Pediatric Acute Lung Injury Consensus Conference Research Articles

Paediatric acute respiratory distress syndrome incidence and epidemiology (PARDIE): an international, observational study

Paediatric acute respiratory distress syndrome (PARDS) is associated with high mortality in children, but until recently no paediatric-specific diagnostic criteria existed. The Pediatric Acute Lung Injury Consensus Conference (PALICC) definition was developed to overcome limitations of the Berlin definition, which was designed and validated for adults. We aimed to determine the incidence and outcomes of children who meet the PALICC definition of PARDS. In this international, prospective, cross-sectional, observational study, 145 paediatric intensive care units (PICUs) from 27 countries were recruited, and over a continuous 5 day period across 10 weeks all patients were screened for enrolment. Patients were included if they had a new diagnosis of PARDS that met PALICC criteria during the study week. Exclusion criteria included meeting PARDS criteria more than 24 h before screening, cyanotic heart disease, active perinatal lung disease, and preparation or recovery from a cardiac intervention. Data were collected on the PICU characteristics, patient demographics, and elements of PARDS (ie, PARDS risk factors, hypoxaemia severity metrics, type of ventilation), comorbidities, chest imaging, arterial blood gas measurements, and pulse oximetry. The primary outcome was PICU mortality. Secondary outcomes included 90 day mortality, duration of invasive mechanical and non-invasive ventilation, and cause of death. Between May 9, 2016, and June 16, 2017, during the 10 study weeks, 23 280 patients were admitted to participating PICUs, of whom 744 (3·2%) were identified as having PARDS. 95% (708 of 744) of patients had complete data for analysis, with 17% (121 of 708; 95% CI 14-20) mortality, whereas only 32% (230 of 708) of patients met Berlin criteria with 27% (61 of 230) mortality. Based on hypoxaemia severity at PARDS diagnosis, mortality was similar among those who were non-invasively ventilated and with mild or moderate PARDS (10-15%), but higher for those with severe PARDS (33% [54 of 165; 95% CI 26-41]). 50% (80 of 160) of non-invasively ventilated patients with PARDS were subsequently intubated, with 25% (20 of 80; 95% CI 16-36) mortality. By use of PALICC PARDS definition, severity of PARDS at 6 h after initial diagnosis (area under the curve [AUC] 0·69, 95% CI 0·62-0·76) discriminates PICU mortality better than severity at PARDS diagnosis (AUC 0·64, 0·58-0·71), and outperforms Berlin severity groups at 6 h (0·64, 0·58-0·70; p=0·01). The PALICC definition identified more children as having PARDS than the Berlin definition, and PALICC PARDS severity groupings improved the stratification of mortality risk, particularly when applied 6 h after PARDS diagnosis. The PALICC PARDS framework should be considered for use in future epidemiological and therapeutic research among children with PARDS. University of Southern California Clinical Translational Science Institute, Sainte Justine Children's Hospital, University of Montreal, Canada, Réseau en Santé Respiratoire du Fonds de Recherche Quebec-Santé, and Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care Medicine.

Abstract P-595: IMPLEMENTATION OF RECLASSIFICATION AT 24 HOURS AFTER THE DIAGNOSIS OF ACUTE RESPIRATORY DISTRESS SYNDROME IN CHILDREN

Aims & Objectives: Definition of pediatric acute respiratory distress syndrome (PARDS) is a pragmatic snippet based on the degree of hypoxia at the time of its onset. We aimed to determine whether reclassification by PARDS definition 24 hours after meeting PARDS criteria could have better prognostic ability for risk stratification. Methods A total of 1,101 children who admitted to the intensive care unit (ICU) at Severance hospital were screened. And 283 patients diagnosed as PARDS according to the Pediatric Acute Lung Injury Consensus Conference (PALICC) definition were retrospectively analyzed. Reclassification based on data measured at 24 hours after diagnosis were compared with the initial classification. Primary outcome was in-hospital mortality. Results Overall mortality rate of PARDS in ICU was 36.1%. Multivariate analysis revealed that the risk for mortality was significantly increased according to severity stratification based on metrics collected at 24 hours after the diagnosis (HR [95%CI], 4.809 [2.821–8.197]) for severe PARDS. And mortality risk increased for severe PARDS (2.279 [1.414–3.672]) using the initial classification. Oxygenation index (OI) at the time of diagnosis and at 24 hours after onset showed associations with mortality (aOR [95%CI], 1.042 [1.026–1.058] for initial OI; 1.073 [1.056–1.091] for OI at 24 hours after diagnosis). Change in OI over the first 24 hours were also associated with mortality (1.047 [1.019–1.076]). Conclusions Improvements in oxygenation over the first 24 hours were associated with lower mortality. Implementation of reclassification based on oxygenation metrics 24 hours after the initial diagnosis of PARDS seems valid and may contribute to more individualized treatment in PARDS.

