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Pediatric acute lung injury: prospective evaluation of risk factors associated with mortality
Heidi R Flori1, David V Glidden, George W Rutherford
1Department of Critical Care, Children's Hospital and Research Center at Oakland, PICU Offices, 747 52nd Street, Oakland, CA 94609, USA. hflori@mail.cho.org
Insights
Pediatric acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) have high mortality. Key risk factors include oxygenation defects and organ dysfunction, with early hypoxemia predicting outcomes.
Area of Science:
- Pediatric critical care medicine
- Respiratory medicine
- Epidemiology
Background:
- The 1994 American European Consensus Committee definitions for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) lack systematic application in pediatric populations.
- Understanding pediatric ALI/ARDS epidemiology and risk factors is crucial for improving patient outcomes.
Purpose of the Study:
- To prospectively evaluate the epidemiology and clinical risk factors for mortality and prolonged mechanical ventilation in pediatric patients with ALI/ARDS.
- To apply Consensus Committee criteria for ALI/ARDS in a pediatric intensive care unit setting.
Main Methods:
- Prospective identification of all pediatric patients meeting Consensus Committee definitions for ALI.
- Inclusion in a relational database for analysis.
- Utilizing multivariate logistic regression to identify independent risk factors.
Main Results:
- A total of 328 admissions for ALI/ARDS were recorded, with a 22% mortality rate.
- Independent predictors of mortality and prolonged mechanical ventilation included initial oxygenation defect (PaO2/FiO2 ratio), nonpulmonary/non-CNS organ dysfunction, and CNS dysfunction.
- 28% of patients did not require initial mechanical ventilation, but 46% of these later required intubation.
Conclusions:
- Pediatric ALI/ARDS carries a high mortality rate, with significant prognostic value from identified risk factors.
- Unlike in adults, initial arterial hypoxemia severity strongly correlates with mortality in children.
- A notable proportion of pediatric ALI/ARDS patients can be identified prior to intubation, offering opportunities for novel therapeutic trials.
Rationale:
The 1994 American European Consensus Committee definitions of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) have not been applied systematically in the pediatric population.
Objectives:
The purpose of this study was to evaluate prospectively the epidemiology and clinical risk factors associated with death and prolonged mechanical ventilation in all pediatric patients admitted to two large, pediatric intensive care units with ALI/ARDS using Consensus criteria.
Methods:
All pediatric patients meeting Consensus Committee definitions for ALI were prospectively identified and included in a relational database.
Measurements And Main Results:
There were 328 admissions for ALI/ARDS with a mortality of 22%. Multivariate logistic regression analyses revealed (1) the initial severity of oxygenation defect, as measured by the Pa(O2)/FI(O2) ratio; (2) the presence of nonpulmonary and non-central nervous system (CNS) organ dysfunction; and (3) the presence of CNS dysfunction were independently associated with mortality and prolonged mechanical ventilation. A substantial fraction of patients (28%) did not require mechanical ventilation at the onset of ALI; 46% of these patients eventually required intubation for worsening ALI.
Conclusions:
Mortality in pediatric ALI/ARDS is high and several risk factors have major prognostic value. In contrast to ALI/ARDS in adults, the initial severity of arterial hypoxemia in children correlates well with mortality. A significant fraction of patients with pediatric ALI/ARDS can be identified before endotracheal intubation is required. These patients provide a valuable group in whom new therapies can be tested.
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