ARDS In Children Research Articles

Complicated Falciparum Malarial ARDS Requiring Noninvasive Support.

Severe plasmodium falciparum infection can induce respiratory distress and clinical ARDS in children, requiring intensive care admission and respiratory support. We present 3 cases of imported malarial acute respiratory distress syndrome requiring noninvasive ventilation in the pediatric intensive care unit, in the absence of any cerebral involvement. Radiological features and their relationship with severe hematological complications are also illustrated.

Pathophysiological pathway differences in children who present with COVID-19 ARDS compared to COVID -19 induced MIS-C

COVID-19 has infected more than 275 million worldwide (at the beginning of 2022). Children appear less susceptible to COVID-19 and present with milder symptoms. Cases of children with COVID-19 developing clinical features of Kawasaki-disease have been described. Here we utilise Mass Spectrometry proteomics to determine the plasma proteins expressed in healthy children pre-pandemic, children with multisystem inflammatory syndrome (MIS-C) and children with COVID-19 induced ARDS. Pathway analyses were performed to determine the affected pathways. 76 proteins are differentially expressed across the groups, with 85 and 52 proteins specific to MIS-C and COVID-19 ARDS, respectively. Complement and coagulation activation are implicated in these clinical phenotypes, however there was significant contribution of FcGR and BCR activation in MIS-C and scavenging of haem and retinoid metabolism in COVID-19 ARDS. We show global proteomic differences in MIS-C and COVID-ARDS, although both show complement and coagulation dysregulation. The results contribute to our understanding of MIS-C and COVID-19 ARDS in children.

Pediatric Acute Respiratory Distress Syndrome (PARDS) in Children With Pulmonary Contusion.

There is paucity of data about prevalence of pediatric acute respiratory distress syndrome (PARDS) in children with pulmonary contusion (PC). We intend to evaluate PC in children with chest trauma and the association between PC and PARDS. Retrospective review of Institutional Trauma Registry for patients with trauma. Level 1 trauma center. Age 18 years and younger with a diagnosis of PC. None. Of the 1916 children with trauma, 50 (2.6%) had PC. Patients with PC and PARDS had lower Glasgow Coma Scale (GCS) score (7 [3-15] vs 15 [15-15], P = .0003), higher Injury Severity Scale (ISS) score (29 [22-34] vs 19 [14-22], P = .004), lower oxygen saturations (96 [93-99] days vs 99 [98-100] days, P = .0009), higher FiO2 (1 [1-1] vs 0.21 [0.21-0.40], P < .0001), lower oxygen saturation/FiO2 (S/F) ratios (97 [90-99] vs 457 [280-471], P < .0001), need for invasive mechanical ventilation (IMV; 86% vs 23%, P < .0001), and mortality (28% vs 0%, P = .006) compared to those without PARDS. Forty-two percent (21/50) of patients needed IMV, of these 61% (13/21) had PARDS. Patients who needed IMV had significantly lower GCS score (8 [3-11] vs 15 [15-15], P < .0001), higher ISS score (27 [22-34] vs 18 [14-22], P = .002), longer length of stay (LOS; 7.5 [4-14] days vs 3.3 [2-5] days, P = .003), longer hospital LOS (18 [7.0-25] vs 5 [4-11], P = .008), higher PARDS rate (62% vs 7%, P < .0001), and lower S/F ratios (99 [94-190] vs 461 [353-471], P < .0001) compared to those who did not require IMV. Lower GCS score was independently associated with both PARDS and need for IMV. Pediatric ARDS in children with PC is independently associated with lower GCS score, and its presence significantly increased morbidity and mortality. Further larger studies are needed to explore association of lower GCS and higher injury score in children with PARDS and PC.

Pediatric acute respiratory distress syndrome associated with human metapneumovirus and respiratory syncytial virus.

To study the incidence, risk factors, clinical course, and outcome of ARDS in children with HMP and RSV. We hypothesized that ARDS in children with HMP was similar in incidence, risk factors, clinical course, and outcomes to ARDS in children with RSV. Retrospective, observational study over 2 years. Patients included were <18 years old with HMP or RSV detected from nasopharyngeal specimens by commercial reverse transcriptase polymerase chain reaction assay admitted to a study site. We described the incidence of ARDS within 1 week following the detection of HMP or RSV using recently developed Pediatric ARDS (PARDS) criteria. We also assessed risk factors, clinical course, and outcomes of children in the PICU with HMP or RSV and PARDS or non-PARDS. We identified 57 patients with HMP and 161 patients with RSV: the proportions of patients with either virus who developed PARDS (HMP: 23%, RSV: 20%) and severe PARDS (HMP: 9%, RSV: 7%) were similar, as were the proportions of patients with acute (or acute-on-chronic) respiratory failure who developed PARDS (HMP: 41%, RSV: 31%). In a logistic regression model, risk factors associated with PARDS included neurologic comorbidity and PIM 3 probability of mortality, but not virus type. The risk factors, clinical course, and outcomes were similar for patients with PARDS associated with HMP and RSV. About 1/3 of children with HMP or RSV and acute (or acute-on-chronic) respiratory failure developed PARDS. Children with either virus and a neurologic comorbidity or an increased PIM 3 probability of mortality were at increased risk for PARDS.

