oxygenation response was observed. Time to 90% (T90) of the maximum change in oxygenation and compliance was computed. Differences between oxygenation and compliance T90 were compared using a paired t test. The effect of severity of illness (by oxygen saturation index) upon oxygenation and compliance was analyzed.

MEASUREMENTS AND MAIN RESULTS

A total of 200 subjects were enrolled and 1,150 positive end-expiratory pressure change cases were analyzed. Of these, 54 subjects with 171 positive end-expiratory pressure change case were included in the analysis (67% were responders).Changes in dynamic compliance (T90 = 38 min) preceded changes in oxygenation (T90 = 71 min; p < 0.001). Oxygenation response differed depending on severity of illness quantified by oxygen saturation index; lung dysfunction was associated with a longer response time (p = 0.001).

CONCLUSIONS

T90 requires 38 and 71 minutes for dynamic pulmonary compliance and oxygenation, respectively; the latter was directly observed to be dependent upon severity of illness. To our knowledge, this is the first report of oxygenation and compliance equilibration data following positive end-expiratory pressure increases in pediatric mechanically ventilated subjects.

Mechanism of Cxc Chemokine Ligand 5 (CXCL5)/Cxc Chemokine Receptor 2 (CXCR2) Bio-Axis in Mice with Acute Respiratory Distress Syndrome

BACKGROUND Acute respiratory distress syndrome (ARDS) is a common acute and severe disease in clinic. Recent studies indicated that Cxc chemokine ligand 5 (CXCL5), an inflammatory chemokine, was associated with tumorigenesis. The present study investigated the role of the CXCL5/Cxc chemokine receptor 2 (CXCR2) bio-axis in ARDS, and explored the underlying molecular mechanism. MATERIAL AND METHODS The pathological morphology of lung tissue and degree of pulmonary edema were assessed by hematoxylin-eosin staining and pulmonary edema score, respectively. Real-time PCR and Western blot analysis were performed to detect the expression levels of CXCL5, CXCR2, Matrix metalloproteinases 2 (MMP2), and Matrix metalloproteinases 9 (MMP9) in lung tissues. Enzyme-linked immunosorbent assay (ELISA) was performed to determine the expression levels of CXCL5 and inflammatory factors (IL-1ß, IL-6, TNF-alpha, and IL-10) in serum. RESULTS The results demonstrated that diffuse alveolar damage and pulmonary edema appeared in lipopolysaccharide (LPS)-induced ARDS and were positively correlated with the severity of ARDS. In addition, CXCL5 and its receptor CXCR2 were overexpressed by upregulation of MMP2 and MMP9 in lung tissues of ARDS. In addition, CXCL5 neutralizing antibody effectively alleviated inflammatory response, diffuse alveolar damage, and pulmonary edema, and decreased the expression levels of MMP2 and MMP9 compared to LPS-induced ARDS. CONCLUSIONS We found that CXCL5/CXCR2 accelerated the progression of ARDS, partly by upregulation of MMP2 and MMP9 in lung tissues with the release of inflammatory factors.

The Current State of Pediatric Acute Respiratory Distress Syndrome

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.

Clinical Profile and Predictors of Outcome of Pediatric Acute Respiratory Distress Syndrome in a PICU: A Prospective Observational Study

OBJECTIVES

To study the clinical profile, predictors of mortality, and outcomes of pediatric acute respiratory distress syndrome.

DESIGN

A prospective observational study.

SETTING

PICU, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

PATIENTS

All children (age > 1 mo to < 14 yr) admitted in PICU with a diagnosis of pediatric acute respiratory distress syndrome (as per Pediatric Acute Lung Injury Consensus Conference definition) from August 1, 2015, to November 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Out of 1,215 children admitted to PICU, 124 (11.4%) had pediatric acute respiratory distress syndrome. Fifty-six children (45.2%) died. Median age was 2.75 years (1.0-6.0 yr) and 66.9% were male. Most common primary etiologies were pneumonia, severe sepsis, and scrub typhus. Ninety-seven children (78.2%) were invasively ventilated. On multiple logistic regressions, Lung Injury Score (p = 0.004), pneumothorax (p = 0.012), acute kidney injury at enrollment (p = 0.033), FIO2-D1 (p = 0.018), and PaO2/FIO2 ratio-D7 (p = 0.020) were independent predictors of mortality. Positive fluid balance (a cut-off value > 102.5 mL/kg; p = 0.016) was associated with higher mortality at 48 hours. Noninvasive oxygenation variables like oxygenation saturation index and saturation-FIO2 ratio were comparable to previously used invasive variables (oxygenation index and PaO2/FIO2 ratio) in monitoring the course of pediatric acute respiratory distress syndrome.

