Acute Lung Injury Consensus Conference Research Articles

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

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. 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. Not applicable. Patients with or at risk for PARDS. None. 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%. 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.

A Comprehensive Review on the Management of ARDS among Pediatric Patients

Pediatric acute respiratory distress syndrome (PARDS) is a complex inflammatory syndrome of lungs leading to disruption of alveolar epithelial membrane barrier in the lungs. It includes varying age groups from infants to adolescents. PARDS definition has changed over decades as current definition is given by the Pediatric Acute Lung Injury Consensus Conference group. Although most of management principles are extrapolated from adult data, physiology of Acute Respiratory Distress Syndrome (ARDS) in children is different when compared to adults. The present review mainly focused on current evidence in the management of ARDS with emphasis to pediatric population. MeSH headings such as ARDS, positive end-expiratory pressure (PEEP), and lung protective ventilation were used for searching publications in PubMed, Embase, and SciELO. Publications were limited to human studies in the past 20 years. Core ventilatory strategies in PARDS include use of low-tidal volume, higher PEEP and acceptance of permissive hypercapnia and permissive hypoxemia. Supportive strategies such as restrictive fluid therapy, prone positioning, early enteral nutrition, and adequate analgosedation remain the mainstay of management of principles. As PARDS contains heterogeneous population, personalized mechanical ventilation under umbrella of lung protective ventilator strategies such as low-tidal volume ventilation, open lung strategy, acceptance of permissive hypercapnia, and permissive hypoxia is standard of care.

P50 implies adverse clinical outcomes in pediatric acute respiratory distress syndrome by reflecting extrapulmonary organ dysfunction

Hypoxemia and multiple organ dysfunction are significant contributors to mortality in patients with pediatric acute respiratory distress syndrome (PARDS). P50, the oxygen tension at which hemoglobin is 50% saturated, is a measure of hemoglobin-oxygen affinity, and its alteration might have implications for tissue hypoxia and organ dysfunction. The purpose of this single-center, retrospective study was to evaluate P50 levels in PARDS and to determine the association between P50 and clinical outcomes. The study included 212 children diagnosed with PARDS according to the Pediatric Acute Lung Injury Consensus Conference definition who required invasive mechanical ventilation and had arterial blood gas results of hemoglobin oxygen saturation < 97% at the time of diagnosis. P50 levels were calculated using Doyle’s method, and organ dysfunction was assessed using the Pediatric Logistic Organ Dysfunction-2 score. Most patients exhibited more than one dysfunctional extrapulmonary organ at PARDS onset. P50 increased with increasing PARDS severity (mild (26.6 [24.9–29.6]), moderate (26.8 [25.0–29.5]), and severe PARDS (29.1 [26.1–32.4] mmHg; P = 0.025). Moreover, P50 demonstrated a significant positive association with extrapulmonary organ dysfunction score (β = 0.158, P = 0.007) and risk of mortality (adjusted hazard ratio, 1.056; 95% confidence interval, 1.015–1.098; P = 0.007), irrespective of initial PARDS severity. The relationship between P50 and mortality was largely mediated by extrapulmonary organ dysfunction. A high P50 value at the time of PARDS diagnosis may be associated with mortality via dysfunctional extrapulmonary organs. Future studies should consider P50 as a potential candidate index for risk stratification of PARDS patients.

Recognizing Pediatric ARDS: Provider Use of the PALICC Recommendations in a Tertiary Pediatric ICU.