New insights into pediatric acute respiratory distress syndrome

Pediatric acute respiratory distress syndrome (PARDS) is one of the most severe disease in pediatric critical care medicine with high mortality.Pediatric practitioners have recognized that ARDS in children is different from ARDS in adults.In the absence of identification of these differences, however, children have been characterized as having ARDS based on the adult definitions.Therefore, the managements for PARDS were conducted without specific considerations of children, and have limitations when applied to patients.With the purpose to highlight the gaps of ARDS between children and adults, the new insights into PARDS on the epidemiology, pathophysiology, diagnosis, treatment and prognosis in the recent years were summarized. Key words: Acute respiratory distress syndrome; Diagnostic criteria; Treatment; Child

Pulse oximetry vs. PaO2 metrics in mechanically ventilated children: Berlin definition of ARDS and mortality risk.

Requiring PaO2/FiO2 ratio (PF) to define ARDS may bias towards children with cardiovascular dysfunction and hypoxemia. We sought to evaluate (1) the Berlin definition of ARDS in children using PF; (2) the effect of substituting SpO2/FiO2(SF) ratio; (3) differences between patients with and without arterial blood gases; and (4) the ability of SpO2 and PaO2 indices to discriminate ICU mortality. Single center retrospective review (3/2009-4/2013) of mechanically ventilated (MV) children. Initial values for PF, SF, oxygenation index (OI), and oxygen saturation index (OSI) after intubation and average values on day 1 of MV were analyzed against ICU mortality, subgrouped by Berlin severity categories. Of the 1,833 children included, 129 met Berlin PF ARDS criteria (33 % mortality); 312 met Berlin SF ARDS criteria (22 % mortality). Children with a PaO2 on day 1 of MV had higher mortality and severity of illness, were older, and had more vasoactive-inotropic infusions (p < 0.001). SF could be calculated for 1,201 children (AUC for ICU mortality 0.821), OSI for 1,034 (0.793), PF for 695 (0.706), and OI for 673 (0.739). Average SF on day 1 discriminated mortality better than PF (p = 0.003). Berlin PF criteria for ARDS identified less than half of the children with ARDS, favoring those with cardiovascular dysfunction. SF or OSI discriminate ICU mortality as well as PF and OI, double the number of children available for risk stratification, and should be considered for severity of illness scores and included in a pediatric-specific definition of ARDS. Multicenter validation is required.

Surfactant Therapy of Pulmonary Conditions Excluding those with Primary Surfactant Deficiency and Bronchoscopy as Delivery Method: An Overview of Russian Patents and Publications

Preparations of pulmonary surfactant are used for the treatment of respiratory distress syndrome in a newborn. Their applicability as a method of routine for lung diseases beyond the neonatal period is questionable. Some publications from the former Soviet Union (SU) have reported on successful surfactant therapy of ARDS in children and adults as well as for inhalation injuries, pneumonia, and tuberculosis. Bronchoscopy was used and recommended as a method of surfactant delivery for ARDS, some types of pneumonia and tuberculosis. Manufacturing processes of surfactant preparations from bovine lung and amniotic fluid, described by Russian patents, and bronchoscopy as a delivery mode are discussed here. A concluding point is that some reports from the former SU about administration of exogenous surfactant in pulmonary conditions, excluding those with primary surfactant deficiency, are only partly confirmed by the international literature.