CONCLUSIONS

Pediatric acute respiratory distress syndrome contributes to a significant burden in the PICU of a developing country and is associated with significantly higher mortality. Infection remains the most common etiology. Higher severity of illness scores at admission, development of pneumothorax, and a positive fluid balance at 48 hours predicted poor outcome.

Positive Cumulative Fluid Balance Is Associated With Mortality in Pediatric Acute Respiratory Distress Syndrome in the Setting of Acute Kidney Injury

OBJECTIVES

As acute kidney injury and elevated cumulative fluid balance commonly co-occur in pediatric acute respiratory distress syndrome, we aimed to identify risk factors for their development and evaluate their independent relationships with mortality. We hypothesized that acute kidney injury and elevated cumulative fluid balance would be associated with markers of inflammation and that children with elevated cumulative fluid balance and concomitant acute kidney injury would have worse outcomes than other children.

DESIGN

Prospective observational study using the pediatric Risk, Injury, Failure, Loss, End-Stage acute kidney injury classification.

SETTING

Five academic PICUs.

PATIENTS

Two-hundred sixty patients 1 month to 18 years old meeting the Berlin definition of acute respiratory distress syndrome between 2008 and 2014.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

PICU mortality was 13% (34/260). Relative to survivors, nonsurvivors had greater cumulative fluid balance on day 3 of acute respiratory distress syndrome (+90.1 mL/kg; interquartile range 26.6-161.7 vs +44.9 mL/kg; interquartile range 10.0-111.3; p = 0.008) and also had higher prevalence of acute kidney injury on day 3 of acute respiratory distress syndrome (50% vs 23%; p = 0.001). On stratified analysis, greater cumulative fluid balance on day 3 of acute respiratory distress syndrome was associated with mortality among patients with concomitant acute kidney injury (+111.5 mL/kg for nonsurvivors; interquartile range 82.6-236.8 vs +58.5 mL/kg for survivors; interquartile range 0.9-176.2; p = 0.041) but not among patients without acute kidney injury (p = 0.308). The presence of acute kidney injury on acute respiratory distress syndrome day 3 was associated with mortality among patients with positive cumulative fluid balance (29.1% vs 10.4% mortality; p = 0.001) but not among patients with even or negative cumulative fluid balance (p = 0.430). Day 1 plasma interleukin-6 levels were associated with the development of day 3 positive cumulative fluid balance, day 3 acute kidney injury, and PICU mortality and the association between elevated day 1 interleukin-6 and PICU mortality was partially mediated by the interval development of day 3 positive cumulative fluid balance and day 3 acute kidney injury (p < 0.001).

CONCLUSIONS

In pediatric acute respiratory distress syndrome, elevated cumulative fluid balance on day 3 of acute respiratory distress syndrome is associated with mortality specifically in patients with concomitant acute kidney injury. Plasma interleukin-6 levels are associated with the development of positive cumulative fluid balance and acute kidney injury, suggesting a potential mechanism by which inflammation might predispose to mortality.