Re-recognition of infectious acute respiratory distress syndrome

From 1903, when Ophuls elaborated infectious pulmonary edema pathologically for the first time, till to 2015, acute respiratory distress syndrome: Consensus Recommendations From the Pediatric Acute Lung Injury Consensus Conference was defined by Pediatric Acute Lung Injury Consensus Conference(PALICC), the development of infectious pulmonary edema experienced more than 110 years.In order to improve the re-recognition of infectious pulmonary edema, infectious acute respiratory distress syndrome was expounded on the infectious pathogeny, infection sites, risk factors, diagnosis and treatment in this review. Key words: Infection; Pulmonary edema; Acute respiratory distress syndrome,

Comparison of Prevalence and Outcomes of Pediatric Acute Respiratory Distress Syndrome Using Pediatric Acute Lung Injury Consensus Conference Criteria and Berlin Definition

Our objective was to compare the prevalence and outcomes of pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria and Berlin definitions. We screened case records of all children aged 1 month to 17 years of age admitted to the Pediatric Intensive Care Unit (PICU) over a 3-year period (2015-2017) for presence of any respiratory difficulty at admission or during PICU stay. We applied both PALICC and Berlin criteria to these patients. Data collection included definition and outcome related variables. Data were compared between the "PALICC only group" and the "Berlin with or without PALICC" group using Stata 11. Of a total of 615 admissions, 246 were identified as having respiratory difficulty at admission or during PICU stay. A total of 61 children (prevalence 9.9%; 95% CI: 7.8-12.4) fulfilled the definition of acute respiratory distress syndrome (ARDS) with either of the two criteria. While 60 children (98%) fulfilled PALICC criteria, only 26 children (43%) fulfilled Berlin definition. There was moderate agreement between the two definitions (Kappa: 0.51; 95% CI: 0.40-0.62; observed agreement 85%). Greater proportion of patients had severe ARDS in the "Berlin with or without PALICC group" as compared to the "PALICC only" group (50 vs. 19%). There was no difference between the groups with regard to key clinical outcomes such as duration of ventilation (7 vs. 8 days) or mortality [51.4 vs. 57.7%: RR (95% CI): 0.99 (0.64-1.5)]. In comparison to Berlin definition, the PALICC criteria identified more number of patients with ARDS. Proportion with severe ARDS and complications was greater in the "Berlin with or without PALICC" group as compared to the "PALICC only" group. There were no differences in clinical outcomes between the groups.

Recent Advances in Pediatric Acute Respiratory Distress Syndrome (PARDS)

The purpose of this review is to summarize the recent literature on pediatric acute respiratory distress syndrome (PARDS). This review will focus on, but not be limited to, literature using the recent definition of PARDS established by the Pediatric Acute Lung Injury Consensus Conference (PALICC) group in 2015. Mortality rates for PARDS have recently decreased to 10–15%. Clinical trials in PARDS have (1) emphasized the relative importance of early oxygenation in predicting mortality; (2) suggested a role for protocolized sedation in patients managed with extracorporeal membrane oxygenation (ECMO); (3) found no mortality benefit to high-frequency oscillatory ventilation (HFOV), exogenous surfactant, or corticosteroids; and (4) suggested biomarkers and whole exome sequencing as methods for personalizing management. Recent laboratory studies have suggested differences in responsiveness to high tidal volume injury in juvenile rodents. The near future of PARDS management could include earlier risk stratification of patients by (1) oxygenation within 24 h of PARDS diagnosis and (2) use of biomarkers and subphenotypes. Despite challenges in performing clinical trials in children, the PALICC definition presents an opportunity to explore these and more research questions in PARDS separately from adult cohorts.

Pediatric ARDS.

The Pediatric Acute Lung Injury Consensus Conference (PALICC) has provided the critical care community with the first pediatric-focused definition for ARDS. The PALICC recommendations provide guidance on conventional ventilator management, gas exchange goals, use of high-frequency ventilation, adjunct management approaches, and the application of extracorporeal membrane oxygenation for pediatric ARDS (PARDS). Although outcomes for PARDS have improved over the past decade, mortality and morbidity remain significant. Pediatric-specific criteria may provide the ability to more promptly recognize and diagnose PARDS in clinical practice. Improvements in prognostication and stratification of disease severity may help to guide therapeutic interventions. Improved comparisons between patients and studies may help to promote future clinical investigations. Hopefully, the recommendations provided by PALICC, in terms of defining and managing ARDS, will stimulate additional research to better guide therapy and further improve outcomes for critically ill infants and children with ARDS.

Surfactants in Acute Respiratory Distress Syndrome in Infants and Children: Past, Present and Future.

There is a lack of definitive data on the effective management of acute respiratory distress syndrome (ARDS) in infants and children. The development and validation of the Berlin definition (BD) for ARDS and the Pediatric Acute Lung Injury Consensus Conference (PALICC) recommendations in children represented a major advance in optimizing research and treatment, mainly due to the introduction of a severe ARDS category. Proposed reasons for the lack of consistent results with surfactants in children and infants compared with neonates include different causes, type of lung damage (direct or indirect), timing and mode of administration as well as the type of surfactant used. Secretory phospholipase A2 plays an important role in inflammation and possible dysfunction of surfactants in ARDS. Bronchoalveolar lavage (BAL) with normal saline and surfactant allows the removal of inhaled material, the recruitment of non-ventilating areas and the maintenance of the surfactant pool size. BAL with diluted surfactant allows rapid absorption of the surfactant at the air/liquid interface, which blocks the progression of pathological lung disease and in turn disrupts the inflammatory cycle. Importantly, it is now recognized that the type of surfactant, the time of administration and the method of administration could all play an important role in the management of ARDS, and there is evidence that surfactant is effective and well tolerated in children and infants with ARDS.

Syndrome de détresse respiratoire aiguë de l’enfant : évolution de la définition et nouveautés de la conférence de consensus pédiatrique

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.