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Published on: September 24, 2020
Recognizing Pediatric ARDS: Provider Use of the PALICC Recommendations in a Tertiary Pediatric ICU
Avi J Kopstick1, Christina R Rufener2, Adrian O Banerji3
1Division of Pediatric Critical Care Medicine, Texas Tech University Health Science Center, El Paso, Texas. avi.kopstick@ttuhsc.edu.
Insights
Pediatric Acute Respiratory Distress Syndrome (ARDS) is common in ventilated children but often unrecognized. Improved recognition and adherence to consensus recommendations are needed for better pediatric critical care.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Medicine
- Clinical Research
Background:
- Pediatric Acute Respiratory Distress Syndrome (ARDS) diagnosis historically relied on adult guidelines.
- Specific criteria for pediatric ARDS were established in 2015.
- The frequency of provider recognition of pediatric ARDS and its impact on care recommendations were previously unclear.
Purpose of the Study:
- To assess the recognition rate of pediatric ARDS by healthcare providers.
- To determine if provider recognition of pediatric ARDS influences adherence to lung-protective ventilation (LPV) and other consensus recommendations.
- To explore provider knowledge and beliefs regarding pediatric ARDS management.
Main Methods:
- A mixed-method, retrospective study involving mechanically ventilated pediatric subjects.
- Pediatric ARDS cases identified using 2015 criteria; provider recognition assessed via medical record documentation.
- Quantitative comparison of clinical characteristics, LPV adherence, adjunctive therapies, and outcomes between recognized and unrecognized cases.
- Qualitative document analysis (QDA) to evaluate understanding of Pediatric Acute Lung Injury Consensus Conference recommendations.
Main Results:
- Pediatric ARDS was identified in 16% of 1,983 encounters; provider recognition occurred in 30% of these cases.
- Recognition was more frequent in older children, those with worse oxygenation deficits, or bone marrow transplant recipients; recognition rates increased annually.
- No difference in LPV practices based on recognition, but recognized cases showed more permissive hypoxemia and adherence to extrapulmonary recommendations.
- No significant differences in outcomes between recognized and unrecognized pediatric ARDS groups.
- QDA revealed pediatric ARDS is often viewed within a complex context, sometimes as a 'visual diagnosis,' with a focus on non-evidence-based interventions over consensus guidelines.
Conclusions:
- Pediatric ARDS is prevalent in mechanically ventilated children but frequently unrecognized.
- Opportunities exist to improve the dissemination and implementation of best practice recommendations, potentially through strategies like opt-out LPV approaches.
Background:
For almost 50 years, pediatricians used adult guidelines to diagnose ARDS. In 2015, specific criteria for pediatric ARDS were defined. However, it remains unclear how frequently providers recognize pediatric ARDS and whether recognition affects adherence to consensus recommendations.
Methods:
This was a mixed-method, retrospective study of mechanically ventilated pediatric subjects after the release of the pediatric ARDS recommendation statement. Pediatric ARDS cases were identified according to the new criteria. Provider recognition was defined by documentation in the medical record. Pediatric ARDS subjects with and without provider recognition were compared quantitatively according to clinical characteristics, adherence to lung-protective ventilation (LPV), adjunctive therapies, and outcomes. A qualitative document analysis (QDA) was performed to evaluate knowledge and beliefs surrounding the Pediatric Acute Lung Injury Consensus Conference recommendations.
Results:
Of 1,983 subject encounters, pediatric ARDS was identified in 321 (16%). Provider recognition was present in 97 (30%) cases and occurred more often in subjects who were older, had worse oxygenation deficits, or were bone marrow transplant recipients. Recognition rates increased each studied year. LPV practices did not differ based on provider recognition; however, subjects who received it were more likely to experience permissive hypoxemia and adherence to extrapulmonary recommendations. Ultimately, there was no differences in outcomes between the provider recognition and non-provider recognition groups. Three themes emerged from the QDA: (1) pediatric ARDS presents within a complex, multidimensional context, with potentially competing organ system failures; (2) similar to historical conceptualizations, pediatric ARDS was often considered a visual diagnosis, with measures of oxygenation unreferenced; and (3) emphasis was placed on non-evidence-based interventions, such as pulmonary clearance techniques, rather than on consensus recommendations.
Conclusions:
Among mechanically ventilated children, pediatric ARDS was common but recognized in a minority of cases. Potential opportunities, such as an opt-out approach to LPV, may exist for improved dissemination and implementation of recommended best practices.
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