Pediatric Acute Respiratory Distress Syndrome in Pediatric Allogeneic Hematopoietic Stem Cell Transplants: A
Courtney M Rowan1, Lincoln S Smith, Ashley Loomis
11Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis IN. 2Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA. 3Division of Critical Care, Department of Pediatrics, Masonic Children's Hospital, University of Minnesota, Minneapolis, MN. 4Division of Critical Care, Department of Pediatrics, St. Jude's Children's Research Hospital, Memphis, TN. 5Division of Critical Care, Department of Pediatrics, Joseph M Sanzari Children's Hospital at Hackensack University Medical Center, Bergen County, NJ. 6Division of Critical Care, Department of Anesthesia, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 7Department of Biostatistics, Indiana University, Indianapolis IN. 8Division of Critical Care, Department of Pediatrics, Weil Cornell Medical College, New York Presbyterian Hospital, New York City, NY. 9Division of Oncology, Department of Pediatrics, Dana-Farber Cancer Institute Harvard University, Boston, MA. 10Division of Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY. 11Division of Blood and Marrow Transplant, Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC. 12Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH. 13Division of Critical Care, Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, PA. 14Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC.
Insights
Pediatric acute respiratory distress syndrome (PARDS) is common in stem cell transplant patients, with survival decreasing as PARDS severity increases. Severe PARDS significantly increases mortality risk in this vulnerable population.
Area of Science:
- Pediatric critical care medicine
- Hematology/Oncology
- Pulmonology
Background:
- Immunodeficiency is a significant risk factor for mortality in pediatric acute respiratory distress syndrome (PARDS).
- Pediatric allogeneic hematopoietic stem cell transplant (HCT) recipients represent a unique population with immunodeficiency and increased susceptibility to critical illness.
Purpose of the Study:
- To define the survival rates of pediatric allogeneic HCT patients experiencing PARDS.
- To characterize the severity of PARDS in this population using the Pediatric Acute Lung Injury Consensus Conference (PALICC) guidelines.
Main Methods:
- Retrospective analysis of data from 211 pediatric allogeneic HCT recipients across twelve U.S. centers.
- Patients were categorized based on PARDS severity (mild, moderate, severe) within the first week of mechanical ventilation using oxygenation indices.
- Univariable logistic regression was used to assess the association between PARDS severity and pediatric intensive care unit (PICU) mortality.
Main Results:
- 91.5% of patients met criteria for PARDS, with 61.1% classified as severe.
- Overall survival was 39.3%, decreasing significantly with increasing PARDS severity (66.7% for no PARDS, 24.6% for severe PARDS).
- Severe PARDS was associated with a 6.1-fold increased odds of mortality (p < 0.001), longer PICU stays, and prolonged mechanical ventilation.
Conclusions:
- The majority of pediatric allogeneic HCT patients with respiratory failure develop PARDS, often severe, within the first week of mechanical ventilation.
- PARDS severity is directly correlated with increased mortality, longer PICU length of stay, and extended mechanical ventilation duration in this cohort.
- These findings highlight the critical impact of PARDS on outcomes for pediatric HCT survivors and underscore the need for targeted management strategies.
Objective:
Immunodeficiency is both a preexisting condition and a risk factor for mortality in pediatric acute respiratory distress syndrome. We describe a series of pediatric allogeneic hematopoietic stem cell transplant patients with pediatric acute respiratory distress syndrome based on the recent Pediatric Acute Lung Injury Consensus Conference guidelines with the objective to better define survival of this population.
Design:
Secondary analysis of a retrospective database.
Setting:
Twelve U.S. pediatric centers.
Patients:
Pediatric allogeneic hematopoietic stem cell transplant recipients requiring mechanical ventilation.
Interventions:
None.
Measurements And Main Results:
During the first week of mechanical ventilation, patients were categorized as: no pediatric acute respiratory distress syndrome or mild, moderate, or severe pediatric acute respiratory distress syndrome based on oxygenation index or oxygen saturation index. Univariable logistic regression evaluated the association between pediatric acute respiratory distress syndrome and PICU mortality. A total of 91.5% of the 211 patients met criteria for pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition: 61.1% were severe, 27.5% moderate, and 11.4% mild. Overall survival was 39.3%. Survival decreased with worsening pediatric acute respiratory distress syndrome: no pediatric acute respiratory distress syndrome 66.7%, mild 63.6%, odds ratio = 1.1 (95% CI, 0.3-4.2; p = 0.84), moderate 52.8%, odds ratio = 1.8 (95% CI, 0.6-5.5; p = 0.31), and severe 24.6%, odds ratio = 6.1 (95% CI, 2.1-17.8; p < 0.001). Nonsurvivors were more likely to have multiple consecutive days at moderate and severe pediatric acute respiratory distress syndrome (p < 0.001). Moderate and severe patients had longer PICU length of stay (p = 0.01) and longer mechanical ventilation course (p = 0.02) when compared with those with mild or no pediatric acute respiratory distress syndrome. Nonsurvivors had a higher median maximum oxygenation index than survivors at 28.6 (interquartile range, 15.5-49.9) versus 15.0 (interquartile range, 8.4-29.6) (p < 0.0001).
Conclusion:
In this multicenter cohort, the majority of pediatric allogeneic hematopoietic stem cell transplant patients with respiratory failure met oxygenation criteria for pediatric acute respiratory distress syndrome based on the Pediatric Acute Lung Injury Consensus Conference definition within the first week of invasive mechanical ventilation. Length of invasive mechanical ventilation, length of PICU stay, and mortality increased as the severity of pediatric acute respiratory distress syndrome worsened.
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