For almost 50 years, pediatricians used adult guidelines to diagnose ARDS. In 2015, specific criteria for pediatric ARDS were defined. However, it remains unclear how frequently providers recognize pediatric ARDS and whether recognition affects adherence to consensus recommendations. This was a mixed-method, retrospective study of mechanically ventilated pediatric subjects after the release of the pediatric ARDS recommendation statement. Pediatric ARDS cases were identified according to the new criteria. Provider recognition was defined by documentation in the medical record. Pediatric ARDS subjects with and without provider recognition were compared quantitatively according to clinical characteristics, adherence to lung-protective ventilation (LPV), adjunctive therapies, and outcomes. A qualitative document analysis (QDA) was performed to evaluate knowledge and beliefs surrounding the Pediatric Acute Lung Injury Consensus Conference recommendations. Of 1,983 subject encounters, pediatric ARDS was identified in 321 (16%). Provider recognition was present in 97 (30%) cases and occurred more often in subjects who were older, had worse oxygenation deficits, or were bone marrow transplant recipients. Recognition rates increased each studied year. LPV practices did not differ based on provider recognition; however, subjects who received it were more likely to experience permissive hypoxemia and adherence to extrapulmonary recommendations. Ultimately, there was no differences in outcomes between the provider recognition and non-provider recognition groups. Three themes emerged from the QDA: (1) pediatric ARDS presents within a complex, multidimensional context, with potentially competing organ system failures; (2) similar to historical conceptualizations, pediatric ARDS was often considered a visual diagnosis, with measures of oxygenation unreferenced; and (3) emphasis was placed on non-evidence-based interventions, such as pulmonary clearance techniques, rather than on consensus recommendations. Among mechanically ventilated children, pediatric ARDS was common but recognized in a minority of cases. Potential opportunities, such as an opt-out approach to LPV, may exist for improved dissemination and implementation of recommended best practices.

A single-center PICU present status survey of pediatric sepsis-related acute respiratory distress syndrome.

To describe the incidence, clinical features, outcomes, and mortality risk factors of sepsis associated with acute respiratory distress syndrome (ARDS) in pediatric patients. Patients were included in the study if they met the 2005 version of the International Pediatric Sepsis Consensus Conference and met the Pediatric Acute Lung Injury Consensus Conference (PALICC) definition within 48 h of sepsis diagnosis. Patients were classified as mild, moderate, and severe by the worst oxygenation index (OI) within 72 h of sepsis-related ARDS diagnosis. Between January 1, 2015 and March 13, 2020, 9836 patients were admitted to the pediatric intensive care unit(PICU) of the Children's Hospital of Chongqing Medical University and 828 (8.4%) were identified with sepsis and 203 (24.5%) met the PALICC definition with a PICU mortality rate of 24.6% (50/203) and a 90-day mortality rate of 40.9% (83/203). After adjusting for septic shock, the pediatric logistic organ dysfunction 2 (PELOD-2), high-frequency oscillation ventilation (HFOV), and continuous renal replacement therapy (CRRT), the variables that retained an independent association with increased 90-day mortality in pediatric sepsis-related ARDS included ARDS severity, the pediatric risk of mortality III (PRISM III), number of organ dysfunctions and use of vasoactive drug types during PICU stay. PICU mortality in pediatric sepsis-related ARDS was high (24.6%) and severity of hypoxemia based on the worst OI value 72 h after meeting the PALICC definition accurately stratified the patient outcomes. ARDS severity, PRISM III score, comorbid multiorgan dysfunction, and use of multiple vasoactive drugs during PICU stay were independent risk factors for 90-day mortality in pediatric sepsis-related ARDS.

Clinical Outcomes of Acute Respiratory Failure Associated With Noninvasive and Invasive Ventilation in a Pediatric ICU.

It remains unknown if pediatric patients failing initial noninvasive ventilation (NIV) experience worse clinical outcomes than those successfully treated with NIV or those primarily intubated. This was a single-center, retrospective review of patients admitted with acute respiratory failure to the University of Michigan pediatric intensive care or cardiothoracic ICUs and receiving NIV or invasive mechanical ventilation as first-line therapy. One hundred seventy subjects met inclusion criteria and were enrolled: 65 NIV success, 55 NIV failure, and 50 invasive mechanical ventilation alone. Of those failing NIV, median time to intubation was 1.8 (interquartile range [IQR] < 1-7) h. On multivariable regression, ICU-free days were significantly different between groups (NIV success: 22.9 ± 6.9 d; NIV failure: 13.0 ± 6.6 d; invasive ventilation: 12.5 ± 6.9 d; P < .001 across all groups). Multivariable regression revealed no difference in ventilator-free days between NIV failure and invasive ventilation groups (15.4 ± 10.1 d vs 15.9 ± 9.7 d, P = .71). Of 64 subjects (37.6%) meeting Pediatric Acute Lung Injury Consensus Conference pediatric ARDS criteria, only 14% were successfully treated with NIV. Ventilator-free days were similar between the NIV failure and invasive ventilation groups (11.6 vs 13.2 d, P = .47). On multivariable analysis, ICU-free days were significantly different across pediatric ARDS groups (P < .001): NIV success: 20.8 + 31.7 d; NIV failure: 8.3 + 23.8 d; invasive alone: 8.9 + 23.9 d, yet no significant difference in ventilator-free days between those with NIV failure versus invasive alone (11.6 vs 13.2 d, P = .47). We demonstrated that critically ill pediatric subjects unsuccessfully trialed on NIV did not experience increased ICU length of stay or fewer ventilator-free days when compared to those on invasive mechanical ventilation alone, including in the pediatric ARDS subgroup. Our findings are predicated on a median time to intubation of < 2 h in the NIV failure group and the provision of adequate monitoring while on NIV.