Protective effects of propofol on experimental neonatal acute lung injury

The present study aimed to investigate the effects of propofol on neonatal acute lung injury (ALI) in a rat model and to examine the molecular mechanisms underlying propofol function. A rat model of ALI was established by intraperitoneal injection of lipopolysaccharides (LPS). The neonatal rats were treated with various concentrations of propofol and a lung injury score was assessed. The protein expression levels of pro‑inflammatory cytokines was detected using ELISA. In the present study, oxidative stress was determined by measuring the level of malondialdehyde (MDA) and the activity of superoxide dismutase (SOD) in lung tissues. Reverse transcription quantitative‑polymerase chain reaction and western blot analysis were used to examine the mRNA and protein expression levels of the factors downstream to LPS signaling pathway. Treatment with propofol significantly alleviated LPS‑induced lung injury in neonatal rats as suggested by the decreased lung injury score, increased partial pressure of oxygen and decreased lung wet‑dry weight ratio. LPS promoted the upregulation of tumor necrosis factor α (TNF‑α), interleukin (IL)‑6 and IL‑1β in lung tissues and bronchoalveolar lavage fluid from neonatal rats exhibiting ALI. Notably, treatment with propofol decreased the expression levels of these factors. Additionally, LPS caused an increase in the levels of MDA, and a decrease in SOD activity, and treatment with propofol suppressed these effects in a dose‑dependent manner. Furthermore, LPS induced the upregulation of phosphorylated (p‑)p38, nuclear factor κ‑light‑chain‑enhancer of activated B cells (NF‑κB), p‑p65, NLR family pyrin domain containing 3 (NLRP3), apoptosis‑associated speck‑like protein containing CARD and caspase‑1 in lung tissues of neonatal rats, and treatment with propofol was able to downregulate these factors in a dose‑dependent manner. Propofol alleviated lung injury in neonatal rats with LPS‑induced ALI by preventing inflammation and oxidative stress via the regulation of the activity of the p38 mitogen‑activated protein kinase/NF‑κB signaling pathway and the expression levels of the NLRP3 inflammasome.

Outcomes of Children With Critical Bronchiolitis Meeting at Risk for Pediatric Acute Respiratory Distress Syndrome Criteria

OBJECTIVES

New definitions of pediatric acute respiratory distress syndrome include criteria to identify a subset of children "at risk for pediatric acute respiratory distress syndrome." We hypothesized that, among PICU patients with bronchiolitis not immediately requiring invasive mechanical ventilation, those meeting at risk for pediatric acute respiratory distress syndrome criteria would have worse clinical outcomes, including higher rates of pediatric acute respiratory distress syndrome development.

DESIGN

Single-center, retrospective chart review.

SETTING

Mixed medical-surgical PICU within a tertiary academic children's hospital.

PATIENTS

Children 24 months old or younger admitted to the PICU with a primary diagnosis of bronchiolitis from September 2013 to April 2014. Children intubated before PICU arrival were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Collected data included demographics, respiratory support, oxygen saturation, and chest radiograph interpretation by staff radiologist. Oxygen flow (calculated as FIO2 × flow rate [L/min]) was calculated when oxygen saturation was 88-97%. The median age of 115 subjects was 5 months (2-11 mo). Median PICU length of stay was 2.8 days (1.5-4.8 d), and median hospital length of stay was 5 days (3-10 d). The criteria for at risk for pediatric acute respiratory distress syndrome was met in 47 of 115 subjects (40.9%). Children who were at risk for pediatric acute respiratory distress syndrome were more likely to develop pediatric acute respiratory distress syndrome (15/47 [31.9%] vs 1/68 [1.5%]; p < 0.001), had longer PICU length of stay (4.6 d [2.8-10.2 d] vs 1.9 d [1.0-3.1 d]; p < 0.001) and hospital length of stay (8 d [5-16 d] vs 4 d [2-6 d]; p < 0.001), and increased need for invasive mechanical ventilation (16/47 [34.0%] vs 2/68 [2.9%]; p < 0.001), compared with those children who did not meet at risk for pediatric acute respiratory distress syndrome criteria.

CONCLUSIONS

Our data suggest that the recent definition of at risk for pediatric acute respiratory distress syndrome can successfully identify children with critical bronchiolitis who have relatively unfavorable clinical courses.

Pulmonary Functions in Children Ventilated for Acute Hypoxemic Respiratory Failure

OBJECTIVE

To assess pulmonary functions of children who received mechanical ventilation for acute hypoxemic respiratory failure.

DESIGN

Longitudinal study.

SETTING

PICU and Pediatric Pulmonology Clinic of a tertiary care teaching hospital in North India.

PATIENTS

All children, 5-12 years old, ventilated for acute hypoxemic respiratory failure in PICU from July 2012 to June 2013 and survived.

