Risk factors for mortality in children with hypoxemia in resource-constrained settings: a secondary analysis of
Carter Biewen1, Shän L Ward2, Asya Agulnik3
1Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA. carter.biewen@gmail.com.
Insights
Children with hypoxemia in resource-constrained settings face higher mortality due to limited respiratory care. Improving healthcare resources and diagnostic support is crucial for better pediatric acute respiratory distress syndrome (PARDS) outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Global Health
- Respiratory Medicine
Background:
- Hypoxemia is a key indicator of pediatric acute respiratory distress syndrome (PARDS) and is more prevalent in resource-constrained settings (RCS).
- Diagnosing PARDS in RCS is challenging due to limited resources, despite a high incidence of clinical triggers like pneumonia and sepsis.
- The study addresses the critical need to understand PARDS burden and outcomes in underserved regions.
Purpose of the Study:
- To assess respiratory care resource availability in RCS hospitals and its correlation with mortality.
- To determine the prevalence of hypoxemia in children presenting to RCS hospitals and their outcomes.
- To investigate the association between PARDS triggers and mortality in hypoxemic children.
Main Methods:
- Operational definitions for five tiers of respiratory care resource bundles were developed.
- Secondary analysis of the Global Paediatric Acute Critical Illness Point Prevalence Study (PARITY) data was conducted.
- Descriptive statistics, hypothesis testing (chi-square, Wilcoxon rank-sum), and logistic regression were employed.
Main Results:
- 10.1% of the Global PARITY cohort (763/7538) presented with hypoxemia, with 70% treated at facilities with limited respiratory resources.
- Mortality was 6.8% and inversely associated with resource availability; higher mortality (aOR 18) was observed in facilities with intermediate or fewer resources.
- While 56% had a PARDS trigger (pneumonia, bronchiolitis, sepsis), insufficient data prevented diagnosis in 94% according to PALICC-2 guidelines; no trigger-mortality association was found.
Conclusions:
- Children with hypoxemia in lower socio-demographic index countries experience significantly higher mortality, linked to respiratory care resource limitations.
- Strengthening health systems, improving resource availability, and enhancing diagnostic capabilities are vital for better PARDS management and outcomes.
- These findings underscore the need for targeted interventions to support pediatric healthcare providers in risk stratification and tailored management of critically ill children.
Background:
Hypoxemia, a mortality predictor and hallmark of pediatric acute respiratory distress syndrome (PARDS), is disproportionately common in resource-constrained settings (RCS). The burden of PARDS in RCS is likely substantial considering the high prevalence of known clinical triggers (e.g., sepsis, pneumonia, trauma), but it is challenging to diagnose due to limited diagnostic resources. We aimed to: (1) describe respiratory care resource availability in RCS hospitals and test whether availability was associated with mortality; (2) determine the proportion of children who presented to RCS hospitals with hypoxemia and their associated outcomes; and (3) test whether, in children with hypoxemia, having a PARDS trigger was associated with mortality.
Methods:
We developed and applied operational definitions for five tiered respiratory care resource bundles. Through a secondary analysis of Global Paediatric Acute Critical Illness Point Prevalence Study (PARITY) data, we performed descriptive statistics, hypothesis testing (i.e., chi-square and Wilcoxon rank-sum tests), and logistic regression analyses.
Results:
Among the entire Global PARITY cohort (n = 7538), 763 (10.1%) were admitted with hypoxemia. Seventy percent (n = 531) were treated at a site with the intermediate or less respiratory care resource bundle available. Mortality was 6.8% (n = 52) and inversely associated with respiratory resource availability. The odds of mortality were higher for patients treated at sites with the intermediate bundle or less compared to those with the advanced or expert bundle available (adjusted odds ratio [OR] 18, 95% confidence interval [CI] 4.1-83). Fifty-six percent (n = 430) had a PARDS trigger, most commonly pneumonia (n = 256), bronchiolitis (n = 116), and sepsis (n = 58). There was no association between the presence of a PARDS trigger and mortality. Ninety-four percent of patients with a PARDS trigger (n = 405/430) had insufficient data available for a PARDS-related diagnosis according to the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines.
Conclusions:
Children with hypoxemia treated at hospitals with respiratory care resource constraints in countries with lower socio-demographic index (SDI) had significantly higher mortality. These findings highlight the importance of ongoing work to improve resource availability, strengthen health systems, and support pediatric healthcare providers in identifying PARDS in order to help clinicians risk stratify children, focus resources, and tailor management to optimize outcomes.
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