Temperature Inversions, Meteorological Variables and Air Pollutants and Their Influence on Acute Respiratory Disease in the Guadalajara Metropolitan Zone, Jalisco, Mexico

The presence of temperature inversions (TI), concentration of air pollutants (AP) and meteorological variables (MV) affect the welfare of the population, creating public health problems (acute respiratory diseases ARDs, among others). The Guadalajara Metropolitan Zone (GMZ) experiences high levels of air pollution, which associated with the presence of temperature inversions and meteorological variations is conducive to the incidence of ARDs in children. The aim of this work is to evaluate the TI, MV, AP and their influence on the ARDs in children under five years in the GMZ from 2003 to 2007. In this period, the moderate and strong TI are the most frequent presenting from November to May. The AP shows a variable behavior during the year and between years, with the highest concentration of particles less than 10 microns (PM10), followed by ozone (O3), nitrogen dioxide (NO2), nitrogen oxides (NOX), carbon monoxide (CO) and sulfur dioxide (SO2), the most affected areas are the southeast of the GMZ. Annual arithmetic mean is 213,510 ± 41,209 ARDs consultations. The most important diseases are acute respiratory infections (98.0%), followed by pneumonia and bronchopneumonia (1.1%), asthma and status asthmaticus (0.5%) and streptococcal pharyngitis and tonsillitis (0.4%). Months with most inquiries were from October to March, mainly in the southeast, south and center of the city, coinciding with high levels of AP. Statistical analysis shows that the TI have significant correlation with ARDs in three years, temperature (Temp) in two, relative humidity (RH) in two, wind speed (WS) in three, wind direction (WD) in two, while that air pollutants NOX and NO2 showed significant correlation with ARDs throughout the period. CO and SO2 showed significance in two years, while the PM10 and O3 in one.

Posición prono en síndrome de distress respiratorio agudo

Objective: To review and discuss the prone position manoeuvre in ARDS as a strategy of lung protection. Method: A computerized search in MEDLINE of all publicated articles of prone position in ARDS in children and adults was performed. We analyzed mechanisms of action, indications and timing of use, characteristics of the response, positioning manoeuvres, contraindications and complications. Results: An increase in the effective transpulmonary pressure, which is believed to be an important mechanism of alveolar recruitment, is one of the most important factors in the improvement of systemic oxygenation. In the paedriatric series about 80% of patients presented a positive response to the prone position with an improvement of oxygenation, occurring early and being sustained with time. We found differences in the timing of initiation of the prone position, as well as its duration and frequency. The evidence suggests that the optimum response is most likely to occur during early ARDS. Major iatrogenic complications are limited. Conclusions: Prone positioning is a manoeuvre with a biological rational to its use. It is an easy and harmless therapeutic intervention in order top improve systemic oxygenation and a reduction in mechanical ventilation parameters in ARDS patients.

Treatment of Severe Non-Neonatal ARDS in Children with Surfactant and Nitric Oxide in a “PRE-ECMO”-Situation

The use of exogenous surfactant and nitric oxide in neonates has reduced the number of infants requiring ECMO. The purpose of this study was to demonstrate whether these two therapeutic options might reduce the number of over 28 days old children with severe ARDS requiring ECMO, without reducing changes of survival and morbidity. Over a 30 month period all non-neonatal ARDS patients transferred to our institution for ECMO evaluation were treated based on a study-algorithm. If they did not fulfill "fast entry criteria" (paO2 < 40 for more than 3 hrs.) we first tried different ventilation, vasodilatation, and hemodynamic strategies for max. 4 hrs. (inv. I/E ratio, HFOV, epoprostenol, high doses norepinephrine. If the OI did not decrease by < 10, 30-280 mg natural surfactant or 1-20 ppm nitric oxide were treatment options depending on the degree of pulmonary hypertension measured by echocardiography and by mixed venous saturation measurements. It was possible to use NO and surfactant sequentially. The patients had different etiologies of ARDS as near drowning, pneumonia, immunosuppression, and sepsis. If their OI did not decrease by 10 in 8 hrs. ECMO was installed. Nineteen patients were evaluated, 6 improved with conventional therapy, their OI decreased without a relapse (mean OI at begin of the study: 38). Six patients improved with surfactant therapy alone (mean OI: 54), 4 patients improved after surfactant and sequential NO-treatment, 3 patients were initially treated with NO, 1 sequentially with surfactant. One patient did not show any benefit from NO or surfactant and was put on ECMO. Three patients died (withdrawal of life support because of severe brain damage caused by the underlying disease). We could not observe any respiratory related failure. No patient had to be discharged on oxygen. A sophisticated treatment algorithm integrating different modern ARDS treatment options can reduce the number of patients requiring ECMO. We speculate however that these options can only be used effectively in centers involved in ARDS treatment quite frequently and that these centers have to provide ECMO as one of their therapeutic tools.