INTERVENTIONS

The baseline admission variables recorded were as follows: age, sex, duration of illness, primary diagnosis at admission, Pediatric Risk of Mortality III score, lung injury score, mechanical ventilation parameters, oxygenation indices, and duration of PICU stay. The children were followed up twice, at 3 and 9-12 months, after discharge from PICU and evaluated for any residual respiratory symptoms and signs, pulse oximetry, chest radiograph, 6-minute walk test, peak expiratory flow rate, and spirometry. Age, sex, duration of illness, primary diagnosis, Pediatric Risk of Mortality III score, lung injury score, mechanical ventilation parameters, oxygenation indices (PaO2/FIO2 ratio and oxygenation index), and duration of PICU stay were recorded from patient records.

MEASUREMENTS AND MAIN RESULTS

Twenty-nine children (25 boys and four girls; mean [SD] age, 8.4 [2.4] yr) were followed up at 3.5 (± 1.2) and 10.6 (± 2.7) months after discharge from PICU. Recurrent respiratory symptoms were noted in 37.9% patients (11/29) during first and in none during second follow-up. None had limitation of physical activity or need of supplemental oxygen. Chest examination was normal in all, except one during first follow-up, but 13.8% (4/29) had abnormal chest radiograph during first follow-up. Nearly all children could perform 6-minute walk test although mean distance walked increased significantly from first (352 ± 66.7 m) to second follow-up (401 ± 60.7 m; p = 0.002). Abnormal spirometry was seen in 82.7% (24/29) versus 18.5% (5/27) children during first and second follow-up visits, respectively (p = 0.0001). Most cases had restrictive abnormality (58.6% vs 11.1%; p = 0.002) during first and second follow-up, respectively. There was no correlation between pulmonary functions and lung injury scores, oxygenation indices (PaO2/FIO2 ratio and oxygenation index), and mechanical ventilation parameters.

CONCLUSIONS

Significant number of children ventilated for acute hypoxemic respiratory failure had subclinical pulmonary function abnormality, without limiting physical activity, which improved over time. Further research on this topic with a larger sample size and patient categorization according to recent pediatric acute respiratory distress syndrome definition is needed.

Developmental differences in focal adhesion kinase expression modulate pulmonary endothelial barrier function in response to inflammation

Compromised pulmonary endothelial cell (PEC) barrier function characterizes acute respiratory distress syndrome (ARDS), a cause of substantial morbidity and mortality. Survival from ARDS is greater in children compared with adults. Whether developmental differences intrinsic to PEC barrier function contribute to this survival advantage remains unknown. To test the hypothesis that PEC barrier function is more well-preserved in neonatal lungs compared with adult lungs in response to inflammation, we induced lung injury in neonatal and adult mice with systemic lipopolysaccharide (LPS). We assessed PEC barrier function in vivo and in vitro, evaluated changes in the expression of focal adhesion kinase 1 (FAK1) and phosphorylation in response to LPS, and determined the effect of FAK silencing and overexpression on PEC barrier function. We found that LPS induced a greater increase in lung permeability and PEC barrier disruption in the adult mice, despite similar degrees of inflammation and apoptosis. Although baseline expression was similar, LPS increased FAK1 expression in neonatal PEC but increased FAK1 phosphorylation and decreased FAK1 expression in adult PEC. Pharmacologic inhibition of FAK1 accentuated LPS-induced barrier disruption most in adult PEC. Finally, in response to LPS, FAK silencing markedly impaired neonatal PEC barrier function, whereas FAK overexpression preserved adult PEC barrier function. Thus, developmental differences in FAK expression during inflammatory injury serve to preserve neonatal pulmonary endothelial barrier function compared with that of adults and suggest that intrinsic differences in the immature versus pulmonary endothelium, especially relative to FAK1 phosphorylation, may contribute to the improved outcomes of children with ARDS.

First report that prior ECMO therapy does not preclude hematopoietic cell transplantation

Hematopoietic stem cell transplantation (HCT) offers a potential cure for patients with high-risk malignancies but carries a risk of death from transplant-related complications. Extracorporeal membrane oxygenation (ECMO) is often considered a contraindication to transplant with the assumption that lung injury puts the patient at risk for pulmonary complications post-HCT. Although patients who have required prolonged intubation show gradual improvement in pulmonary function over time, there is little data on pulmonary functional recovery after ECMO which makes assessment pre-HCT difficult. We present a case series of two patients with high-risk hematologic malignancies, who had previously received ECMO and then underwent reduced-intensity HCT. Although both patients had complications post-HCT, neither patient suffered significant pulmonary toxicity related to their prior ECMO exposure. We conclude that, although patients who have previously been treated with ECMO remain at high risk for complications after transplant, but they should not be excluded from consideration for reduced intensity transplantation.