ONE LUNG LUCY: PEDIATRIC ARDS IN A CHILD WITH LUNG AGENESIS

TYPE: Case Report TOPIC: Critical Care INTRODUCTION: Pediatric acute respiratory distress syndrome (PARDS) is a relatively common clinical problem in the PICU. However, ARDS in a pediatric patient with one lung is unique and not well defined. We present such a case and highlight challenges in management. CASE PRESENTATION: Our patient is a 14month old girl who presented to the ER in acute hypoxemic respiratory failure secondary to RSV bronchiolitis. Her past medical history is significant for left lung agenesis and supracardiac total anomalous pulmonary venous return (surgically repaired). She was admitted to the PICU and subsequently developed severe ARDS, with peak OI of 28. Single lung protective strategy was initially applied with the use of lower tidal volumes of 5-6 ml/kg and a PEEP of 6. Inhaled NO was employed and she was subsequently placed on tidal volumes of 8ml/kg and PEEP of 8 with subsequent improved lung compliance. She was successfully extubated after 2 weeks of MV. DISCUSSION: The Pediatric Acute Lung Injury Consensus Conference (PALICC) developed pediatric-specific definitions for ARDS and recommendations regarding treatment. Recommendations regarding management of patients with one lung who develop ARDS are lacking. One lung ventilation is a standard approach to facilitate surgical exposure for pulmonary and other thoracic surgeries, however it is not known whether ventilation strategies suggested by the anesthesia literature is applicable to PARDS. CONCLUSIONS: Our case presented challenges in providing adequate ventilation and oxygenation while minimizing further lung injury in a patient with one lung PARDS. Further study is needed to elucidate the optimum mechanical ventilation strategy. DISCLOSURE: Nothing to declare. KEYWORD: One Lung ARDS

Clinical Outcome Discrimination in Pediatric ARDS by Chest Radiograph Severity Scoring.

Background There is no accurate radiological measurement to estimate the severity of pediatrics acute respiratory distress syndrome (PARDS). We validated the effectiveness of an adult radiographic assessment of lung edema (RALE) score in PARDS. Aim To assess the severity and prognosis of PARDS based on a chest radiograph (CXR) RALE scoring method. Methods Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria were used to diagnose PARDS. General demographics, pulmonary complications, and 28‐day mortality of the patients were recorded. Subgroups were compared by prognosis (survive and death) and etiology (infection and noninfection). Two observers calculated RALE independently. Each quadrant of CXR was scored by consolidation scores 0 (none alveolar opacity), 1 (extent <25%), 2 (extent 25%–50%), 3 (50%–75%), and 4 (>75%) and density scores 1 (hazy), 2 (moderate), and 3 (dense). Quadrant score equals consolidation score times density score. Total score equals to the sum of four quadrants scores. The ROC curve and survival curve were established, and the optimal cutoff score for discrimination prognosis was set. Results 116 PARDS (72 boys and 44 girls) and 463 CXRs were enrolled. The median age was 25 months (5 months, 60.8 months) and with a mortality of 37.9% (44/116). The agreement between two independent observers was excellent (ICC = 0.98, 95% CI: 0.97–0.99). Day 3 score was independently associated with better survival (p < 0.001). The area under the curve of ROC was 0.773 (95% CI: 0.709–0.838). The cutoff score was 21 (sensitivity 71.7%, specificity 76.5%), and the hazard ratio (HR) was 9.268 (95% CI: 1.257–68.320). The pulmonary complication showed an HR of 3.678 (95% CI: 1.174–11.521) for the discrimination. Conclusion CXR RALE score can be used in PARDS for discriminating the prognosis and has a better agreement among radiologist and pediatrician. PARDS with pulmonary complications, day 3 score whether greater than 21 points, have a better predictive effectiveness.

Гострий респіраторний дистрес-синдром у дітей. Що нового?

