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Surfactant Depletion Combined with Injurious Ventilation Results in a Reproducible Model of the Acute Respiratory Distress Syndrome ARDS
Published on: April 7, 2021
A Simple and Robust Bedside Model for Mortality Risk in Pediatric Patients With Acute Respiratory Distress Syndrome
Aaron C Spicer1, Carolyn S Calfee, Matthew S Zinter
11Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA.2Departments of Anesthesia and Medicine, University of California, San Francisco, CA.3Division of Critical Care, Department of Pediatrics, University of California, Benioff Children's Hospital-San Francisco, San Francisco, CA.4Departments of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA.5Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.6Department of Pediatrics, Children's Hospital of Central California, Fresno, CA.7Department of Pediatrics, University of Wisconsin-Madison, Madison, WI.8Division of Pediatric Critical Care, University of California, San Francisco Benioff Children's Hospital-Oakland, Oakland, CA.9Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA.
Insights
A simple model using oxygenation index and cancer history can predict mortality in pediatric acute respiratory distress syndrome (ARDS) patients. This aids clinical trials and interventions, simplifying risk assessment for better patient outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Medicine
- Oncology
Background:
- Acute respiratory distress syndrome (ARDS) remains a significant cause of mortality in pediatric intensive care units (PICUs).
- Accurate risk stratification is crucial for managing ARDS patients and enrolling them in clinical trials.
- Existing models may be too complex for rapid bedside assessment.
Purpose of the Study:
- To develop a simple and robust model for predicting mortality risk in pediatric ARDS patients.
- To facilitate targeted application of investigational therapies and improve clinical trial stratification.
Main Methods:
- A prospective, multicenter cohort study involving 308 children with ARDS across five academic PICUs.
- Clinical variables including demographics, medical history, oxygenation, ventilation, imaging, and organ dysfunction were collected on days 1 and 3 post-ARDS onset.
- Statistical analyses were used to identify predictors of hospital mortality.
Main Results:
- Overall mortality in the cohort was 17%.
- Children with a history of cancer or hematopoietic stem cell transplant had significantly higher mortality (47% vs 11%).
- Oxygenation index and cancer/stem cell transplant history emerged as key predictors, forming a parsimonious yet effective mortality risk model.
Conclusions:
- A simple risk model incorporating oxygenation index and cancer/stem cell transplant history can accurately predict hospital mortality in pediatric ARDS patients.
- This model can be applied on day 1 or day 3 of ARDS, simplifying bedside risk assessment.
- Findings support improved clinical trial enrollment, family counseling, and the use of high-risk interventions like extracorporeal life support.
Objectives:
Despite declining mortality, acute respiratory distress syndrome is still involved in up to one third of pediatric intensive care deaths. The recently convened Pediatric Acute Lung Injury Consensus Conference has outlined research priorities for the field, which include the need for accurate bedside risk stratification of patients. We aimed to develop a simple yet robust model of mortality risk among pediatric patients with acute respiratory distress syndrome to facilitate the targeted application of high-risk investigational therapies and stratification for enrollment in clinical trials.
Design:
Prospective, multicenter cohort.
Setting:
Five academic PICUs.
Patients:
Three hundred eight children greater than 1 month and less than or equal to 18 years old, admitted to the ICU, with bilateral infiltrates on chest radiograph and PaO2/FIO2 ratio less than 300 in the clinical absence of left atrial hypertension.
Interventions:
None.
Measurements And Main Results:
Twenty clinical variables were recorded in the following six categories: demographics, medical history, oxygenation, ventilation, radiographic imaging, and multiple organ dysfunction. Data were measured 0-24 and 48-72 hours after acute respiratory distress syndrome onset (day 1 and 3) and examined for associations with hospital mortality. Among 308 enrolled patients, mortality was 17%. Children with a history of cancer and/or hematopoietic stem cell transplant had higher mortality (47% vs 11%; p < 0.001). Oxygenation index, the PaO2/FIO2 ratio, extrapulmonary organ dysfunction, Pediatric Risk of Mortality-3, and positive cumulative fluid balance were each associated with mortality. Using two statistical approaches, we found that a parsimonious model of mortality risk using only oxygenation index and cancer/hematopoietic stem cell transplant history performed as well as other more complex models that required additional variables.
Conclusions:
In the PICU, oxygenation index and cancer/hematopoietic stem cell transplant history can be used on acute respiratory distress syndrome day 1 or day 3 to predict hospital mortality without the need for more complex models. These findings may simplify risk assessment for clinical trials, counseling families, and high-risk interventions such as extracorporeal life support.
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