A Systematic Review of Risk Factors Associated With Cognitive Impairment After Pediatric Critical Illness

OBJECTIVES

To identify risk factors associated with cognitive impairment as assessed by neuropsychologic tests in neurotypical children after critical illness.

DATA SOURCES

For this systematic review, we searched the Cochrane Library, Scopus, PubMed, Ovid, Embase, and CINAHL databases from January 1960 to March 2017.

STUDY SELECTION

Included were studies with subjects 3-18 years old at the time of post PICU follow-up evaluation and use of an objective standardized neuropsychologic test with at least one cognitive functioning dimension. Excluded were studies featuring patients with a history of cardiac arrest, traumatic brain injury, or genetic anomalies associated with neurocognitive impairment.

DATA EXTRACTION

Twelve studies met the sampling criteria and were rated using the Newcastle-Ottawa Quality Assessment Scale.

DATA SYNTHESIS

Ten studies reported significantly lower scores in at least one cognitive domain as compared to healthy controls or normed population data; seven of these-four case-control and three prospective cohort studies-reported significant lower scores in more than one cognitive domain. Risk factors associated with post critical illness cognitive impairment included younger age at critical illness and/or older age at follow-up, low socioeconomic status, high oxygen requirements, and use of mechanical ventilation, sedation, and pain medications.

CONCLUSIONS

Identifying risk factors for poor cognitive outcomes post critical illness may help healthcare teams modify patient risk and/or provide follow-up services to improve long-term cognitive outcomes in high-risk children.

Effects of probiotics on ghrelin and lungs in children with acute lung injury: A double-blind randomized, controlled trial

AIM

To assess the effects of probiotics on serum ghrelin levels and protection for lungs in children with acute lung injury (ALI).

METHODS

This study was performed as a double-blind, randomized, and controlled trial in a pediatric intensive care unit (PICU). The eligible children with ALI were assigned to either probiotic treatment or an identical placebo for 10 days. Serum ghrelin, SP-A(surfactant protein-A), TNF-α, and IL-6 concentrations were assessed at baseline and at the end of trial. Meanwhile, pulmonary function test and echocardiography were examined, then VPEF (volume to peak tidal expiratory flow), TPEF/TE (the ratio of time taken to reach peak expiratory flow to total expiratory time), MAP (mean arterial pressure), and PAP (pulmonary artery pressure) were recorded.

RESULTS

Eighty participants fulfilled the study requirements with 40 children for each group. The groups were comparable in baseline characteristics. Serum SP-A, TNF-α, and IL-6 levels in the probiotic group were 212.6 ± 52.9 ng/mL, 401.9 ± 56.4 pg/mL, and 245.1 ± 55.1 pg/mL on day 10, respectively, significantly lower levels compared to the control group where the same parameters were 248.2 ± 57 ng/mL, 449.4 ± 60.1 pg/mL, and 308.3 ± 92.2 pg/mL (P < 0.01). However, ghrelin concentrations were elevated in the intervention group (P < 0.05). On measurement of pulmonary function, the probiotic group demonstrated a VPEF of 26.1 ± 4.2 mL and TPEF/TE of 29.1 ± 4.7%, which were higher than the control group (24.7 ± 4.3 mL and 26.9 ± 4.7%, respectively) (P < 0.05). MAP and PAP also improved in the probiotic group (P < 0.05). Furthermore, ghrelin, SP-A, TNF-α, IL-6, and PAP were negatively correlated. Positive correlations were found between ghrelin, TPEF/TE, and MAP. There were no probiotic-associated adverse events during the observation.

CONCLUSION

Probiotics administrated to children with ALI alleviates the inflammation of lungs, improves pulmonary function and circulation by ghrelin.

Impact of Obesity on Outcomes in Critically Ill Children

PURPOSE

To examine whether obesity confers a protective effect on critically ill pediatric patients, similar to what has been reported in critically ill adults.

METHODS

A retrospective cohort study including patients aged 2-18 years admitted to a 24-bed pediatric intensive care unit from 2009 to 2014. Patients were divided into 1 of 3 weight categories: normal weight (body mass index [BMI], 5%-84.9%), overweight (BMI, 85%-94.9%), and obese (BMI ≥95%). Outcomes investigated included mortality, need for intubation, need for inotropic support, and duration of mechanical ventilation.