Респіраторний дистрес-синдром у дітей — одна з найскладніших патологій, з якою доводиться стикатися у відділеннях реанімації та інтенсивної терапії. У педіатричній практиці були відсутні конкретні рекомендації щодо діагностики та лікування дітей різних вікових груп. Не було конкретних педіатричних дефініцій для респіраторного дистрес-синдрому дорослих. У 2015 році експертами Погоджувальної конференції з педіатричного гострого респіраторного дистрес-синдрому (ПГРДС) (The Pediatric Acute Lung Injury Consensus Conference) були опубліковані конкретні визначення по ГРДС у дітей, а також подані пріоритетні напрямки для майбутніх досліджень. Було розроблено в цілому 151 рекомендацію, що стосуються розділів, пов’язаних із педіатричним гострим респіраторним дистрес-синдромом: визначення, поширеність та епідеміологія; патофізіологія, супутні захворювання та тяжкість; респіраторна підтримка; легенева, допоміжна і нелегенева терапія; моніторинг; неінвазивна респіраторна підтримка та вентиляція; екстракорпоральні методи лікування; захворюваність і довгострокові результати. У цій статті надані основні розроблені рекомендації та конкретизований ряд позицій, що мають особливості тільки для педіатричного ГРДС. До того ж, визначено ряд відмінностей між гострим респіраторним дистрес-синдромом дорослих та дітей як в його діагностиці, так і в лікуванні. При оцінці оксигенації, рівня гіпоксемії та визначенні тяжкості педіатричного ГРДС були прийняті такі показники, як індекс осксигенації (OI) = (FIO2 × середній тиск в дихальних шляхах (Paw) × 100) / РаО2, та індекс насичення киснем (OSI) = (FIO2 × Paw × 100) / SpO2 [11, 12]. Все це буде оптимізувати та покращувати терапію ГРДС у дітей і в подальшому знижувати показник їх смертності від цієї патології.

Influenza Virus Associated Pediatric Acute Respiratory Distress Syndrome: Clinical Characteristics and Outcomes.

The aim of this multicenter retrospective study was to determine the clinical characteristics, treatment approaches and the course of pediatric acute respiratory distress syndrome (PARDS) which developed associated with the influenza virus in the 2019-20 season. Patients included 1 month to 18 years who were diagnosed with PARDS associated with the influenza virus in the 2019-20 season. Sixty-seven patients were included in the study. The mean age of the patients was 64.16 ± 6.53 months, with 60% of the group <5 years. Influenza A was determined in 54 (80.5%) patients and Influenza B in 13 (19.5%). The majority of patients (73.1%) had a comorbidity. Fifty-eight (86.6%) patients were applied with invasive mechanical ventilation, Pediatric Acute Lung Injury Consensus Conference classification was mild in 5 (8.6%), moderate in 22 (37.9%) and severe in 31 (52.5%) patients. Ventilation was applied in the prone position to 40.3% of the patients, and in nonconventional modes to 24.1%. A total of 22 (33%) patients died, of which 4 had been previously healthy. Of the surviving 45 patients, 38 were discharged without support and 7 patients with a new morbidity. Both Influenza A and Influenza B cause severe PARDS with similar characteristics and at high rates. Influenza-related PARDS cause 33% mortality and 15.5% morbidity among the study group. Healthy children, especially those aged younger than 5 years, are also at risk.

Oxygenation Defects, Ventilatory Ratio, and Mechanical Power During Severe Pediatric Acute Respiratory Distress Syndrome: Longitudinal Time Sequence Analyses in a Single-Center Retrospective Cohort.