Measles pneumonia in the critically ill child: application of alternative ventilation strategies

Measles pneumonia is a life-threatening complication in children infected with the measles virus. The increased number of reported cases over the last several years suggests a need for heightened awareness of the complication among pediatric critical care nurses. Application of alternative ventilation strategies in the critical care setting continues to be explored in children with ARDS refractory to more conventional ventilation support, because the mortality and morbidity associated with ARDS in children remain high. Patients who present with diffuse, bilateral lung injury, such as in measles pneumonia, may be candidates for alternative ventilation strategies. Few investigators have studied alternative ventilation strategies in the pediatric ICU setting. Therefore, nursing research related to the impact of nursing interventions during alternative ventilation strategies is needed. Specifically, evaluation of ET suctioning practices and other interventions that influence oxygen delivery and consumption are necessary to plan effective care during alternative ventilation strategies and improve patient outcome. Prevention of measles pneumonia is clearly the preferred "treatment." Preventive healthcare is paramount in providing optimal care for children. However, until we can address the environmental factors that predispose children to communicable diseases such as measles, critical care nurses must be knowledgeable about the assessment and management of measles pneumonia.

Is there a role for inhaled nitric oxide in pediatric ARDS?

Despite advances in ventilator management and use of extracorporeal lung support, mortality related to ARDS in pediatric patients has not been reduced over the past 20 years. Progressive respiratory failure, due to evolution of the primary illness or to complications of ventilator therapy, significantly contributes to poor outcome. ARDS is characterized by severe ventilation-perfusion mismatch and by pulmonary hypertension. Because of their side effects which affect systemic hemodynamic status or worsen intrapulmonary shunting, intravenous vasodilator trials have been of limited interest. Nitric oxide (NO) has been recognized as a gas with vasodilator properties. In neonates studies have shown that inhaled NO may have an important role in the therapy of persistent pulmonary hypertension. Inhaled NO in adults with severe ARDS has been shown to reduce pulmonary hypertension without producing systemic vasodilation. This reduction of pulmonary vascular resistances may reduce pulmonary edema formation, decrease vasoconstrictor response to cardiotonic agents, and improve biventricular function. In addition, arterial oxygenation seems to be increased by improved matching of ventilation with perfusion. Improvement of oxygenation with inhaled NO suggests that use of lower tidal volumes and FIO2 may be more successful. Until now, there are no published studies regarding NO administration in ARDS affecting nonneonatal pediatric patients. However, the results obtained in adults and newborns suggest that inhaled NO may be a useful adjuvant therapy of ARDS in children, possibly in association with other therapies. Even in adults it remains unclear whether therapy with inhaled NO can reduce morbidity and mortality. Prospectives and randomized studies are essential to assess the real utility of inhaled NO in ARDS.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhaled nitric oxide for a severe respiratory syncytial virus infection in an infant with bronchopulmonary dysplasia

ObjectiveTo report the first case of ARDS in children treated with nitric oxide (NO) inhalation.MethodsA 13-months infant presented with BPD and severe hypoxemia related to RSV infection and ARDS. Inhaled NO was delivered in the ventilatory circuit of a continuous flow ventilator (Babylog 8000, Dräger) in a concentration of 20–80 ppm for 7 days. NO and NO2 were continuously monitored (Polyton Draeger). Respiratory mechanics were evaluated by using the method of passive inflation by the ventilator.ResultsNO inhalation improved oxygenation (tcSaO2) and reduced respiratory system resistance without affecting arterial pressure. NO2 level remained below 5 ppm, and methaemoglobin level below 1%. The child survived without neurologic sequela.ConclusionsTwo mechanisms to explain oxygenation improvement can be suggested:selective improvement in perfusion of ventilated regions and bronchodilation.

363 PROSPECTIVE SURVEY OF ARDS IN CHILDREN

In order to identify the incidence and natural history of ARDS in children, a prospective survey was conducted in German paediatric intensive care units by questionnaire in 1993. So far, 39 patients beyond the neonatal period have been reported who fulfilled the predetermined criteria of ARDS. Median age was 23 months, range 1 month to 20 years. ARDS was associated with a primary pulmonary disease (predominantly infectious pneumonia) in 17, with an extrapulmonary disease in 12 and with a mixed pulmonary / extrapulmonary lesion in 9 patients. 5 Patients had aquired immunodeficiency. The predominent ventilatory mode applied was pressure controlled ventilation. ECMO was used in 5, HFOV in 2 and nitrous oxide in 2 patients. The mortality rate of 54% (21/39) corresponded to published data. Multiple organ system failure was a major complication of ARDS the number of affected systems being correlated to outcome. The data of this survey can be used as a basis for prospective multicenter trials of new treatment modalities which are urgently needed to improve the poor prognosis of ARDS in children.