RESULTS

A total of 1817 patient encounters met inclusion criteria. There was no difference in Pediatric Index of Mortality 2 scores between groups. There was a significantly smaller percentage of overweight and obese patients requiring intubation ( P = .003) and inotropic support ( P = .031) compared with normal-weight patients. Being overweight or obese was neither protective nor a risk factor for mortality with an adjusted odds ratio of 1.83 (confidence interval [CI], 0.82-3.85; P = .12) and 1.51 (CI, 0.70-3.12; P = .27) comparing the overweight and obese groups with the normal-weight group, respectively. There was no difference in duration of mechanical ventilation between the normal-weight and overweight and obese groups ( P = .893 and 0.484, respectively).

CONCLUSIONS

In critically ill pediatric patients, being overweight or obese was associated with decreased need for intubation and inotropic support compared with normal-weight patients. However, being overweight or obese is neither protective nor a risk factor for mortality or duration of mechanical ventilation.

Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit

Purpose of review

With increasing survival of children requiring admission to pediatric intensive care units (PICU), neurodevelopmental outcomes of these patients are an area of increased attention. Our goal was to systematically review recently published literature on neurologic outcomes of PICU patients.

Recent Findings

Decline in neurofunctional status occurs in 3%-20% of children requiring PICU care. This proportion varies based on primary diagnosis and severity of illness, with children admitted for primary neurologic diagnosis, children who suffer cardiac arrest or who require invasive interventions during the PICU admission, having worse outcomes. Recent research focuses on early identification and treatment of modifiable risk factors for unfavorable outcomes, and on long-term follow-up that moves beyond global cognitive outcomes and is increasingly including tests assessing multidimensional aspects of neurodevelopment.

Summary

The pediatric critical care research community has shifted focus from survival to survival with favorable neurologic outcomes of children admitted to the PICU.

Mortality in Pediatric Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis

OBJECTIVE

Sparse and conflicting evidence exists regarding mortality risk from pediatric acute respiratory distress syndrome (ARDS). We aimed to determine the pooled mortality in pediatric ARDS and to describe its trend over time.

DATA SOURCES AND STUDY SELECTION

MEDLINE, EMBASE, and Web of Science were searched from 1960 to August 2015. Keywords or medical subject headings (MESH) terms used included "respiratory distress syndrome, adult," "acute lung injury," "acute respiratory insufficiency," "acute hypoxemic respiratory failure," "pediatrics," and "child." Study inclusion criteria were (1) pediatric patients aged 0 days to 18 years, (2) sufficient baseline data described in the pediatric ARDS group, and (3) mortality data. Randomized controlled trials (RCTs) and prospective observational studies were eligible.

DATA EXTRACTION AND SYNTHESIS

Data on study characteristics, patient demographics, measures of oxygenation, and mortality were extracted using a standard data extraction form. Independent authors conducted the search, applied the selection criteria, and extracted the data. Methodological quality of studies was assessed. Meta-analysis using a random-effects model was performed to obtain pooled estimates of mortality. Meta-regression was performed to analyze variables contributing to change in mortality over time. Eight RCTs and 21 observational studies (n = 2274 patients) were included. Pooled mortality rate was 24% (95% confidence interval [CI]: 19-31). There was a decrease in mortality rates over 3 epochs (≤2000, 2001-2009, and ≥2010: 40% [95% CI: 24-59], 35% [95% CI: 21-51], and 18% [95% CI: 12-26], respectively, P < .001). Observational studies reported a higher mortality rate than RCTs (27% [95% CI: 24-29] versus 16% [95% CI: 12-20], P < .001). Earlier year of publication was an independent factor associated with mortality.

CONCLUSION

Overall mortality rate in pediatric ARDS is approximately 24%. Studies conducted and published later were associated with better survival.