Our understanding of pediatric acute respiratory distress syndrome is based on information from studies reporting intermittent, serial respiratory data. We have analyzed a high-resolution, longitudinal dataset that incorporates measures of hypoxemia severity, metrics of lung mechanics, ventilatory ratio, and mechanical power and examined associations with survival after the onset of pediatric acute respiratory distress syndrome. Single-center retrospective cohort, 2013-2018. Tertiary surgical/medical PICU. Seventy-six cases of severe pediatric acute respiratory distress syndrome, determined according to the Pediatric Acute Lung Injury Consensus Conference criteria. None. The high-resolution database included continuous monitoring of ventilatory data (0.03 Hz) for up to 14 days after the diagnosis of pediatric acute respiratory distress syndrome or until extubation or death (n = 26). In the 12,128 hours of data during conventional mechanical ventilation, we used generalized estimating equations to compare groups, accounting for any effect of time. We identified an association between survival and faster rate of improvement in delta pressure (peak inspiratory pressure minus positive end-expiratory pressure; p = 0.028). Nonsurvival was associated with higher daily Pediatric Logistic Organ Dysfunction-2 scores (p = 0.005) and more severe hypoxemia metrics (p = 0.005). Mortality was also associated with the following respiratory/pulmonary metrics (mean difference [95% CI]): positive end-expiratory pressure level (+2.0 cm H2O [0.8-3.2 cm H2O]; p = 0.001), peak inspiratory pressure level (+3.0 cm H2O [0.5-5.5 cm H2O]; p = 0.022), respiratory rate (z scores +2.2 [0.9-3.6]; p = 0.003], ventilatory ratio (+0.41 [0.28-0.55]; p = 0.0001], and mechanical power (+5 Joules/min [1-10 Joules/min]; p = 0.013). Based on generalized linear mixed modeling, mechanical power remained associated with mortality after adjustment for normal respiratory rate, age, and daily Pediatric Logistic Organ Dysfunction-2 score (+3 Joules/breath [1-6 Joules/breath]; p = 0.009). Mortality after severe pediatric acute respiratory distress syndrome is associated with the severity of organ dysfunction, oxygenation defects, and pulmonary metrics including dead space and theoretical mechanical energy load.

Performance of acute respiratory distress syndrome definitions in a high acuity paediatric intensive care unit

BackgroundFor 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).MethodsWe 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).ResultsData 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).ConclusionsPALICC 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.

Epidemiology and Outcomes of Critically Ill Children at Risk for Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

Interventional trials aimed at pediatric acute respiratory distress syndrome prevention require accurate identification of high-risk patients. In this study, we aimed to characterize the frequency and outcomes of children meeting "at risk for pediatric acute respiratory distress syndrome" criteria as defined by the Pediatric Acute Lung Injury Consensus Conference. Planned substudy of the prospective multicenter, international Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study conducted during 10 nonconsecutive weeks (May 2016-June 2017). Thirty-seven international PICUs. Three-hundred ten critically ill children meeting Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria. None. We evaluated the frequency of children at risk for pediatric acute respiratory distress syndrome and rate of subsequent pediatric acute respiratory distress syndrome diagnosis and used multivariable logistic regression to identify factors associated with subsequent pediatric acute respiratory distress syndrome. Frequency of at risk for pediatric acute respiratory distress syndrome was 3.8% (95% CI, 3.4-5.2%) among the 8,122 critically ill children who were screened and 5.8% (95% CI, 5.2-6.4%) among the 5,334 screened children on positive pressure ventilation or high-flow oxygen. Among the 310 at-risk children, median age was 2.1 years (interquartile range, 0.5-7.3 yr). Sixty-six children (21.3%) were subsequently diagnosed with pediatric acute respiratory distress syndrome, a median of 22.6 hours (interquartile range, 9.8-41.0 hr) later. Subsequent pediatric acute respiratory distress syndrome was associated with increased mortality (21.2% vs 3.3%; p < 0.001) and longer durations of invasive ventilation and PICU care. Subsequent pediatric acute respiratory distress syndrome rate did not differ by respiratory support modality at the time of meeting at risk criteria but was independently associated with lower initial saturation:Fio2 ratio, progressive tachycardia, and early diuretic administration. The Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria identify critically ill children at high risk of pediatric acute respiratory distress syndrome and poor outcomes. Interventional trials aimed at pediatric acute respiratory distress syndrome prevention should target patients early in their illness course and include patients on high-flow oxygen and positive pressure ventilation.

Paediatrics: how to manage acute respiratory distress syndrome.

BackgroundAcute 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).MethodsA 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.DiscussionNon-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.ConclusionPARDS 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.

Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome. A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher Fio2 grid recommendations. Seventy-one international PICUs. Children with pediatric acute respiratory distress syndrome. None. Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3-8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/Fio2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/Fio2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome. Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence.

P0397 / #958: CONCORDANCE STUDY OF BERLIN AND PALICC DEFINITIONS FOR ACUTE RESPIRATORY DISTRESS SYNDROME WITH AUTOPSY FINDINGS IN PEDIATRIC PATIENTS.

Aims & Objectives: Acute respiratory distress syndrome (ARDS) is an important cause of mortality. In pediatrics, its diagnosis is based on the Berlin consensus definition (BERLIN) and more recently on the Pediatric Acute Lung Injury Consensus Conference (PALICC). We measure the concordance of ARDS by BERLIN and PALICC definitions with autopsy findings in deceased patients from a pediatric intensive care unit (PICU). Methods: A cross-sectional study of clinical and autopsy records of patients who died in a PICU from a Hospital in Bogotá between 2000 and 2018. Concordance was measured with a Cohen Kappa coefficient test and a comparative analysis between definition components and diffuse alveolar damage (DAD) was performed and expressed as median with interquartile percentiles or relative frequencies with a Chi2 o a K-Wallis test were appropriate. Results: In a total of 222 autopsies, 53 (23.9%) met BERLIN criteria, 56 (25.2%) PALICC and 45 (20.2%) had DAD. Agreement was 0.48 for BERLIN and PALICC in relation to DAD. DAD cases were only significantly associated with bilateral opacities on chest X ray (77.8% vs. 56.0%; p = 0.025) and the presence of severe values in oxygenation (p = 0.04) or saturation (p = 0.04) indices. Conclusions: The agreement between ARDS definitions and DAD is moderate and has not changed with the most recent adjustment in the definition. Bilateral opacities and high oxygenation or saturation index are related to DAD. Models seeking therapeutic strategies should limit cases to these two findings to improve their specificity.

P0439 / #2139: INCIDENCE AND OUTCOME OF PEDIATRIC ARDS: RETROSPECTIVE COMPARAISON BETWEEN THE BERLIN DEFINITION AND THE PALICC CRITERIA

Aims & Objectives: Aim was to compare incidence and outcomes of pediatric acute respiratory distress syndrome (pARDS) according to Berlin definitions and Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria. Methods: Data of all admitted patients (1 month to 14 years) to our Pediatric Intensive Care Unit over a 30-months period (July 2017–Dec 2019) were reviewed for presence of any respiratory distress at admission or during PICU stay. Patients with significant cardiac L-R shunt were excluded. PALICC and Berlin criteria were retrospectively applied to these patients. Collected data including criteria, severity and outcom. Patients was classified in 2 groups: the “PALICC only group” and the “Berlin with or without PALICC”. Results: A total of 568 admissions was recorded during the study period: Among them, 359 (63%) were identified had respiratory distress at admission or during PICU stay. A total of 87 childrens (15,3%; 95%) fulfilled definition of pARDS with either of the two PALICC and BERLIN criteria. 81 children (93,1%) fulfilled PALICC criteria and only 47 childrens (54%) fulfilled BERLIN definition. Statistical Agreement between two definitions was moderate (Kappa: 0,59; 95%, observed agreement 88%). More patients had severe ARDS in the “Berlin with or without PALICC group” as compared to the “PALICC only” group (61,7% vs. 25,2%). There was no difference regarding the duration of mechanical ventilation (8 vs. 10 days) but there was a non trend to increased mortality in the BERLIN group [36,1% vs. 22,1%). Conclusions: Compared to the Berlin definition, PALICC criteria seems to identify more patients with pARDS with more severe severity in “Berlin with or without PALICC” group with no difference in outcome.

Development of a Standardized Clinical Assessment and Management Plan for Pediatric Acute Respiratory Distress Syndrome.

Pediatric acute respiratory distress syndrome (PARDS) is one of the most challenging patient populations for a clinician to manage with mortality between 8 and 31%. The project was designed to identify patients with PARDS, implement management guidelines with the goal of standardizing practice. Our objectives were to describe the development and implementation of a protocolized approach to identify patients with PARDS and institute ventilator management guidelines. Patients who met criteria for moderate or severe PARDS as per the Pediatric Acute Lung Injury Consensus Conference (PALICC) definitions were identified using the best practice alert (BPA) in the electronic health record (EHR). Patients who did not meet exclusion criteria qualified for management using the Standardized Clinical Assessment and Management Plan (SCAMP), a quality improvement (QI) methodology with iterative cycles. The creation of a BPA enabled identification of patients with PARDS. With our second cycle, the number of false BPA alerts due to incorrect data decreased from 66.7 (68/102) to 29.2% (19/65; p < 0.001) and enrollment increased from 48.3 (14/29) to 73.2% (30/41; p = 0.03). Evaluation of our statistical process control chart (SPC) demonstrated a shift in the adherence with the tidal volume guideline. Overall, we found that SCAMP methodology, when used in the development of institutional PARDS management guidelines, allows for development of a process to aid identification of patients and monitor adherence to management guidelines. This should eventually allow assessment of impact of deviations from clinical practice guidelines.