[Acute respiratory distress syndrome in childhood: Changing definition and news from the Pediatric Consensus Conference]

Acute respiratory distress syndrome (ARDS) is a rapidly progressive hypoxemic respiratory insufficiency induced by alveolar filling mainly caused by alveolocapillary wall disruption, following direct or indirect pulmonary injury. Much less frequent in children than in adults, pediatric intensivists had long applied adult guidelines to their daily practice. In 2015, experts from the Pediatric Acute Lung Injury Consensus Conference (PALICC) published the first international guidelines specifically dedicated to pediatric ARDS. After a short summary of the history of the ARDS definition since its first report in 1967, we describe the main diagnostic and therapeutic guidelines for PALICC.

Predictive Value of Intraoperative Troponin I Elevation in Pediatric Living Donor Liver Transplant Recipients With Biliary Atresia

BACKGROUND

Pediatric living donor liver transplantation is associated with slight alteration in cardiac enzymes without ongoing acute cardiac injury, but available information about the significance of these changes is limited. The aims of this study were to analyze the link between the anomalies of intraoperative serum cardiac troponin I (cTnI) and acute lung injury during the first week after liver transplantation.

METHODS

In this retrospective study, 123 children suffering from biliary atresia were enrolled. Several perioperative variables, particularly cTnI before operation and at 30 minutes of neohepatic phase were recorded. Sixty-four recipients were divided into high cTnI group (≥0.07 ng/mL) and 59 recipients composed normal cTnI group (<0.07 ng/mL). The clinical data between 2 groups were compared and the association between serum cTnI level and acute lung injury after living donor liver transplantation were evaluated by univariate and multivariate logistic regression analyses.

RESULTS

The percentage of acute lung injury after pediatric living donor liver transplantation among high cTnI group and normal cTnI group was 34.3% and 11.9%, respectively. Intratransplant cTnI ≥ 0.07 ng/mL (odds ratio [OR], 3.475; 95% confidence interval [CI], 1.114-10.842) was the risk factors for acute lung injury after transplantation. The value of cTnI showed the close correlation with preoperative bilirubin (OR, 1.005; 95% CI, 1.002-1.008) and pretransplant albumin (OR, 0.915; 95% CI, 0.849-0.986).

CONCLUSIONS

Intraoperative cTnI elevation was the significant prognostic risk factor in acute lung injury after pediatric living-donor liver transplantation for children with biliary atresia. And the value of cTnI was associated with preoperative bilirubin and albumin level.

Long-Term Function After Pediatric Critical Illness: Results From the Survivor Outcomes Study

OBJECTIVE

Knowledge of the long-term outcomes of survivors of pediatric critical illness is sparse but important. The aim of this study was to evaluate morbidity and mortality 6 months and 3 years after hospital discharge.

DESIGN

Prospective cohort study.

SETTING

Urban, inner city, academic PICU.

PATIENTS

Consecutive patients admitted to the PICU from June 2012 to August 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We collected descriptive and demographic information and functional status assessments at baseline, admission, hospital discharge, 6 months and 3 years following discharge. Functional status was measured with the Functional Status Scale. New morbidity was defined as a change in Functional Status Scale score of greater than or equal to 3. Postdischarge assessments utilized scripted telephone surveys. Of 303 consecutive PICU patients, 253 were eligible and 129 parents consented. Follow-up outcomes were obtained for 77 patients (59.7%) at 6 months and 70 of these patients (54.2%) at 3 years. Both mortality and morbidity increased after discharge. Cumulative mortality increased from 3.9% (n = 3) at discharge to 7.8% (n = 6) at 6 months (p = 0.08) and 10.4% (n = 8) at 3 years (p = 0.03). New morbidity increased cumulatively from 5.2% (n = 4) at discharge to 6.5% (n = 5) at 6 months (p = 0.65) and 10.4% (n = 8) at 3 years (p = 0.16). Almost as many children demonstrated worsening of their functional status or died (38%) as children who survived without a change in functional status (44%). Less than 10% of children exhibited functional gains over time. Long-term functional outcome was associated with PICU variables including the need for invasive therapies and indicators of severity of illness such as use of mechanical ventilation, ventilator days, use of vasoactive medications, and PICU length of stay. The combined poor outcomes of new morbidity and mortality increased cumulatively from 9.1% (n = 7) at discharge to 14.3% (n = 11) at 6 months (p = 0.16) and 20.8% (n = 16) by 3 years (p = 0.01).

CONCLUSIONS

Mortality and new morbidity appear to substantially increase after discharge. Critical illness is associated with a sustained impact on survival and functional status.