Acute viral bronchiolitis as a cause of pediatric acute respiratory distress syndrome

The Pediatric Acute Lung Injury Consensus Conference (PALICC) published pediatric-specific guidelines for the definition, management, and research in pediatric acute respiratory distress syndrome (PARDS). Acute viral bronchiolitis (AVB) remains one of the leading causes of admission to PICU. Respiratory syncytial virus (RSV) is the most common cause of AVB. We aimed to evaluate the incidence of PARDS in AVB and identify the risk of RSV as a trigger pathogen for PARDS. This study is a retrospective single-center observational cohort study including children < 2 years of age admitted to the pediatric intensive care unit at St Mary’s Hospital, London, and presented with AVB in 3 years (2016–2018). Clinical and demographic data was collected; PALICC criteria were applied to define PARDS. Data was expressed as median (IQR range); non-parametric tests were used. In this study, 144 infants with acute viral bronchiolitis were admitted to PICU in the study period. Thirty-nine infants fulfilled criteria of PARDS with RSV as the most common virus identified. Bacterial infection was identified as a risk factor for development of PARDS in infants with AVB.Conclusion: AVB is an important cause of PARDS in infants. RSV is associated with a higher risk of PARDS in AVB. Bacterial co-infection is a significant risk factor for development of PARDS in AVB.What is Known:• Bronchiolitis is a common cause of respiratory failure in children under 2 years.• ARDS is a common cause of PICU admission.What is New:• Evaluation of bronchiolitis as a cause of PARDS according to the PALLIC criteria.• Evaluation of different viruses’ outcome in PARDS especially RSV as a commonest cause of AVB.

Prognostic relevance and inter-observer reliability of chest-imaging in pediatric ARDS: a pediatric acute respiratory distress incidence and epidemiology (PARDIE) study

PurposeDefinitions of acute respiratory distress syndrome (ARDS) include radiographic criteria, but there are concerns about reliability and prognostic relevance. This study aimed to evaluate the independent relationship between chest imaging and mortality and examine the inter-rater variability of interpretations of chest radiographs (CXR) in pediatric ARDS (PARDS).MethodsProspective, international observational study in children meeting Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria for PARDS, which requires new infiltrate(s) consistent with pulmonary parenchymal disease, without mandating bilateral infiltrates. Mortality analysis focused on the entire cohort, whereas inter-observer variability used a subset of patients with blinded, simultaneous interpretation of CXRs by intensivists and radiologists.ResultsBilateral infiltrates and four quadrants of alveolar consolidation were associated with mortality on a univariable basis, using CXRs from 708 patients with PARDS. For patients on either invasive (IMV) or non-invasive ventilation (NIV) with PaO2/FiO2 (PF) ratios (or SpO2/FiO2 (SF) ratio equivalent) > 100, neither bilateral infiltrates (OR 1.3 (95% CI 0.68, 2.5), p = 0.43), nor 4 quadrants of alveolar consolidation (OR 1.6 (0.85, 3), p = 0.14) were associated with mortality. For patients with PF ≤ 100, bilateral infiltrates (OR 3.6 (1.4, 9.4), p = 0.01) and four quadrants of consolidation (OR 2.0 (1.14, 3.5), p = 0.02) were associated with higher mortality. A subset of 702 CXRs from 233 patients had simultaneous interpretations. Interobserver agreement for bilateral infiltrates and quadrants was “slight” (kappa 0.31 and 0.33). Subgroup analysis showed agreement did not differ when stratified by PARDS severity but was slightly higher for children with chronic respiratory support (kappa 0.62), NIV at PARDS diagnosis (kappa 0.53), age > 10 years (kappa 0.43) and fluid balance > 40 ml/kg (kappa 0.48).ConclusionBilateral infiltrates and quadrants of alveolar consolidation are associated with mortality only for those with PF ratio ≤ 100, although there is high- inter-rater variability in these chest-x ray parameters.Electronic supplementary materialThe online version of this article (10.1007/s00134-020-06074-7) contains supplementary material, which is available to authorized users.